How to profit from NHS-funded torture and neglect

[Zetetic]

LD an abbreviation could mean learning disability or learning difficulty (two different things in your mainstream usage)

There's no such thing as "learning difficulty nursing" in the UK.

[TrenterPercenter]

By contrast, getting to the end of the first actual page of content in England's "Implementing the Five Year Forward View" document (for example) makes it exceedingly clear that "releasing savings" from within the health system is a fundamental part of the transformation being demanded, and the cash it requires.

This comes back to - I think - that you and I might see that this competition for resources is unnecessary and a consequence of ideological commitment to overall underfunding. I think we are on the same page there.

However, that doesn't change the prevailing ideological stance, and the common assumptions bound up with that.

No that is your (very poor) interpretation of what is being said.  Just because Early Intervention saves moneys does mean long-term care should be underfunded.

As I keep saying this is something you've made up and I don't know why but perhaps it is something to do with your psychiatry/medical model interest and the fact this is being challenged.

[Zetetic]

It doesn't matter about funding pots

Up there with "No one in the UK is left behind".

that is a distraction to the point I was making.

You were the one who brought up budgets!

[TrenterPercenter]

There's no such thing as "learning difficulty nursing" in the UK.

Right sorry I missed the fact you said nursing, a mistake not a conspiracy.

[TrenterPercenter]

Up there with "No one in the UK is left behind".
You were the one who brought up budgets!

Pedantry.  I think most people can see that cancer prevention and cancer treatment have a symbiotic relationship with each other - not rocket science.

[Zetetic]

Just because Early Intervention saves moneys does mean long-term care should be underfunded.

No, but in the context of an effectively fixed budget, then paying for early intervention (etc.) has to involve drawing resources away from long-term and acute care.

The optimistic view is, of course, that the latter still ends up better off because the former reduces demand sufficiently to more than compensate for the yet-more constrained capacity.

(This optimism isn't limited to mental healthcare of course.)

[Zetetic]

PI think most people can see that cancer prevention and cancer treatment have a symbiotic relationship with each other - not rocket science.

But we don't try to pay for one with savings from the other, and certainly not from one funding cycle to the next.

(Partly because the actual resources involved in delivering either one are very obviously largely non-fungible with each other. Contrast with mental health nursing, for example.)

[TrenterPercenter]

But we don't try to pay for one with savings from the other, and certainly not from one funding cycle to the next.

Can i get some evidence here.  I talking a graph/chart in which inpatient care is retrospectively paid for out of early intervention budgets.

Don't forget to factor in all the people that do not enter longterm care due to Early Intervention either.

[Zetetic]

"A common theme across many objectives is of building capacity within community-based services to reduce demand and release capacity from the acute sector and in-patient beds"

"A combination of the different activities to deliver transformation... with savings to reinvest in local mental health services."

"Investment to pump-prime .. should further release money currently within the specialist commissioning budget"

"These plans will include locally agreed trajectories for aligning in-patient beds to meet local need, and where there are reductions [Ed. LOL] releasing resources to be redeployed in community-based services"

"Further monies are also expected to be released following the closure of in-patient beds for people with a learning disability and/or autism in
order to develop community services, as part of implementing Building the right support"

None of this is even slightly ambiguous. There's no reason for it to be ambiguous - the agenda is entirely open and widely supported and has been since Ely.

Don't forget to factor in all the people that do not enter longterm care due to Early Intervention either.

The optimistic view is, of course, that the latter still ends up better off because the former reduces demand sufficiently to more than compensate for the yet-more constrained capacity.

And so we come back to the mantras - the problem with capacity for the seriously unwell is that we haven't slashed it enough to pay for the services that will reduce demand for it!

[TrenterPercenter]

"A common theme across many objectives is of building capacity within community-based services to reduce demand and release capacity from the acute sector and in-patient beds"

"A combination of the different activities to deliver transformation... with savings to reinvest in local mental health services."

