Many of us are all too familiar with the difficulties of juggling our everyday lives and attempting to get an appointment with our GP, or to fit in regular dental check-ups. Imagine, for a moment, the likelihood of you booking and attending a GP appointment when you do not have the motivation or energy to eat or wash, when you consider yourself worthless and undeserving, when public spaces terrify you for all the potential catastrophes that could occur. Imagine you believed your life was genuinely in danger, and an organisation intends to control and denigrate you. You won’t be making or attending that appointment. You’ll stay in your room.

As with all things, if you don’t cause trouble or make a noise you will remain in the background. As a clinician, I’m generally less concerned by those self-presenting to us and am more worried about the hidden many, suffering alone in their rooms, locked away from the world.

We know that 90% of all adults with mental health difficulties are supported and treated by their GP (2) leaving only 10% to be treated by specialist Psychiatrists. This begs the question; how many people are not presenting at all?

The Government tells us that there is ‘No Health Without Mental Health’ (1) and that it intends to bridge the gap of financial disparity between physical and mental health funding. Mental health problems account for 23 per cent of the burden of disease in the United Kingdom, but spending on mental health services consumes only 11 per cent of the NHS budget. (3)

Approximately £34 billion pounds is spent on mental health in England annually, this pales in comparison to the £105 billion conservatively estimated to be lost through economic and social costs. (2)

The reality is that NHS services are being cut and working teams are placed under enormous pressure to achieve health targets with fewer resources; this naturally results in teams taking measures to protect their caseloads and manage patient flow. Anyone that works within healthcare, but particularly mental health or Primary care, will be familiar with the frustrations of inter-team referrals and inclusion/exclusion criteria.

What follows from strict acceptance criteria is a ‘cherry-picking’ of referrals. The patients that pass the gauntlet of ‘self-referral’, assessment interviews and self-questionnaires are then placed under teams or on waiting lists whilst those that didn’t complete the referral pathway are lost.

Psychiatry is well-aware of this problem, it is in part placated by the allocation of ‘care co-ordinators’, mental health professionals that are deputised to orchestrate all of the appointments, reviews and treatments for those with the most severe mental disorders under community psychiatric teams. But what of the unknown patients? What of those that don’t come to the attention of Psychiatry?

We’ve created a system whereby the most unwell and isolated will remain that way until they are detained under the Mental Health Act or do something dangerous.

Step up Crisis Teams. By 2020/21, the Department of Health and Social Care has said that NHS England should ensure there is a 24/7 community-based mental health crisis response available in all areas across England (2).

The rollout has already started, albeit in stages, it is hoped that Crisis Teams will be the new answer to the problem of access. The theory goes, anyone can call, walk in off the street, or be referred by friends/family/neighbour to be seen by a mental health professional when they need it without having to go through the normal pathway.

Having worked in parallel to a newly formed crisis team; it appears to me that we have opened the floodgates. They should have undoubtedly been opened a long time ago, but I’m worried that Psychiatry is now about to be overwhelmed.

Mental Health is now in its own crisis, Psychiatry needs to be given the resources to meet the new demands and not ignored because it’s not making enough noise.


  1. Department of Health 2011
  2. The Five Year Forward View 2016
  3. The King’s Fund