A chap telephoned a while ago to ask if he could start treatment but not finish it. It made good sense at the time — after he had explained it, that is — but things worked out rather differently than expected.
He had developed quite severe symptoms that meant he could not work, so he went to his GP, and his GP referred him for CBT in the NHS.
Now the NHS at that time and in that place had a waiting list of several weeks, and this chap did not feel he could afford to be away from work. So he reasoned that he would be better off in the long run paying for a little private therapy to start with, and then transferring to the NHS to complete his treatment. See? It makes good sense.
Is CBT like that? Can you start with one therapist and continue with another? I thought it was worth a try.
Part I — Assessment
When he turned up for assessment it looked like the plan was working. He had been offered an NHS appointment in only a couple of weeks.
His assessment went well. The formulation (the explanation of his problems in terms of CBT theory) seemed straightforward, and he was enthusiastic about the CBT approach. He arranged to fit in just one more private session before the start of his NHS treatment.
So the session came and went, a letter was sent off to his GP, and that was that.
But not quite. He telephoned again.
His NHS appointment turned out not to be CBT after all. He saw a — well, no one seems to be clear who or what he saw. Whoever it was asked some formal questions that did not touch on his particular difficulties and said he would be contacted again in a couple of weeks with regard to his CBT assessment. So this interview was not itself a CBT assessment, and certainly not the start of any kind of treatment.
But by now he had made a promising start with CBT, and it would be foolish not to continue, so he asked if he could have just a couple more sessions while he was waiting for his NHS appointment in just a few weeks.
His next couple of sessions resulted in marked improvement. He worked on the underlying issues that had come to light in his assessment, following up on his homework tasks with increasing determination and insight, and he was ready to tackle the presenting symptoms that had been keeping him from working. This was an opportune time for the NHS to take over and complete his therapy.
So another letter was sent off to his GP, and that was that.
But not quite. He telephoned yet again.
His second NHS appointment turned out to be much the same as the first, but with a different (though equally mysterious) person. Actual CBT treatment in the NHS was still “just a few weeks” away. It was at this point that he gave up on the NHS and decided to complete his treatment privately.
Three more sessions saw him symptom free and back to work. Underlying issues that had dogged him for decades had been cleared up along the way. The total cost to him was less than the earnings he would have lost if he had waited for NHS treatment.
Why does this happen? We have all been taught the knee-jerk response, which is to say that the NHS is short of resources (meaning money). But is that how an organisation that is short of money really behaves?
Rationally, shortage of money should be expected to affect an organisation’s staffing and the focus of its work. It’s easy to work out what effects to look for.
Imagine an organisation that has sufficient money and treats a certain number of patients a year. Now imagine that its budget is cut. It now has too little money to treat all those patients. What will it do?
Will it employ extra low-grade staff to delay treatment by conducting pointless interviews? How does that help it to operate within a restricted budget?
It’s true that by delaying treatment a few patients will give up, paying for private treatment or committing suicide or whatever. But the numbers will be small. And the delay will make the remaining patients harder to treat. Overall there’s no cost saving in delay.
The theory that delays and ineffectiveness in the NHS are the result of shortage of money just doesn’t hold water. Organisations that are short of money don’t behave like that. When an organisation hires sub-professional staff and pads out its processes with ineffective steps, that’s a sign that it has too much money, not too little.
Organisations that are genuinely short of money reduce their staff and retain only their most effective people. They cannot afford to do anything else. Organisations that are over-funded can afford to hire staff who are not really effective, and whom they don’t really need.
Now imagine that same organisation again and think about the number of patients it treats. When its budget is cut, what will it do?
Will it expand its operations, accepting additional referrals of people it would not previously have treated? Or will it contract its operations, becoming more focussed on the patients it can make the most difference to?
Organisations that are genuinely short of money have strict boundaries so that they focus their activities where they can be most effective. They cannot afford to do anything else. Organisations that are over-funded can afford to expand their operations and dabble in areas where they are not very effective.
The NHS approach to mental health often seems to exhibit tell-tale signs of over-funding. A post by blogger Dr John Crippen last week is just one of many lamenting the dumbing down and incompetence within the NHS: Caring for the mentally ill: you get what you pay for
To me, the impenetrable layers of sub-professional staff that he describes are a clear indication of what is wrong.
And yesterday’s Department of Health announcement of “further action to target credit crunch stress“, promising even more money and even less focus on actual illness, backs it up.
It’s ironic that the more money the government prints and throws at the NHS, the more it dilutes the professionalism of NHS staff, and the more it blurs the boundaries of illness, the more easily it can be overtaken by simple, effective treatment in the private sector.