Briefing Notes and Evidence Base

Our concerns about the Redevelopment of Park House Psychiatric Hospital and the future of Mental Health services in Greater Manchester are based on these issues:

The Issues
1.1. Racism and Mental Health
1.2.Human Rights
1.3.Inequalities in Physical Health
1.4.The Manchester Crisis in Stepping down
1.5.Emergency care
1.6.Covid 19

2. A Different Way?

2.1 A Paradigm Change? Alternative Crisis Service models for adults

2.2 Making Best Use of Mental Health Funding

2.3. Research and Action

2.4 Directions for future travel

1. The Issues
In our experience Manchester’s mental health services have been constructed around biological understandings of illness for far too long. The best efforts of our mental health workers and services are compromised by the narrow focus on illnesses and medical responses of our crisis services. This mindset eclipses the significance of social determinants on peoples’ lives. It places the emphasis on disease processes rather than racism; social-economic adversity; people fleeing persecution; homelessness and poor housing; adverse childhood events; trauma; oppression; microaggressions; toxic situations and relationships. These we know are amongst the most significant contributors to undermining our well-being and resilience, leading to poor mental health.

The disproportionate representation of black and ethnic minority people within the mental health system is in part the result of this over reliance on a medical system and the lack of community support infrastructure. This is due to the over diagnosis of crisis as an illness, the misinterpretation of culture and not building trusting relationships. The University of Manchester (2019) found that tackling the ‘impact of racism’ is the number one priority to reduce ethnic inequalities in severe mental illness.

We can see nothing in the Park House redevelopment consultation that describes the overall vision of the service in relation to the above issues and the strategy to support people’s recovery journeys. The service through its culture, size and location will remain remote, separated and unaccountable to the communities it serves.

In the consultation document about the new hospital building it says:
“The new building will be a place of innovation, using the latest technology and therapeutic techniques in an environment that is conducive to holistic treatment and rehabilitation. On the site, specialists in mental health problems, from occupational therapists to psychologists, from support staff, nurses, and a wide range of disciplines will be part of the service.” (2019)

We doubt this is achievable when there is little evidence that services in the new building will move away from the following entrenched practices:

  • Rapid tranquillisation
  • Seclusion rooms
  • Physical Restraint
  • Locked doors and lock downs
  • Depo Clinics
  • Long term use of medication
  • Psychiatric intensive Care Unit
  • Sectioning under the mental health act
  • Increasing the use of Community Treatment Orders
  • Inappropriate cultural responses

Existing practices mean that Greater Manchester already has an unenviable record for:
using physical restraint at higher levels than other parts of the UK (Mind, 2018)
the worst record in the country for missing patients (625 patients in 2018 – 2019, NHS)
too many Black people come into contact with mental health services through the criminal justice system than via a GP referral.
Black and minority ethnic patients are more likely to be held in seclusion, forcibly given medication and regularly readmitted and on average, they remain in hospital twice as long as White British people and are more likely to be

  • discharged on costly Community Treatment Orders (CTOs)
  • regular use of physical restraint including prone position and drugging
  • those needing access to mental health services face waits longer than almost anywhere in the country (MEN, 2017)

1.1 Culture of inequality:
Of the one million strong NHS workforce 45% of doctors and 25% of nurses are from BAME backgrounds. In the February 2020 BMJ special issue on Racism in Medicine highlighted continued inequalities and discrimination faced both by service users as well as staff in the NHS. WRES figures suggest continued discrimination amongst all grades within the NHS with a rise in bullying and discrimination felt by BME staff from other staff, up from 27% to 29% in 2019 with 15% having experienced bullying from their managers.
Working conditions that don’t tackle racism must have a knock-on effect on patients, especially on those of BME backgrounds.

The University of Manchester found that tackling the ‘impact of racism’ is the number one priority to reduce ethnic inequalities in severe mental illness. Black Caribbean patients with psychosis are more likely to be coercively treated under the powers of the Mental Health Act than White patients, and less likely to receive psychologically-based interventions. Also, Black patients are just over 50 per cent more likely to be prescribed injectable antipsychotic drugs than White patients.

