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THIRTY YEARS IN THE NHS: A COMMUNITY PSYCHIATRIC NURSE’S VIEW

I will try not to make this too much about me, or about the patients, or even about psychiatry as such, but about the issues that I encountered regarding NHS policy and governance, during my thirty years as a psychiatric nurse. I can’t really give an insider’s opinion on the recent closure of NHS England, but I am sure that it will be beneficial to remove a layer of bureaucracy and hand back control to the front-line managers and Consultants. What I will talk about are issues such as community care, funding, management, and nurse education. The NHS’s problems are systemic and throwing money at it will not solve the problems by itself.

(By the way, by the time I started, we were supposed to call psychiatric patients “clients”. By the 2000s, “Users”, as in “Service Users” was the official term; presumably whoever came up with that idea did not know that drug users also call themselves “users”. I shall use "patients" in this account, for clarity).

I graduated from the University of Surrey in 1981 with a degree in Mechanical Engineering just as the country went into recession. In those days we had proper recessions, and I totally failed to find a job in Engineering. Admittedly that was probably also due to being rubbish at interviews, and having even worse dress sense than I do now. To cut the story short, I then spent six years in the university of life doing dead-end jobs, until 1987 when I was 28, when I started training as an RMN (Registered Mental Nurse). This meant going back to live with my parents, as a student nurse’s pay was even worse than the dead-end jobs. At least it was pay, not a grant or a bursary. I had been living in Cobham, Surrey, but my parents were in Beckenham, Kent, so I enrolled at Bexley Hospital. The School of Nursing was in the hospital grounds and took about ten students three times a year, for three-year courses. At least in those days we learned largely on the job, in various placements on wards or in the Community, divided by three-week stints in class. Later the training became university-based; that would have made the prospect less attractive for me as a mature student. I shall come back later to the subject of Nurse Education, as I believe it is one of the NHS’s self-inflicted problems, or at least government-inflicted problems.

Bexley Hospital, which by then was run by the Bexley and Greenwich Health Authority, was originally one of the old-style asylums. It had accommodated around 3000 patients in it’s heyday, but there were now about 800 due to the move to community care. But it was still in many ways a Total Institution, as defined by Goffman, and there were still patients there who had been there for decades. But I am glad that I got an idea of how institutionalised mental health care was done in the pre-community care days. If I had started a couple of years earlier I would have had to wear a white coat on the wards, but by 1987 ordinary clothes were allowed. Community Care for mental health patients had started in the 1970s; some mistakes were made at the time, but the system was gradually improving. Essentially, the advent of medication that could to some extent control the symptoms of mental illness, meant that there was no excuse for the old asylums where people stayed for their entire adult lives and came out in a wooden box. There are plenty of controversies around medication, which I don’t have time to go into now, but believe me the old days were worse. The Hospital is of course now demolished, and a housing estate has been built on it. The only part left is the Bracton Forensic Medium Secure Unit which is a much newer building, and I notice is separated from the housing estate by a very stout fence.

I qualified as an RMN in November 1990, and spent another 18 months as a staff nurse on an acute psychiatric ward, still in Bexley Hospital. Sometimes I was left in charge of the ward which was a character-building experience. In 1992 I moved to the Maudsley Hospital in Camberwell, and worked on a ward there for about a year. The Maudsley, which is home to the Institute of Psychiatry, had a reputation of being the top psychiatric hospital of the country. This reputation came from its status as being a leader in Research. I soon found that the standards on the wards were no better than at Bexley, and possibly worse. There were an awful lot of people, psychiatrists, psychologists and nurses who were determined to make a name for themselves in Research and have as little as possible to do with patients except as research fodder. I must stress that I am not against research, but there seems to be a whole industry devoted to it which feeds off itself.

However, I was lucky in that I then moved to a Maudsley community team, serving the Peckham Rye and Nunhead area. I had a brilliant and inspirational team manager, and two wonderful and dynamic Consultant Psychiatrists, who were great with the patients as well as being innovators in community care. Our patients were living in their own or their family’s homes, or in Group Homes if they needed a greater level of care. Unfortunately our Psychiatrists had to constantly fight the Maudsley establishment to progress their ideas. The Maudsley was still run by old white men, and our Psychiatrists did not fit that mould. One was female: Geraldine Strathdee; she found time to invite me to her home in Herne Hill for interview practice and career coaching. The other was a gay Asian man, Dinesh Bhugra. I am glad to say that they both went on to greater things; they are both now CBEs; Dinesh became Chairman of the Royal College of Psychiatrists, and he is on Wikipedia’s list of influential gay people.