"Investment to pump-prime .. should further release money currently within the specialist commissioning budget"

So no evidence then.  You are interpreting this in a ridiculous way. This does not mean taking money away from long-term care ffs it means people that don't need longterm care will not need to be funded for the longterm care resource they are not getting.  It's like you don't just want extra funding for longterm care you specifically want it from prevention budgets.  It's bizarre.

The semblance of point here isn't a difficult thing to communicate either we can talk about the underfunding of care and budgetary holders using efficiency savings as excuses for underfunding but you've decided to make this about some made up competitive aspect of prevention vs longterm care.  It's not a good approach and like I say I can only see someone with an axe grind for some reason (being pro-med, pro-psychiatry) taking that approach.

[Zetetic]

So no evidence then.

I'm quoting from an NHS England policy implementation document.

You are interpreting this in a ridiculous way. This does not mean taking money away from long-term care ffs it means people that don't need longterm care will not need to be funded for the longterm care resource they are not getting.

This isn't how healthcare resourcing work though, much though the internal market fantasists wanted to believe otherwise in the 2000s. You can't actually save money (and more importantly, redeploy tangible resources) by simply reducing demand - you can only do it by getting rid of capacity. Having fewer admissions or shorter lengths-of-stay doesn't actually save any money or give you any more staff unless you get rid of beds (and everything that should go with them).

(Edit: And another punchline is that even when you've tried to farm out all your really seriously unwell people to private providers, you still don't get reliably sustained savings by reducing admissions to their services! Not least because they're close to a cartel.)

So, let's be generous and assume that there's some pump-priming or invest-to-save cash - whatever you want to call it - upfront to setup whatever services are supposed to reduce demand for acute services. Let's be really generous, and assume it's for three years - that means three years to get rid of some of those acute services. Not to reduce demand, not show that you could reduce capacity (and keep those services as shit as they were already) - you need to get them gone, because at the end of those three years you need the money available in your budgets to keep these new services alive.

(Edit: And I know that sometimes they don't keep the new services alive - even when they are helping people, and reducing the demand that these people are placing on other services. I don't think that's a good outcome either!)

It's like you don't just want extra funding for longterm care you specifically want it from prevention budgets.  It's bizarre.

No, no. I didn't write that policy implementation document.

I don't want them to compete for resources. I don't want to pretend that cuts to acute services are justified by reinvesting those 'savings' upstream.

[TrenterPercenter]

This isn't how healthcare resourcing work though, much though the internal market fantasists wanted to believe otherwise in the 2000s. You can't actually save money (and more importantly, redeploy tangible resources) by simply reducing demand - you can only do it by getting rid of capacity. Having fewer admissions or shorter lengths-of-stay doesn't actually save any money or give you any more staff unless you get rid of beds (and everything that should go with them).

(Edit: And another punchline is that even when you've tried to farm out all your really seriously unwell people to private providers, you still don't get reliably sustained savings by reducing admissions to their services! Not least because they're close to a cartel.)

So, let's be generous and assume that there's some pump-priming or invest-to-save cash - whatever you want to call it - upfront to setup whatever services are supposed to reduce demand for acute services. Let's be really generous, and assume it's for three years - that means three years to get rid of some of those acute services. Not to reduce demand, not show that you could reduce capacity (and keep those services as shit as they were already) - you need to get them gone, because at the end of those three years you need the money available in your budgets to keep these new services alive.

As I've said you are talking about something else, you are approaching this problem the one you outline here wrongly in going on about Early Intervention.  Of course you save money by reducing demand and need but you are talking about some funny business which isn't the responsibility of EI or preventative models of care.  You are also looking at cost savings from a purely acute bed situation and not cost savings (as is worked out in EI health economics) over a much broader section of societal resources.

Regardless, trying privatise the NHS by stealth is not the fucking fault of Early Intervention so stop going on about it in this sense.  I'm not going to disagree with you regarding underfunding services to privatise them (my point has always been this) - you just need to focus on that and stop dragging unrelated aspects into it. 

I don't want them to compete for resources. I don't want to pretend that cuts to acute services are justified by reinvesting those 'savings' upstream.

As explained try working on how you communicate that and I'm sure you'll find a lot of support for that across the mental health sector.