Research published in the Lancet (2019) found that compulsory detention and readmission in all BAME populations is significantly increased compared with majority groups, as is that of migrant populations compared with host nation populations. Detention rates vary across different BAME groups, with the highest rate seen in black Caribbean populations, and less marked, but still significantly increased rates in south Asian populations.
Black people and detentions under the Mental Health Act (2020): In the year to March 2019, Black people were more than 4 times as likely as White people to be detained under the Mental Health Act – 306.8 detentions per 100,000 people, compared with 72.9 per 100,000 people. Out of the 16 specific ethnic groups, Black Caribbean people had the highest rate of detention out of all ethnic groups (excluding groups labelled ‘Other’)
The highest rate of detention was for people in the Black Other ethnic group, followed by those in the Mixed Other ethnic group – however, these rates are considered to be overestimates because ‘Other’ categories may have been used for people whose specific ethnicity wasn’t known, the actual rates of detention for people in the ethnic groups not labelled as ‘Other’ may be underestimated, particularly those within the Black ethnic groups. Gov UK

Covid 19 has exposed the racialised inequalities in our society. As we have witnessed racism kills. We need a service which challenges racist attitudes and behaviour. It is time for the NHS to admit that racism remains an underlying cause of poor mental health in its own BAME staff. Racism kills and it is everyone’s business to make sure thatwe stamp it out. Source: Mental Health Today

1.2 Human Rights – The Use of Physical Restraint
Mental health campaigners fear that the use of physical restraints can cause patients physical harm or revive painful memories of the trauma that many have suffered in childhood: ‘Restraint by its nature restricts a person’s liberty, but the frightening, overwhelming and traumatising nature of this experience can amount to degrading treatment, which is never lawful. …The over-reliance on restrictive practices in services can create a toxic culture characterised by the cycle of trauma for both staff and patients. It is also important to remember that many of the people who come to be in a position where they are restrained may already have a history of trauma and this experience can be re-traumatising.’
Professor Joy Duxbury, Professor of Mental Health MMU, Chair of the Restraint Reduction Network

In 2016-17 patients in mental health units were physically restrained by staff more than 80,000 times. 10,000 who were held face down or given injections to subdue them. Chemical restraint was used on another 8,600 occasions (NHS data)
The data indicates that women and black people are disproportionately affected:
Girls and young women under the age of 20 were the most likely to be restrained, each being subjected 30 times a year on average to techniques that can involve a group of staff combining to tackle a patient who is being aggressive or violent.
Black people were three times more likely to be restrained than white people, according to the first comprehensive NHS data on the use in England of such techniques. Digital NHS

1.3 Inequalities in Physical Health
The Lancet Psychiatry Commission 2019 noted that the drastic physical health challenges which contribute towards a gap in life expectancy of around 20 years, people with mental illness could be regarded as a ‘human rights scandal’.
The Commission found that a broad range of mental illnesses are associated with obesity, diabetes, and cardiovascular disease, which contribute towards the lower life expectancy of people with mental illness. Key risk factors include higher rates of smoking, sleep disturbance, physical inactivity, unhealthy diet, the side effects of many psychiatric medications, and a lack of access to adequate physical healthcare.
Recommendations include adopting an ‘early intervention’ approach towards protecting physical health and the provision of lifestyle treatments targeting a range of behaviours, such as physical activity and healthy eating. Alongside this, the Commission calls for better integration of physical and mental healthcare, and evidence-based use of psychiatric and cardio-protective medications for people with mental illness.

1.4 The Manchester crisis in ‘Stepping Down’
Historically, people with ‘severe and enduring’ mental health needs, including those with conditions such as schizophrenia, have been treated in the long-term by mental health professionals. Recently the charity Manchester MIND reported that an increasing number of such patients are being handed over to the care of their GP in Manchester.
Many felt they were discharged for non-medical reasons, including missed appointments, using the service for too long and insufficient resources. Some said a shift in treatment has had a detrimental impact on their lives. One person said: “There is a rolling back of adult mental health services for those of us with severe enduring diagnoses who need ongoing support.”
“The medical model has been superseded by the recovery model which is all about how we live best with our illnesses, but the recovery model is being used in a way that is destroying quality of life for most service users.”
“We can’t live full lives because we are terrified of becoming ill as we don’t know what we will do on our own.”
Many complained of losing benefits, housing and community support as a result of being stepped-down. Paul Reed, mental health campaigner and chair of the Manchester User’s Network: “It’s a damning report which shows that something needs to be done.
The Greater Manchester Mental Health Trust did not wish to respond to the findings of the report. Stepping Down Report