In 1997 I moved back to what had been the Bexley and Greenwich Health Authority, which was now Oxleas NHS Trust, which later also took over mental health care in Bromley and Croydon. For the next 21 years, apart from some brief secondments, I was a Community Psychiatric Nurse in the Greenwich sector, which included Woolwich and Charlton so had some socially deprived areas. Like any job there were some difficult days, but I can say that I enjoyed most of it most of the time (apart from sitting in interminable meetings). I met some fantastic people: patients, colleagues, and not least, families. Families save the NHS and Social Services huge amounts of money by looking after very difficult relatives day and night for no pay, maybe just a Carers Allowance if they can get it. Of course all of us moaned about Oxleas management, but in fact it was a pretty good place to work for, judging by the horror stories I heard about other NHS Trusts. The teams that I worked for were all ok to great. Some of my managers and Consultants required careful handling: you had to be very sure of your ground if you were going to disagree with them, and be careful not to let them have genuine reason to be annoyed with you: but there were others who were brilliant and great to work with.

Community care is constantly evolving, and although it is criticised when something goes wrong, the systems and safeguards did improve greatly during my working life. The Care Programme Approach may create paperwork but it does ensure that patients are regularly reviewed and their care plans updated. Regarding IT systems: we went from having to carry bundles of paper files in brown manila covers in order to hand-write progress notes, to doing everything on-line, and in my last couple of years we even had iPads to carry around on community visits. Of course it felt as though the advent of online systems just generated more work. I probably spent at least a third of my time in front of a screen; I sometimes wondered if the only reason I was writing up patients’ notes was to cover myself if anything went wrong. If I factor in meetings, training sessions, travel, etc, I doubt if I spent even a third of my time face-to-face with patients.

Since about the late 1990s, and a lot earlier in some areas, the community teams for each Borough have been located in various buildings around the area, sometimes shared with GP practices. Acute psychiatric in-patient care is provided by each Borough having a psychiatric unit in the local General Hospital. These typically comprise about 100 beds in three or four wards, with the expectation that patients will stay about four weeks before being discharged back to the Community Teams such as mine. Let’s just say that there were several weeks over the next few years when Management told us that there were literally no spare acute psychiatric beds in the whole of the South-East! I know this is a simplistic answer, but I did think “Well, duh, Bexley Hospital had 3000 beds and you knocked it down!” If someone needed long-term care that could not be given in their own home, they were accommodated in Group Homes, which were typically converted houses or former Childrens’ Homes. The trouble with this was that as time went on these homes were increasingly owned by private companies, who could pick and choose which patients they took, so of course they chose the easy patients, so it became very difficult to place the difficult ones, who ended up blocking acute beds or making their family’s lives a misery. Furthermore, the funding for these came from the Local Authority, not the NHS, so when I wanted to place one of my clients, I had to attend a meeting of the Greenwich Placements Team and grovel for the money – or to use the proper term: make a case based on the patient’s needs – and it was by no means certain that this would be granted even though my Team had decided that this was the best plan of care.

Regarding Management: I never did rise higher than G-grade, which became Band 6, which is normally the highest grade for nurses giving face-to-face patient care. I had mixed feelings about whether I wanted to go higher, as any higher grade involved going into management rather than being a nurse, unless you could land a very specialist nursing role. I did try applying for management positions; partly for financial reasons and partly because there was an expectation that I should. In the old days of nursing, you were promoted not interviewed, and theoretically you were promoted for good work. Of course this was open to abuse; it helped if your face fitted and the Matron liked you. (A nurse was expected to resign if she wanted to get married; sometimes they were allowed to stay on if Matron liked them, but they always had to retire if they had children).  But the trouble with the current interview system is that everything hangs on your performance on the day.  Unfortunately, although my dress sense was better by this time, I remained hopeless at interviews, though possibly my ambivalence came through. I am sure there were managers who got where they were through having the gift of the gab, rather than being any good as managers. Only slightly better were the ones who were nice people but hopeless managers. But sour grapes aside, perhaps I was lucky. I was sometimes glad not to have the stress that my immediate manager was under, for not much more pay than I was getting. She was trying to cope with upwards pressure from problems that the team including me brought to her, and downwards pressure from senior management. I remember speaking to one senior manager who admitted that he went into management because he couldn’t afford to give his family a decent standard of living on a nurse’s salary. Another manager admitted that when a nurse goes into management they have to compromise their principles, because so many of their decisions are about finance and what we can afford to fund for each patient. I did have a six-month secondment at acting-H-grade (a role that I did succeed at interview for), and spent a lot of that secondment sitting in management meetings. Until then I had assumed that management was about making the right decisions for each situation and that a good manager always had an answer: but I then realised that management was all too often a group of people sitting round a table saying “What do we do now?!” The scary thing is that government is probably also like that!

