The Representation of the NHS in The Last Asylum and Blue/Orange

The National Health Service, or NHS, was established on the 5^th of July, 1948. England’s division of the NHS provides healthcare to all residents of England. Most services are “free at the point of use”, meaning that most medical care, both critical and non-critical, is accessible and free for individuals who are registered within the NHS system and are legal residents of the UK. It is mostly funded through the general taxation system, with a small amount being funded by National Insurance payments, and it is overseen by the Department of Health. Aspects of the NHS’s role in psychiatric institutions are represented in various plays and novels. In her memoir, The Last Asylum, Taylor highlights the consequences of over prescribing anti-psychotic medications, exemplifies how the UK health system does not provide enough resources for psychotherapy beyond the private sector, and explores the pitfalls of eliminating Victorian era mental asylums. Joe Penhall’s, Blue/Orange allows readers to visualize how lack of resources and bed space in many hospitals due to the underfunded NHS dictates medical decisions while also presenting a divide between junior doctor and senior consultant.Another of Penhall’s plays, Some Voices, explores the importance of the Community Treatment Orders instated in the Mental Health Act of 2007, in detaining psychiatric patients who refuse to take their medications. The authors’ representations of the NHS can be linked to wider issues present in the UK healthcare system, of which many will be explored in this essay.

Barbara Taylor’s purpose in her representation of the NHS in The Last Asylum, is to bring to light three key issues. In her memoir, Taylor recalls the overuse of medication for long term patients in Friern. Taylor also continuously expands upon the importance of the 21 years she spent in private psychotherapy, something that is wholly under-resourced in the NHS. Lastly, she questions whether the closure of mental hospitals during the Victorian era to adhere to the newly instated “Care in the Community” standards, where patients were to be reintegrated into the community as much as possible, got rid of something of necessity for psychologically ill patients at the time, interconnectedness.

 Taylor steers the reader to view and understand the negative consequences of the overuse of anti-psychotic medication. In the epilogue of her memoir, Taylor brings to light how the issues presented in her memoir are linked to wider issues present in the UK health system. She writes about how research has yet to produce evidence for a neurobiological origin of any  mental illness, yet, for decades, western psychiatrists have been handing out immense quantities of ‘anti-psychotics’. These drugs not only have adverse side effects, but also heighten or even produce the psychiatric symptoms that they are supposed to treat by disrupting the natural brain functioning. Recent studies show a correlation between high usage of anti-psychotic medication and poor patient ‘outcomes’. She cites the fact that, in the UK, patients with serious mental disorders on long term anti-psychotic medication are dying, on average, fifteen years earlier than the general population.

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Taylor also steers the reader to view psychotherapy to be underfunded and under resourced in the public health sector, leading patients to have to seek it privately, at a large monetary cost. This viewpoint also links to wider concerns in the UK health system. Many psychiatric inpatients are being treated very far from where they live when beds are not available locally. This has caused much controversy, as some mental health professionals feel that the presence of friends and family is instrumental to recovery for mental health patients, as coping with mental illness is a time of vulnerability, isolation, and fright. Fortunately, there has been increased access to psychotherapy services in the NHS resulting from the Improving Access to Psychological Therapies ( IAPT) service. This service is characterized by: evidence based psychological therapies, meaning they are tested in random clinical trials and highlighted by their ability to get psychological patients “back on their feet”, routine outcome monitoring, and outcomes supervision (“Adult Improving Access to Psychological Therapies Programme” ). However, in recent years, evidence has shown that alongside this increased access to psychological therapies due to the IAPT service, there has been a reduction in choice for patients, a reduction in highly trained and experienced workforce, and the emphasis of the NHS on a narrow Cognitive Behavioral Therapy (CBT) model, which is often seen as a short term intervention focused on minimizing dependency on the mental health system. Cognitive behavior therapy can now be done, on the NHS, without any human contact, due to the introduction of online CBT packages. Another pitfall of this CBT model is that the waiting lists are extremely long. The British psychoanalytic council surveyed members of both the UK Council for Psychotherapy and the British Psychoanalytic Council to obtain a clearer account of the established NHS psychotherapy and psychotherapeutic counselling services. Of the therapists surveyed, 56% saw decreases in the treatment time provided to clients, 38% reported decreases in the range of therapies offered, and 36% indicated that there had been decreases in the frequency of sessions provided (“Quality Psychotherapy Services in the NHS”).