1.5 Emergency Care
Research conducted in 2020 with approved mental health professionals, responsible for administering the Mental Health Act asked why they felt detentions were rising and what they believe could be done to reverse this trend. Their response was the need for investment in hospital alternatives to alleviate the pressures of:
A significant increase in demand for mental health services which has vastly outstripped supply.
A lack of resources and investment within mental health services at both ends of the spectrum. AMHPs felt there were fewer preventative services, such as day centres and support workers, which help people with mental health problems to stay well, but also inadequate provision at the acute end of the spectrum, such as well-resourced crisis services.
An increase in the social stresses faced by people – such as difficulty accessing benefits and problems associated with housing, addiction and social isolation – which is felt to be having a considerable negative impact on the mental health of the population and consequently increasing demand on mental health services.
A lack of viable alternatives to hospitals to serve as ‘places of safety’ for people experiencing mental health crises
The Nuffield Trust found a higher rate of preventable emergency admissions for people with mental ill-health before the pandemic. In 2013/14, it had 3.2 times more A&E attendances and 4.9 times more emergency inpatient admissions.
The Nuffield report found a correlation between deprivation and emergency care use, with the most deprived people with mental ill-health visiting A&E 1.8 times more than the least deprived in 2013/14. The care provided at A&E is also not consistent or a long-term solution, and could lead to multiple admissions.

1.6 Covid – 19:
The impact of Covid 19 on health, including mental health is here to stay for the medium term. Emerging evidence suggests that there are clear inequalities between the mental health impact on women and young people
The impact on the physical health and survival rates for BME communities are already well known. Details of the impact on mental health are still being assessed.

The combination of existing structural inequalities and the unequal impacts of the pandemic mean that people whose mental health was at greatest risk prior to Covid-19 are likely to bear the brunt of the emergency longer term. These include those with existing mental health problems, people with long-term physical conditions, women and children experiencing violence and abuse, and Black, Asian and minority ethnic communities. Poverty and financial precariousness, racism and discrimination, trauma and isolation have all been heightened at this time. There are emerging indications of the possible widespread neuropsychological implications of the disease.

All indications suggest that we need to rethink our mental health system to be able to cope. Mental health advocate and peer support specialist Chrissie Hodges said the finding therapists who do specialised treatment at an affordable rate have been exacerbated by the pandemic because of redundancies and furloughs. Under the current system, specialist care can only be accessed through a GP referral, and it comes with notoriously long waiting lists which can cause people to deteriorate further.

2. A Different Way?

In the Care Quality Commission Report 2018 on services in Manchester and the overuse of the Mental Health Act it states that, “Patients, carers and staff – from both providers and commissioners – agreed that a greater focus on early intervention and intensive support in the community had the greatest potential to reduce admissions to hospital and likelihood of using the Mental Health Act”.

We believe that to improve mental health services in Greater Manchester it is imperative to address the economic and social conditions for people with severe mental problems which in itself may reduce what are usually perceived as symptoms of “illness” and “disorders”, just as “Housing First” has proven to be the most important stepping stone in recovery processes. We believe that combined with new ways of working with people with mental illness such as the Hearing Voices Approach and “Open Dialogue”,we can create a much better solution for communities than the one proposed by GMMHT. It can be a service founded on the need to support people through partnership and community, by building trust and connection and while addressing inequalities and human rights,

2.1 A Paradigm Change? Alternative Crisis Service models for adults
The WHO QualityRights tool kit provides countries with practical information and tools for assessing and improving quality and human rights standards in mental health and social care facilities. The Toolkit is based on the United Nations Convention on the Rights of Persons with Disabilities. It provides practical guidance on:

the human rights and quality standards that should be respected, protected and fulfilled in both inpatient and outpatient mental health and social care facilities;
preparing for and conducting a comprehensive assessment of facilities; and
reporting findings and making appropriate recommendations on the basis of the assessment.
The tool kit is designed for use in low-, middle- and high-income countries. It can be used by many different stakeholders, including dedicated assessment committees, nongovernmental organizations, national human rights institutions, national health or mental health commissions, health service accreditation bodies and national mechanisms established under international treaties to monitor implementation of human rights standards and others with an interest in promoting the rights of people with disabilities.

