Schizophrenia and NICE: Another view

Mental Health Nursing,  Jul 2003  by Gournay, Kevin

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In the last issue, Phil Barker and Poppy Buchanan-Barker criticised the recent guidelines on the treatment of schizophrenia issued by the National Institute of Clinical Excellence (NICE). They looked at issues around the nature of schizophrenia and the use of evidence bases, raised concerns about early interventions and criticised the guideline development group's composition. In the article below, Kevin Gournay challenges these points and others, welcomes the NICE Guidelines and argues that nurses have a good input into the guideline development

I was delighted to accept the offer of responding to the article by Phil Barker and Poppy Buchanan-Barker on the NICE Guidelines for Schizophrenia. It is an opportunity, not only to respond to their arguments but also to say more about what, in my opinion, is a very positive development in improving the lives of people with mental illness, while at the same time developing nurses' focus on a number of priorities.

At the outset, I need to make my own position clear. I am currently the leader of the Guidelines Development Group for NICE'S work on the Management of Violence in Acute Settings in Mental Health Care. However, I write this article as an individual and the views that I express are entirely my own. Having said this, I believe that NICE is, with all its flaws, a body that offers a great deal to sufferers of a range of illnesses, both physical and mental, to their carers and to the health care system as a whole.

Prior to 1997, it is true that mental health was one of the government's priority areas and there were specific initiatives, such as the Clinical Standards Advisory Group (CSAG), which could suggest certain standards in healthcare. Indeed, CSAG, in its last few years, published two excellent reports on schizophrenia and depression respectively.

However, the difficulty with these reports was that, at best, they were aspirational documents that clinicians or trusts could take or leave. Since 1997, setting sound standards has been a centrepiece of government health policy. It also needs to be remembered that the NICE Guidelines on Schizophrenia are only part of a much larger jigsaw.

One of the first efforts of the new government was to set up the National Service Framework (NSF) for Mental Health. The reference group for the NSF spent nearly two years developing standards and performance indicators across all areas and eventually published, in essence, a ten year plan for mental health services. It is worth adding that this initiative has almost universal support among health and social care professionals, patients/service users/consumers (choose your preferred word), their families and a wide range of representative organisations.

NICE and the Commission for Health Improvement (CHI, soon to become CHAI, the Commission for Health Audit and Improvement) are structures of government. They ensure, not only that best practice is defined, but also, through CHI, that government has means of ensuring that all trusts across the country provide services of acceptable standards. The NICE work on schizophrenia is only one of many initiatives in mental health care. NICE has already completed work on computerised treatments and there is work in progress on other mental health topics.

Another over-arching mechanism to ensure that there is equity in the quality of services, with appropriate education and training and research, is the National Institute for Mental Health, England (NIMHE) that is just starting a range of important projects. Considering NICE within the context of a joined-up strategy is a fundamental point. It cannot be seen in isolation.

Criticism of the concept of schizophrenia is a major theme throughout Barker and Buchanan-Barker. My own view is that schizophrenia, as a term, is probably the best (though imperfect) way we have to describe a number of related and clinically similar illnesses, most of which, probably, have a biological underpinning, but are also greatly influenced by social and psychological factors. I believe that arguing, endlessly, about the meaning of the word schizophrenia is currently a waste of time and effort. It will be a number of years before research can define, precisely, the nature of these conditions, and then, perhaps, we can have a new terminology.

For the time being, I think all would agree that the term 'schizophrenia' covers a group of conditions that effect one per cent of the population. They manifest themselves in problems of thinking, feeling and behaviour, of sufficient magnitude, to cause severe handicaps in virtually every area of living. This population suffers a miserable quality of life. They face difficulties in employment and housing. In most cases they, and their families are socially excluded. We also know that, with the best care and treatment, the lives of these individuals can often be greatly improved and the burdens on their carers and families may be considerably reduced.

Barker and Buchanan-Barker criticise the NICE guidelines for stating the obvious in proposing that family interventions are available to all families who are living with, or are in close contact with, the service user. It may be stating the obvious, but most families do not, currently, have access to interventions and, therefore, the guidance is important to ensure that NHS trusts spend appropriate resources on ensuring that access to interventions is improved.