I think I can say that I was respected in the team by the end of my career; I usually functioned as deputy to the team leader; I certainly became part of the furniture! But my problem was always money. Nurse’s pay has always been predicated on the historic assumption that nurses are single women dedicated to their job who live in nurse’s homes and have few extra expenses. Consequently, trying to raise a family on that kind of pay meant that we were getting deeper into debt: every time we went on holiday or had a major expense such as a new boiler, we racked up debt on credit cards and bank overdraft. No-one was knocking at our door, but it became clear that the only way that I was going to pay off this debt was by retiring and using my pension lump sum. Mental Health nurses are able to retire at 55; I stayed on until I was nearly 59 before taking this lump sum, but if they had paid me properly they might have got another couple of years out of me. However, I am glad that I retired before the Covid pandemic!

A couple more brief points. Nurse Education. As I said earlier, when I trained we were in small cohorts, in a school located in the hospital grounds; we were paid a salary, trained largely on the job and when we were on placements on wards we were included in the numbers of ward staff. Some of us in the Just Human Groupe were at the University of Surrey in the late 70s, and we remember that there was a degree-level nursing course there then: but that was way in advance of its time; it may even have been the first one of it’s kind. During the 1990s it all went that way: there was a nationwide change to University Education, using a scheme called Project 2000. The schools of nursing were subsumed into Universities; the Bexley and Greenwich School of Nursing became part of the University of Greenwich. Students were paid grants, and finished with a degree in Nursing, and the different branches of nursing – General, Mental Health, Learning Disability, all learned together, not specialising until half-way through the course. The first eighteen months of the nursing students course became almost entirely theory-based, in the University. When the students did go into ward placements, they were supernumerary, which was probably good as they were mostly completely clueless. All of this would have made it a less attractive prospect for me, as a mature student – going back to classroom and not doing a proper job for three years. Most mental health nursing students have done other work since leaving school, unlike most general nurses who are more likely to join straight from school, so returning to study on a student grant is something to think about very carefully. So for at least a decade the universities were sending out poorly trained nurses with a degree but no capability of working on a ward unsupervised. They had a lot of catching up to do, after qualification, often at the expense of the patients. Worse still, too many of them from overseas struggled to speak English. To be fair, the NHS did come to realise that there was a problem, and there was some degree of re-balancing as time went on. Around 2014 I was talking to a Nurse Tutor from the University who was very clear that too many sub-standard nurses had been turned out; and we had failed the public: so the above is not just my opinion! Throughout this time I was supervising student nurses on their community placements, and completing their assessments, and to be fair most of those who came my way were well aware of the shortcomings of the system and were ready to learn. But in about 2016, the government decided that rather than give grants to student nurses, they would have to pay for their course fees and receive a student loan, like any other student. Fine for business or law students, who can expect to earn enough to pay back those loans and fees, but surely not for students entering a low-paid profession doing a job that the country desperately needs. What next: are they going to make Police Officers or soldiers pay for their training? Surprise, surprise, the NHS’s recruitment and retention problem has got worse! Nursing is an ageing profession, and I felt quite guilty about retiring!

Just one more point: Why do white English people not like doing practical jobs? Which means that they have to recruit immigrants to do those jobs and then they moan about immigration and multi-culturalism! Traditionally, the staff of the lunatic asylums were from Ireland. Once even that source started to dry up, as far back as the 1960s, Bexley Hospital started actively recruiting in Mauritius. So by the time I started training there in 1987, most of the staff, including management and nursing tutors, were Mauritian or Irish. When I worked in the Greenwich Community Mental Health Team from 1997 to 2018, most of the staff were black. And specifically, black African, usually from Nigeria or Ghana: even black Caribbean staff were a small minority, likewise Asian staff. Sometimes I was the only white person in a room of twenty or thirty colleagues. That was not a problem for me - I hasten to add! But it did make me wonder why this should be. Possibly it is especially marked in London. But there were also clear differences in the professions. Social Workers were also mainly African, like the nurses. Psychiatrists were about 50/50, white or black. However, Psychologists were almost all white. And Occupational Therapists were almost all nice middle-class white girls, either English or Australian. In the last few years of my career, I helped to interview prospective nursing students applying to Greenwich University. By then they had to pass English and arithmetic tests before being interviewed: and this was very necessary as few were of white English heritage. I still haven’t really found a reason for this, but certainly it illustrates that the NHS is an organisation very much taken for granted by the public and the government.

So those are my reflections. I will conclude by stressing that, money aside, I can’t think of any other job that I would rather have done!

Adrian Roberts

March 2025