The WHO QualityRights tool kit is an essential resource, not only for putting an end to past neglect and abuses but also for ensuring high quality services in the future.

We would also like to draw your attention to alternative service models for adults such as those being developed and implemented by Hywel Dda University Health Board and Aneurin Bevan UHB in Wales. Other services in the UK that include planning for alternative models are found in Cornwall, Plymouth, Hertfordshire, South London and Maudsley, Tees, Esk and Weir Valley Mental Health Trusts. They are adopting or seeking to adopt a Local Community Mental Health Centre Model (with residential crisis support on site) as an alternative to a large single site hospital.

These services have learnt from the Trieste Mental Health Department, in Italy. Trieste has run a successful community mental health service without traditional psychiatric beds for 40 years.. The Trieste Mental Health Service has four 24/7 Community Mental Health Centres which provide whole life services to the local communities including crisis beds. This is an alternative to traditional in-patient units in that they provide a comprehensive service available to all people with mental health issues from one centre. Critically it also ensures work and purposeful activity through employment by a wider range of social co-operatives.

“The World Health Organization has recognised the system in Trieste, Italy, as a global best practice of mental health care. It’s built upon managing the aspirations of the whole person, tapping into family support, facilitating social inclusion and believing in the human right to a purposeful life. After closing their 1,200-bed asylum in 1980, the citizens of Trieste created a community-based system of care to integrate people back into their neighbourhoods. Their culture of mutual respect and protection of human dignity is breathtaking. In Trieste, police are not the first responders to a mental health crisis; psychiatrists come to the scene and situations are diffused with less trauma to all involved. Involuntary hospitalisation is rare. The city, with a population of 240,000, has only six psychiatric hospital beds, and they are in an unlocked ward where attending staff wear plain clothes. The community mental health centres collaborates with its users to create life plans that lay out goals for work and social activities.”

The UK based International Mental Health Collaborating Network (IMHCN) has been a partner with the Trieste Department of Mental Health for the last 25 years and has been instrumental in promoting this model of service throughout the country and abroad (currently: HLos Angeles County, USA, Praha, Czech Republic, CH01 Health Region, Ireland). As such they have developed a whole system acute and crisis approach (see below). The UK services twinned with Trieste, carry out service visits and exchanges to learn from each other.

The good practice and experiences of the IMHCN came from de-institutionalisation processes and practicalities, that not only downsized but even closed psychiatric hospitals, undertaking a complex process of removing the ideology and power of the institution by putting the person first – with his/her subjectivity, needs, life story, significant relationships, social networks and cultural/social capital – above the institution.

In order to do this it is necessary to remove the power of institutions over people with mental health problems. This requires a shift of resources from hospitals to a range of community based services founded on the whole life needs of the person. Such an approach opens pathways of care that integrate social and health responses and actions.
IMHCN as a collaborating network brings together people, places, services and practices that have been successful in developing good quality community mental health, with those that are in the process of implementing change. With the support of a continuous learning collaboration, organisations and individuals can benefit from others’ experiences. The mission of the IMHCN is to promote and advocate for the human rights of people with mental health issues; to understand and gather the experiences and knowledge of good practice in community mental health from its membership and to disseminate this rich resource throughout the world. Manchester can benefit from tapping into such a network to build a better service.

Power Threat Meaning Framework: A group of senior psychologists and high profile service user campaigners spent five years developing the Power Threat Meaning Framework as an alternative to more traditional models based on psychiatric diagnosis. The Framework applies not just to people who have been in contact with the mental health or criminal justice systems, but to all of us. It summarises and integrates a great deal of evidence about the role of various kinds of power in people’s lives, the kinds of threat that misuse of power pose to us and the ways we have learnt to respond to those threats.
The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour, whether it is confusion, fear, despair or troubled or troubling behaviour. It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity. “
In traditional mental health practice, threat responses are sometimes called ‘symptoms’.
The Framework instead looks at how we make sense of these experiences and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt. The approach of the Framework is summarised in four questions that can apply to individuals, families or social groups:
What has happened to you? (How is power operating in your life?)
How did it affect you? (What kind of threats does this pose?)
What sense did you make of it? (What is the meaning of these situations and experiences to you?)
What did you have to do to survive? (What kinds of threat response are you using?)

