A while ago I talked to a friend, a psychiatric nurse, about his ideas for the future of mental healthcare. I mentioned the national service framework, the promised funding and the expected reforms.
My friend's response was neutral and low-key, as if it didn't affect him.
He explained that his trust had changed names three times in five years, services had been constantly reconfigured, protocols had been developed, managers had come and gone, and none of it had made any difference to him. He just went on seeing the same patients, working under increasing pressure - which he largely blamed on bureaucracy. He was pretty fed up with it all.
I thought of him in a recent meeting when we discussed how to improve staff morale. Managers had opinions, users knew what to do, but practitioners, the few who were there, kept quiet. They probably believed no one would have listened anyway.
These experiences may well reflect how the NHS is perceived by its clinicians: constant change at a structural level, leading to increased demand and bureaucracy but little opportunity to influence the process.
The government's recent consultation exercise brought out an attack of raw cynicism in my friend. We seem to have bred a group of disempowered and demoralised staff.
This is worrying for at least two reasons. First, it is likely to reflect on recruitment and retention. Second, we depend on this group of staff to implement most of the changes strategists think up.
As it stands, we are already facing serious recruitment problems. In psychiatry, 14 per cent of consultant posts are vacant or filled by locums, and more than 80 per cent of trusts found it difficult to recruit or retain nursing staff. Problems are particularly severe in inner cities and for low-status and demanding jobs such as inpatient wards. Numbers applying for nurse and social work training courses are declining. This is partly explained by a shrinking supply of school-leavers, an increasing number of whom are entering higher education. I also wonder whether the public sector has lost much of its attraction.
Meanwhile, mental healthcare is fast becoming more complex, diversifying into an intricate system of services such as assertive outreach, early intervention, liaison, intensive care and a range of secure options.
Each of these elements requires a supply of skilled staff. Whereas it takes some 12 years to train a doctor, and at least three for a nurse, targets as they stand are for an additional 170 assertive outreach teams and 250 secure beds by next April.
The promised new money and anticipated reforms will create further demands and expectations.
Assuming that mental health will receive 10 per cent of the NHS's extra£2bn a year, and 50 per cent will be invested in new staff, around 5,000 people have to be recruited each year, mostly into specialist functions.
While new staff are crucial, demands on the existing workforce are massive. The gap between what we know as best practice and what is available remains vast because new evidence constantly demands incorporation. The evolving modernisation of mental healthcare has meant that roles and skills need constant reviewing.
Take doctors and nurses.
Psychiatrists are overwhelmed by their comprehensive clinical catchment area responsibilities and medical officer status. Then there's training, research, supervision and management. Nurses suffer from severe role ambiguity, increasingly taking on medical as well as social roles. And much of the work of both groups is inefficient. For example, it is a waste for nurses to queue at benefit offices, or for doctors to assess every referral or undertake routine home visits. Even though it may be impractical, someone will have to do it.
The simplistic solution is for everyone to move up a step, potentially to their level of incompetence. Doctors are to become super-specialists, and nurses are supposed to take over many of the doctors' roles. Anyone available on the job market would be recruited to do the boring bits, with a few days' training thrown in. Don't misunderstand me: I am a strong supporter of breaking down professional barriers, but this should not take the form of a naive belief in general competence - or worse, the idea that mental healthcare is simple .
Psychiatry is judged as a low-tech area, very different from surgery and especially intensive care and, in these technology-obsessed days, with a status to match. Intricate interventions, such as cognitive behavioural therapy or the many techniques necessary to treat complex clients, all requiring years of training and personal investment, are poorly respected and therefore insufficiently supported . Nurses want to be respected as nurses and allowed to excel in that role , not to be pitied as second-class doctors. I suspect that this is what frustrates my friend most .
After a recent lecture, I was asked what single solution would make most difference to mental healthcare.
I still cannot answer that question, because I do not believe there is one magic bullet. It will be about hard work on a number of fronts, but, crucially, all will have to involve existing staff. If we show them respect, and involve them in decisions on how to develop and apply their skills, morale will improve, and then recruitment and retention. I know it will not be achieved by next year, but some progress will be made in five years' time.
Maybe the persistent delusion of that magic bullet cleanly hitting the bull's eye of structural change has hindered us from facing the reality. We have created a mess which practitioners have to tread through, and we now need to get on with cleaning the stables.
Volunteers please; not much training available.