JULY - AUGUST 20259EUR PEEUR PEUNTIL WE PRIORITIZE CARE ABOVE ECONOMICS, THE ONLY TWO GROUPS OF PATIENTS WHO WILL RECEIVE COMPREHENSIVE CARE AND TREATMENT ARE THOSE WHO ARE TREATED PRO BONO AND THOSE WHO SELF-FUNDprotocol for treatment of FND patients in an NHS out-patient setting. It was a 12 week programme (3 hours a week), based upon principles of cognitive behaviour therapy (CBT), Compassion-based therapy, Acceptance & Commitment Therapy and Mindfulness. I delivered it together with an Assistant Psychologist, knowing that, when needed, I could call upon the support of my Psychiatry colleagues in our Liaison Psychiatry service. The aims of the treatment were to help patients modify unhelpful beliefs about their condition, suspend their expectations and learn to train their attention away from their symptoms. Our results were pleasingly good but could have been even better had we had the basic resources to supply a comprehensive service. Despite robust evidence that patients with neurological movement disorders frequently recover faster with physiotherapy, this service was beyond our budget. The patients' needs were secondary to the Trust's targets. It seemed that the National Health Service was becoming the National Health Industry.Fast forward the years and I have left the NHS behind. I continue to believe strongly in nationalized medicine, but struggle with its priorities. Psychologists continue to face the impossible choice of either offering partial treatment to a large number of patients or treating fewer people but ensuring that they are well and resilient upon discharge. In the former case, it is inevitable that people will relapse and need to be readmitted - rather like the person who fails to complete a course of antibiotics and subsequently becomes more unwell. Mental health patients, prematurely discharged, are given the unglamorous moniker of `revolving door patients.' In the latter case, targets are missed. Bore responsibility for not meeting targets. Clearly, the economic model is incompatible with, or unreconcilable with, the care model.Naively, I thought that working in private practice would be far simpler. My ethical principles are clear: I work with patients to empower them. Once they have gained all that I can offer, we agree that our work together is complete. People `drop in' for a psychological review if they wish; others return a few years later to tackle a different problem. I now understand that this model is the privilege of very few patients.Insured patients with Functional Neurological Disorder all too often face many of the same restrictions of those who rely on the NHS. Their belief that having medical insurance equals immediate access to treatment is frequently dashed. First, they may have to convince their insurance company that FND is a `real' condition, a hurdle that invariably causes delays, and sometimes perpetuates the stigma of being told that the condition is just `in your head'. Secondly, there is only a small pool of specialists. Thirdly, many of these providers have chosen not to continue to work with AXA PPP health or BUPA because of these companies' extremely low remuneration policies. And fourthly, sessions for FND are often limited in number. This lack of consensus, emblematic of an industrial approach to medical care, is frustrating for both patients and treatment providers - and unsustainable.We need a fresh look at how as a civilized society we think about mental health. Until we prioritize care above economics, the only two groups of patients who will receive comprehensive care and treatment are those who are treated pro bono and those who self-fund. Everyone else falls through the cracks in the market-place of Late Capitalism.
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