[TrenterPercenter]

I'll just add to try and move things on and perhaps trying to exemplify the problems here - approximately 2 million under 21 year olds will go untreated for likely mental health disorder over the next year. 

What do you want to do about that? You cannot hire enough specialist staff to deal with this level of need, going on about longterm care isn't going to solve this problem, denigrating EI isn't going to solve this problem, putting them in inpatient wards is utterly wrong, oh and buying them all a house is just ridiculous.

What is a real workable solution you might consider to this?

[Zetetic]

Of course you save money by reducing demand and need

Whose money? The commissioner?

If they were commissioning an NHS-provided service to meet that demand, that service now needs to go. That money went on capacity for that service.

If they were commissioning a private service, that service puts up its prices for the remaining demand (citing increase acuity, if they like). If you're the financial director of Cygnet, you don't kneel before Hiriam J. Pipersucker XIII's throne of skulls in UHS's HQ in King of Prussia, PA, and tell him that revenue and profit are down because @TrenterPercenter has been too good at intervening on England's youths.

(In reality, the situation is actually much worse because of how vastly oversubscribed every service is at this point - from Rampton down, and out into the community. Any freed up capacity in pretty much any service is rapidly overtaken by suddenly revealed suppressed demand, unless you get the knives out ASAP.)

You are also looking at cost savings from a purely acute bed situation

Because this is what is translated into forcing a competition for resources between acute and preventative services.

and not cost savings (as is worked out in EI health economics) over a much broader section of societal resources.

Because these don't factor in health budgets.

Yes, I know if you huff enough of the right think tank's emissions then you can begin to imagine that you're getting all these would-be-mad people into high-productivity jobs (best not think about this) and all the taxes that they're paying (best not think about this) are going back into the NHS (best not think about this).

To be clear, I really do believe that early intervention is the right thing to do. I also believe that it reduces the demands that people place on other services and avoids wasting the potential of human lives that might otherwise be ruined. There is no disagreement between us here.

trying privatise the NHS by stealth

I don't think that's what's motivating this move. That's not the ideological stance that I've referred to in this thread.

[Zetetic]

What is a real workable solution you might consider to this?

Honestly? I'm desperately trying to work out something I can pretend to myself that I believe in. Not just for mental health, or MH&LD, but the whole service.

(Ideally by next Tuesday. Trying to keep my sick leave under two weeks for a few reasons.)

I do think that a next step, again not just for mental health, has to involve a degree of radical honesty and part of that is being realistic about what 'transformation' in existing budgets means.

[TrenterPercenter]

Had to go out but I agree with much of that is here.  Will try and give a more complete answer tomorrow.

(Ideally by next Tuesday. Trying to keep my sick leave under two weeks for a few reasons.)

Oi you look after yourself Z sorry I'm a prick very passionate about this stuff even though it is a nightmare and of course make a lot of us ill ourselves working in this area (not to mention of course lots of us drawn to it from our own problems and the idea of trying to 'fix' oneself and others).  Anyway sorry to hear you are unwell ignore my gnashing I'm a pillock I can see your point on this now and it comes from a good place mate.

[Sebastian Cobb]

I didn't know if this was more appropriate in here or the discussions around workplace healthcare but opted for here as I suspect this thread is slightly more broad and intended to have a longer lifecycle.

https://12ft.io/proxy?q=https%3A%2F%2Fwww.ft.com%2Fcontent%2Fdbf166ce-1ebb-4a67-980e-9860fd170ba2
bleak

[Zetetic]

If we are topic-policing, then here, maybe, @Sebastian Cobb :
https://www.cookdandbombd.co.uk/forums/index.php?topic=91398.msg4899138#msg4899138

(Since my point with this thread, two years back, was that it was about how we've ended up privatising a bunch of NHS-funded care because we - somewhat deliberately - no longer provide it in the NHS itself.)

[Sebastian Cobb]

Well at least this thread lines up with the chart then!

[Zetetic]

I'm very passionate about this stuff even though it is a nightmare and of course make a lot of us ill ourselves working in this area

Understood.

