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Banned from getting better: loss of funding in mental health

The Doctor magazine
16 x 9

February 2020, Issue 18

Mentally ill patients are often treated in shabby, outdated facilities which are anything but therapeutic. Yet hospitals with money to invest in improving care are being prevented from doing so by the Government. Keith Cooper reports

The front desk that greets you at Lynfield Mount Hospital, Bradford (pictured above), is encased in glass, the friendly receptionists peering out from inside.

Wards are reached through four locked doors, along characterless halls with an institutional magnolia colour scheme. You buzz in, you buzz out.

You’re left in no doubt about where you’re heading.

The wards are windowless. There are four corridors, arranged in a ‘cruciform’ design common to churches and some prisons, around an artificially lit central hub. Here patients, often 25 to a ward, mill around as a nurse switches her eyes, as if checking traffic, down each corridor in turn, some brightly lit, others in darkness, shadows gathering in their corners. Noise builds easily off these walls and low ceilings, a common cause of complaint from patients. Staff are used to it.

This is the facility the NHS has for patients with severe mental ill health in Bradford, West Yorkshire.

It’s where you come when you’re ill, anxious, depressed or suicidal in this city, a once proud international centre of the textile trade. Now it’s like many other de-industrialised towns and cities. The core of inner-city poverty, Gothic Victorian towers and rotting hulks of factories, ribs showing through their rafters. More affluent areas, such as the spa town of Ilkley, cluster on its outskirts.


Hostile environment

Sarfaraz Shora (pictured below), consultant psychiatrist at Bradford District Care NHS Foundation Trust, is open about the state of the wards he oversees as clinical director for acute and inpatient services. His fluency in Urdu, Hindi, and grasp of Punjabi is an obvious asset in a patch with a large Asian but changing population. Some 100 languages are heard here, says deputy chief executive Liz Romaniak – an obvious challenge for talking therapies, a mainstay of treatment.

The Doctor magazine
16 x 9
February 2020, Issue 18

‘We have got the knowledge, skills and expertise of the 21st century but the building is from the 1960s,’ says Dr Shora. ‘We are not able to offer the caring and therapeutic environment we want to help people recover,’ he admits. ‘It’s a locked, dark place. Because of this confined space, there are more incidents of violence. There are issues with noise, the temperature is not well regulated, there are not a lot of green spaces.’

Patients need a calm environment to get better, Dr Shora adds. ‘But here it can be intense and difficult some days. If there’s been violence on the ward, it can affect patients, as well as the staff, including me. We support each other, we do our best.’

These and other problems at Lynfield Mount are far from unique.


Worst estates

The poor quality of mental health hospitals is called ‘a major obstacle’ for good care nationwide in the 2018 wide-ranging report, Modernising the Mental Health Act, by consultant psychiatrist Professor Sir Simon Wessely. ‘People are often placed in some of the worst estates the NHS has, just when they need the best,’ the report adds and calls for extra investment.

So, are better places for people with mental ill health arriving any time soon, here and elsewhere?

Dr Shora and trust managers are not optimistic.

While the Government is increasing funding for staff, it plans also to tighten its grip on the ‘capital budgets’ which trusts use for repairs and new buildings. All of the 40 new hospitals prime minister Boris Johnson announced in his election campaign are acute ones, leaving less, many fear, in the pot for mental health trusts (see below, ‘The trusts blocked from spending their own money’). Leeds Royal Infirmary, up the road from Lynfield Mount, will be one of the first in line.

‘There’s a lot of talk about parity of esteem between physical and mental health,’ Dr Shora says. ‘But acute hospitals, for physical health, are getting investment. That is good but we’re sitting here in a building from the 1960s.

‘When you look at parity, on the ground,’ Dr Shora adds, ‘for professionals in mental healthcare, it does not feel the same.’


Investment blocked

The cost of replacing Lynfield Mount is about £50m, says the trust’s deputy director of estates, Simon Adamson (pictured below). ‘We’ve got the ambition to make a change, we just need the capital to do it,’ he says.