Lastly, Taylor brings to light the wider issues that came about with the installment of the “Care in the Community” Act. The act was to replace dependency and reliance on the mental health system to self-dependency in the community. Individuals were encouraged to get well as soon, so that they can return to work and their normal way of life as quickly as possible. It was hoped that, by doing this, the life of the mental patient would improve and the unhappy figure of an asylum could be eliminated in its entirety. But, Taylor has always been a fierce opponent of the closure of the Victorian mental asylums and the ‘Care in the Community Act’. In her memoir, she states, “For people with severe mental disorders, just being around other people is sometimes all that is desired or tolerable.”  In the epilogue to her memoir, she emphasizes that this lack of interconnectedness brought about by the ‘Care in the Community’ act affects the mentally ill grandly, since it is often failures of social connection, especially in early life, that cause such psychological disorders in the first place. She also highlights the fact that the abolition of patient dependency has created services that completely overlook continuity of care, with patients being shunted from team to team, health personnel to personnel. Taylor continues to emphasize that the greatest and longest lasting recoveries will instigated by patients being allowed to be part of a therapeutic community and establishing continuity of care with their health workers.

 Penhall also contributes to the representation of the NHS in his play, Blue/Orange. This play highlights three key representations of the NHS. The audience sees how a shortage of beds and resources dictates medical decisions, a key theme in many NHS funded psychiatric hospitals. The play also depicts the divide between a junior doctor and senior consultant, something that is very prominent in the healthcare system in England. Bruce represents an advocate of the old asylum system, wanting to keep Chris in the psychiatric hospital for an extended period of time to provide him more treatment time and talking in order to get healthier, whereas Robert represents an advocate of the “Care in the Community” system, as he wants to release Chris and warns that keeping him in the hospital too long might make return to normal life impossible. Bruce seems to be with Christopher more than Robert ever is, and his opinion never seems to matter to Robert, the senior consultant, in the grand scheme of making the decision as to whether or not Chris should stay or be released. Additionally, he is often manipulated by the senior consultant, Robert, who imputes racist thinking to Bruce so that Chris presses career threatening charges against Bruce.  By emphasizing this divide, Penhall also highlights the inequalities and sometimes poor working conditions that junior doctors face.

 Penhall steers the reader to view the negative aspects that cuts to NHS funding have on the health and safety of patients. In Blue/Orange, a major reason why Robert presses for Chris’ discharge from the mental hospital is due to the fact that there are physically not enough beds for Chris. This play brings to light the ever diminishing pool of resources, including money and beds, that is currently prominent in the UK healthcare system due to the underfunding of the NHS. Britain spends a small amount on health compared to other Western countries. In 2013, the UK’s GDP Expenditure on Health (GDPEH) was 9.1%, placing it as 17^th out of the 21 Western countries. Over the past 30 years, Britain’s average GDPEH is 6.9%, the lowest of all the Western nations it was compared to. For comparison, France and Germany spent an average of 9.4% ( “Britain’s NHS Is Chronically Underfunded, But Great Value For Money … For Now”) . At present, around 2500 hospital beds are occupied by patients that are fit to leave the hospital but are awaiting social care, and another 2500 are occupied due to delays in community health services (“Funding and Efficiency”). This has a domino effect, as it causes delays for other patients waiting for beds, and routine operations often have to be delayed. Additionally, it shows that the appropriate care for these individuals, who are often elderly and frail, are often not adequately and promptly met. Additionally, mental health services in the NHS are still largely underfunded. Over 4,000 mental health beds have closed since 2010, and there has been a similar reduction in the number of psychiatric nurses since then.