Two further questions help us think about what skills and resources people might have and how they might pull all these ideas and responses together into a personal narrative

What are your strengths? (What access to Power resources do you have?)
What is your story? (How does all this fit together?)
British Psychological Society (2020)

2.2 Making Best Use of Mental Health Funding – a false economy investing in a large inpatient unit that has a limited shelf-life?
We have been here before. In the 1980s the old Central Manchester Health Authority (CMHA) was based at Manchester Royal Infirmary. Historically CMHA had in-patient services provided first at Prestwich Hospital, then when the new service was set up, the old North West Regional Health Authority leased inpatient services from Cheadle Royal Hospital. Psychiatric Day Hospital facilities were provided at a new build, the Rawnsley Building, on the MRI site. Following on from this, in the late 1980s a new 80-bedded in-patient unit was commissioned and built adjacent to the Rawnsley Building, to replace the service provided at Cheadle Royal.
There was opposition to this proposal, with many people arguing that there would be no need for such a large number of beds if more resources were placed in the community. The Edale unit no longer exists.

Profit making Companies: In Manchester, patients have a 50:50 chance of being admitted to a privately owned hospital and a one in four chance of the bed being provided by an American-owned company, according to research by Candesic, a healthcare consultancy. Source: Financial Times, November 2019

2.3 Research and action
Within Greater Manchester we have strong mental health action research potential:
The National Institute for Health and Care Excellence (NICE) recommends talking therapies, like family intervention, to treat schizophrenia and psychosis. However, Sub-Saharan African and Caribbean people, including people of Mixed heritage, are not usually offered talking therapies.A research team led by Professor Dawn Edge at The University of Manchester pilot-tested a new talking therapy, Culturally-adapted Family Intervention (CaFI), with Caribbean families. People diagnosed with schizophrenia, and their family members, liked CaFI. They thought it helped them better cope with the illness. However, the study was too small to see if the therapy really works. CaFI was originally for families of Caribbean origin only. Now, people of Sub-Saharan African and Caribbean heritage can take part. This includes people who identify as Black British or Mixed heritage. Dawn says: ”Working closely with community members to co-produce culturally-appropriate interventions is an important part of reducing stigma and fear of mental health services. Building service users’ trust in the system and practitioners’ capacity to work cross-culturally are key to improving access, experience and care outcomes.”

The Psychosis Research Unit (PRU)
The Psychosis Research Unit based in Greater Manchester promotes a normalising approach to understanding psychosis. They believe experiences and beliefs commonly regarded as symptoms of psychosis are often highly understandable reactions to adverse life events. Their primary aim is to develop ways of reducing the distress of people with these experiences, as well as developing ways of restoring their autonomy and dignity. They have a strong emphasis on the involvement of service users and people with lived experience of psychosis in the development of research questions and in the design, conduct and dissemination of research studies, including clinical trials.

2.4 Direction of Travel

Redefining Priorities: A Paradigm change in understanding people’s mental health needs;

  • we fundamentally need to shift from only considering and responding to a diagnosis, towards a whole life approach
  • we need to end of the infringement of people’s human rights in the name of care and treatment, by addressing social exclusion and discrimination, and eliminating coercive practices.
  • we need to establish a Societal Whole Systems and Responsibilities through establishing and then sustaining community partnerships and social networks

Transforming Services
We need to transform service responses so that they are;

  • Underpinned and structured by a Human Rights approach
  • Based on a person’s life story, their circumstances and their whole life needs
  • Led by “bottom up and top down” parallel change processes inspired by “people” for “people”
  • Evidenced by increased resources for community services by redistributing existing resources away from hospital-based services
  • Evidenced by increasing Investment in the development of community mental health
  • Driven by a focus on the recovery/discovery approach – emphasising hope, emancipation, equality, connection and continuity
  • Based upon a trauma informed care approach that is based on life stories and needs
  • Encourage moving away from the conviction/emphasis on mental illness to the true meaning of mental health.
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