The Doctor magazine
16 x 9
February 2020, Issue 18

Meanwhile, it must deal with a £7m backlog of repairs and must-dos, including replacing sash windows, known ‘ligature points’. ‘Without this work, we wouldn’t be able to deliver safe care,’ he adds.

A new hospital would be of a modern design, with an open reception leading to public space, a café, then semi-private areas, before wards. Each one would have access to gardens, gyms, calm spaces for relaxation and therapy. Bedrooms with their own bathrooms. All things that Lynfield Mount lacks.

Gone would be the overwhelmed outdated drains, which wash sewage across shared facilities’ floors after heavy rainfall. Staff would at last have changing and rest rooms.

‘We can manage quite difficult situations,’ says ward manager Angie Bethell (below, left). ‘They can be quite traumatic for staff. If they’re upset, you can say, go off the ward, take 10 minutes. Usually, people go and sit in their cars.’


Passion and drive

It makes you wonder why anyone would work here.

‘If we said, the building’s not right, we won’t work here, then no one would and what would happen?’ says Sarah Calvert (below, right), an assistant ward manager. Despite the conditions, nursing students do often return for jobs when qualified, she adds.

The Doctor magazine
16 x 9
February 2020, Issue 18

After four years here, Dr Shora says it is his passion for mental healthcare and Bradford that keeps him in post. ‘If you didn’t have that passion and drive, you wouldn’t survive on these wards.’

Yet, after decades standing here, this dark and frankly depressing place feels out of place in a health service for treating – not stigmatising – mental ill health. For while it still stands, Dr Shora points out, it can only add to it.

‘Patients say it feels like an institution. It’s confined, it’s locked. It has a history that adds to the stigma. That’s the feeling the patients get on the wards.’

It’s a bad feeling which only extra investment will replace.


The trusts blocked from spending their own money

The Doctor magazine
16 x 9
February 2020, Issue 18

The way new hospitals and other healthcare buildings are funded is to be shaken up with big implications for MHTs (mental health trusts).

Under a new ‘health infrastructure plan’, ministers want a more ‘coordinated’ approach. To do this, they will ‘freeze’ £1.7bn, which individual hospital trusts have banked for improvements.

This £1.7bn sits in MHTs’ accounts as cash reserves, which they’ve been encouraged to stockpile to balance out the large deficits of many other hospitals. This keeps the NHS in the black overall.

Nuffield Trust senior policy analyst Sally Gainsbury says foundation trusts hold most of the NHS’s capacity on capital expenditure in their accounts.

‘Depressingly, the Department of Health has responded to this by proposing to change the law to prevent them spending this money. What is the point of having money in your bank account if you’re not allowed to spend it?’

Curbing foundation trusts’ freedom to build or repair hospitals – without raising the capital expenditure limit – would lead to a ‘levelling down’ of available funding. ‘Mental health is likely to be at the bottom of the pile,’ she adds.

Bradford District Care NHS Foundation Trust’s Liz Romaniak says the infrastructure plan would also create a ‘competitive environment for capital’ in which MHTs could fare badly. The 40 new hospitals listed in the plan are all acutes. ‘These very large projects would tie up lots of the available capital,’ Ms Romaniak adds.

The days of MHTs being able to build up reserves are also ‘over’, she says. After eight years of cutting costs, her trust’s surplus fell from £4.8m in 2017/18 to £1.8m last year. It’s part of a national trend of deteriorating finances in mental health, our analysis shows.

‘We are at a crucial point now,’ Ms Romaniak says. ‘We are getting very complex, unwell, patients. Our services are overheating and the ageing infrastructure is exacerbating these difficulties.’

Such difficulties are felt by MHTs across England, says NHS Providers senior policy adviser David Williams. ‘Patients are being placed at an increased level of risk from ageing and often unsafe mental health facilities. Too many are still treated in dormitory-style accommodation. Many are being treated in facilities which may hamper their recovery. For staff, it is extremely demoralising.’

NHS Providers and the BMA are calling for Government to grow capital investment in the NHS.

‘Poor environments in mental health hospitals are harmful to patients and staff,’ BMA mental health policy lead Andrew Molodynski says. ‘We need a proper parity of resources in mental healthcare to create therapeutic environments for patients and a working environment which doesn’t burn out our staff.’

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