Penhall also steers the reader to view the power struggle between junior doctors and senior consultants, and the inequalities that many junior doctors have to face when working in the NHS. The relationship and power struggle between Robert and Bruce highlight the reality that junior doctors often face much maltreatment and bad working conditions when in their years of training. According to a survey done by the Royal College of Physicians, half of junior doctors agree that patient safety is compromised by gaps in junior doctor rotas, with seven out of 10 junior doctors saying they work on a rota with a permanent gap. This permanent gap means that junior doctors are regularly having to cover these gaps, meaning they are doing the work of two medical doctors. These staffing shortages do not only affect junior doctors, but also nurses, other health personnel, and other doctors. Due to these staffing shortages, consultants struggle to find time for teaching and training junior doctors, meaning that healthy relationships between junior doctors and senior consultants are never firmly fostered. 56.1% of junior doctors reported going through at least one shift in the last month without having a meal, with these shifts often lasting for 12 hours or more. Evidence shows that rest breaks contribute to safe care, however junior doctors cite being unable to take adequate breaks. Four in every five doctors reported that their job caused them excessive stress and 61% reported their job has a negative impact on their mental health, ranging from clinical anxiety, panic attacks, and insomnia (“Being A Junior Doctor: Experiences From the Front Line of the NHS” ).

Another of Penhall’s plays, Some Voices, highlights the importance of the Mental Health Act of 2007. He does so by presenting the disastrous effect of Ray refusing to take his medications on both on his way of life and his relationships with those closest to him. In the present time, this refusal to take medication would no longer be tolerated. The Mental Health Act of 2007 introduced Community Treatment Orders, facilitating the mandatory detention of patients who refuse to take their medication. When this was enforced, it was assumed that this mandatory detention would rarely be enforced, but in fact, in the first three years of this order being put in place, 14,295 people were detained in special units which did not have the space or staff to cope with the amount of people, as the asylums had been shut down (“Mental Health Act.”) . This once again highlights how psychiatric facilities in the NHS are underfunded, under resourced, and few and far between.

Aspects of the NHS’s role in psychiatric institutions are represented in various plays and novels. In particular, Joe Penhall’s Blue/Orange and Barbara Taylor’s The Last Asylum bring to light several key issues present in the modern health care system in the United Kingdom. In her memoir, Taylor chooses to focus on and emphasize the overuse of anti-psychotic medications in psychiatric hospitals, the underfunded and under resourced psychotherapy services in the public health sector, and the downfalls of the ‘Care in the Community’ act. Penhall chooses to focus on the diminishing pool of resources available in the NHS, the power struggle between junior doctors and senior consultants, and the under resourcefulness of NHS psychiatric services as seen by the effects of the Mental Health Act of 2007. These two plays collectively inform the audience and the reader about the healthcare system in Britain as a whole, with a specific emphasis on the mental health sector, as the issues presented in these works relate to the wider issues present in the National Healthcare System.

Works Cited

• “Adult Improving Access to Psychological Therapies Programme.” NHS England, NHS, www.england.nhs.uk/mental-health/adults/iapt/. 
• “Being A Junior Doctor: Experiences From the Front Line of the NHS.” Royal College of Physicians.
• “Britain’s NHS Is Chronically Underfunded, But Great Value For Money … For Now.” Gale Business Insights: Essentials, bi.galegroup.com.proxy.library.nd.edu/essentials/article/GALE|. 
• “Funding and Efficiency.” NHS England, NHS, www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/funding-and-efficiency/. 
• “Mental Health Act.” NHS , NHS, 26 Apr. 2016, www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/mental-health-act/. 
• Penhall, Joe. Blue/Orange. Bloomsbury Methuen Drama, 2016. 
• Penhall, Joe. Some Voices and Pale Horse. Methuen Drama, 1996. 
• “Quality Psychotherapy Services in the NHS.” British Psychoanalytic Council, www.bpc.org.uk/sites/psychoanalytic-council.org/. 
• Taylor, Barbara. “The Demise of the Asylum in Late Twentieth Century Britain: A Personal History.” 2010. 
• Taylor, Barbara. The Last Asylum: A Memoir of Madness In Our Times. Hamish Hamilton, 2015.