[Zetetic]

Well at least this thread lines up with the chart then!

I'm not sure I understand.

The FT piece is about people choosing to abandon NHS-funded care, for self-pay healthcare, because of the state of the NHS.

This thread is about people who are violently forced into privately-owned hospitals, paid for by the NHS.

[Sebastian Cobb]

Surely if you "somewhat deliberately - no longer provide [services] in the NHS itself." then along with people being forced into private-owned services via NHS funding, a side effect will be what happens in the above graph, if the private services do not fully encapsulate the previous services provided by the NHS?

[Zetetic]

The sort of services that I started this thread to talk about are (as they're currently run) mostly about containing and isolating people for the benefit of the wider population. You don't generally end up in theses place because you choose to, but because the state has decided that you need to be - forcefully - detained.

No one is self-paying to be locked up in a medium secure unit until they kill themselves. Many of these people aren't considered competent to make decisions about their own care.

I think that the issues of:
1) Handing state-funded involuntary 'care', for a small set of undesirables, over to for-profit providers.
2) People choosing en masse to buy healthcare elsewhere because the NHS no longer meets their needs.
are both important, but really quite different (and with very different drivers).

[TrenterPercenter]

The sort of services that I started this thread to talk about are (as they're currently run) mostly about containing and isolating people for the benefit of the wider population. You don't generally end up in theses place because you choose to, but because the state has decided that you need to be - forcefully - detained.

@Zetetic is correct here, whats more the manner in which you enter services has an influence on outcomes and recovery.  This is what Early Intervention is all about stopping people getting sectioned and in sad cases in which they do trying to ensure transition to inpatient care is as non-traumatic as possible.

I don't think it is quite a simple as saying "the state" wants because often it is families that are desperate and see sectioning as the only option, sectioning is also largely about safety for the individual.  People with MH illnesses kill themselves (and in rare cases other people) at much higher rates outside of inpatient units it's just we think it shouldn't happen on our watch (and that is of course correct).  Still you want to prevent this by treating early in the community and creating support networks for individuals at risk.  I've worked on big investigations into severe psychiatric disorders, reading through case histories of 1000s of people, I've only ever come across one person whose psychosis could be described as sudden, literally everyone else has a lead into their eventual psychotic breakdown (it is called the prodrome), we also know longer and more insidious a prodrome is the poorer outcomes are for people.

My point is that we do not need elements of the MH system being played off against each other, this does happen because cuts fall for people working in different parts of the service and there is a belief that this is because monies are being wasted on things like community projects (the reality is everyone has had cuts).  @Zetetic raises a really important point about long-term care which has made me think it has had very little presence in conversations and doesn't really have commentary in the awareness raising arena (but Owen Jones was doing this and I know from experience you have have an interface to raise issues and make changes).  My work is all at the other end, I'm there to stop people getting ill and then iller (but completely because of the reality of what happens next).  I don't see any contradiction here, in fact what needs to happen is awareness groups need to start talking about this - they are absolutely the kind of people that would be both a) good at this and b) passionate about it anyway.

Btw many moons ago now but my team and I took cameras into secure units to film and speak to the staff whilst at the same time creating a kind of service user rating system to build a publicly accessible commentary on how well these units were performing but guess what........it got cut.

This end of things is something that is very specific also to severe and enduring mental health conditions your psychosis, your eating disorders and your personality disorders, but you need to factor in not just what do we do with these people that received diagnosis of these illness but what happened to them and how did they get there in the first place - looking at illnesses in isolation is neither a solution or progressive treatment of humans - if we can prevent we should be preventing, if we fail in this attempt then suitable care must be available because recovery is still possible (it's all an extension of this paradigm not an atomisation of it).

A very good thing to do though is someone needs to get out there and start documenting the actual state of things.  People need visual information to the incredible poverty that some very ill people live in and alongside this the perilous state of inpatient care.  I'm absolutely not one for the breezy positive mental health approach (self-care has a massive place in treatment however due to it intrapersonal advantages - insight is one of the big predictors of recovery) these are real problems of infrastructure and policy.