Book review

Citation

Deb, S. (2019), "Book review", Advances in Mental Health and Intellectual Disabilities, Vol. 13 No. 1, pp. 52-54. https://doi.org/10.1108/AMHID-01-2019-071

When my daughter was in school she could not wait for the Harry Potter instalments to come out and she would start reading the book on the moment the book was out and would read non-stop until the whole tome was finished by the late evening. Despite a lot of encouragements from her, I have never moved beyond the first page of the first book. However, when I started reading Professor Nick Bouras’ book, I felt the same urge like my daughter to finish the whole book in one go (and I am a slow reader!). Such is the attraction of this book for someone like me who has travelled some of the same paths with him. I know Professor Bouras as an excellent Clinician, Scientist, Leader, Academic, Educator, Mentor, Trainer, Policy Maker, Medical Manager, International Networker (all these qualities that made him the Renaissance man in the field!), but did not know that he is such a master storyteller!

There is a hierarchy in science and at the top is perhaps the “rocket science” and at the bottom, “medicine”. Within “medicine”, “psychiatry” perhaps comes at the bottom and within “psychiatry” the “intellectual disability (ID)”. Professor Bouras’ endeavour to collect data meticulously and analyse them using scientific methods as described in his book, no doubt, helped to make ID psychiatry respectable nationally and internationally. His book is the proof of the disaster that can happen if you go with the flow and do not ask questions and gather the right evidence! In that sense, Professor Bouras was ahead of his time, perhaps because of his exposure to community-based mental health services very early on through the Mental Health Advice Centre about which he writes passionately in his book!

In his book, Professor Bouras through his personal journey also takes us through the journey of the NHS in the UK in the last four decades as well as services for people with ID. Many of us will remember the profound changes that Griffith’s report brought into the NHS that advised the Government to run the NHS like a supermarket only to realise that unlike the supermarket the consumers of health service do not have to pay for the service. In order to rectify this mistake, a pseudo market was created by developing the commissioner-provider split. That was the beginning of the manager culture in the NHS and ring-fenced budget within small units, a small amount of resources guarded dearly by the managers of those units. Professor Bouras talks in his book about the tension that these changes brought for implementing community care and how medical establishment in the hospital was perhaps understandably reluctant to give any of their meagre share of resources to community care. At a personal level, I felt the same as a psychiatry registrar when I went to ask for some syringes and bottles from an inpatient unit as I was going to do a home visit and needed to take some blood samples from a patient. The ward manager told me that I could not use their equipment for patients who were not in their unit. This in a way exemplifies the wider problem of loss of flexibility within the NHS as a whole!

Professor Bouras’ book reminds us of many forgotten stories such the extra-contractual referrals, many of which were necessary because of expensive out of area placements in private settings (£8.8m just from one London area in 2017 quotes the book) that created a false economy in the NHS (the latest figures show in the UK, there are 2,500 psychiatric inpatient beds in the NHS and 2,800 beds in private sectors most of which are in locked units). This book also resurrects for me some of the anecdotes we used to hear through the grapevine as psychiatry SHOs such as Professor Elaine Murphy’s sedan doing home visits in the not so affluent parts of London. His book also reminds us how in the old days our clinical psychologist colleagues were involved more in doing psychological tests than providing meaningful interventions. At a personal level, I remember that as a psychiatry SHO we used to often demand from our clinical psychologist colleagues Minnesota Multiphasic Personality Inventory test without realising how time consuming and how useless this was for our clinical work.

Many of the conflicts mentioned in the book that started decades ago are still rife today. I have already mentioned provider vs commissioner and community vs institutional care conflict. Professor Bouras’ book also discusses other tensions such as health care vs social care (whether psychiatry of ID, particularly problem/challenging behaviour is a mental health issue or an ID issue and who should fund the service), physical health vs mental health care (often both services denying that the health of people of ID is their responsibility, therefore, the funding should come from elsewhere!). Similarly, the issues of the role of the Community Learning/ID Team members, for example, community nurses spending more time in sorting out housing budget rather than helping to monitor mental health, medication, etc., for people with ID in the community (Unwin et al., 2017), and generic mental health vs ID service (specially ID psychiatry) (who has the expertise to treat psychiatric illness, particularly problem behaviour in ID and whose resource should be used), are as prominent now as they were four decades ago as Professor Bouras’ chronicle eloquently discovers.

As a passionate researcher in the field, Professor Bouras talks in his book about his frustration regarding the lack of research funding in the field. For example, funders of mental health research and the ID research both saying simultaneously that research in mental health in ID is not their responsibility (another example of many of the tensions mentioned in his book). However, it is not all doom and gloom in the book, indeed there are many examples of successes even at the face of adversities, the jewel in the crown being, perhaps the establishment of Estia centre (a concept which was ahead of its time in the UK at the time of its establishment). This is an excellent example of how one can combine clinical service with research, education and training, which should be the case in an ideal world.

Similarly, the book shows how international collaboration can raise the profile of ID psychiatry, which was evident from Professor Bouras’ leadership in many international organisations such as the World Psychiatry Association Section on Psychiatry of Intellectual Disability, the European Association of Mental Health in Intellectual Disability, which produced under his leadership the first ever evidence-based international guide on the assessment and diagnosis of psychiatric disorders in ID (Deb et al., 2001), which is still considered as one of the classics in the field and was later followed by the American National Association for the Dually Diagnosed publication, “Diagnostic Manual-Intellectual Disability” (Fletcher et al., 2007). Professor Bouras’ another classic contribution to the field is the textbook in psychiatry of ID that he edited with his colleagues which because of its huge success has been produced in its third edition recently (Hemmings and Bouras, 2016). The chronicle describes how Professor Bouras’ efforts to organise many high quality national and international conferences have brought fruits by raising the profile of the speciality both nationally and internationally. I personally remember the first among many high quality international conferences Professor Bouras organised in the UK in Canterbury in which I took part, which he mentions proudly in his book.

Professor Bouras’ chronicle provides a list of “Who’s Who” among psychiatry, more specifically ID psychiatry not only in the UK but worldwide. This shows his great skill as a networker and friend maker not only within the UK but worldwide, which made him the best person to run the Maudsley International to which he is now the Director. Indeed his book shows that while in trying to achieve your goal you will come across some people who are not so helpful but there will be many more who will be accommodative and enthusiastic about the cause, who have the right attitude of “can do, will do” and who could become your lifelong friends. The book shows how throughout his journey over four decades through all the policy and service changes (from “social role valorisation” in Scandinavia through ENCOR in Nebraska USA to “Valuing People” in the UK), Professor Bouras remained determined to provide person-centred, multi-professional service for people with ID in the right settings to fulfil the well-used prophecy that the measure of how civilised a society is by how well they look after their disadvantaged in the society. Despite his international renown, Professor Bouras was firmly rooted to the ground and committed to the NHS in the UK from de-institutionalisation to community care. This is a lesson for the future generation.

History does not only remind us of the good and the bad of the past but also warns us about the potential problems ahead! Therefore, this book is not only an essential reading for our generation of psychiatrists but also for the others who will be making history in future. This book should be a source of inspiration not only for doctors and psychiatrists but many who want to overcome barriers and achieve their goals at the face of many adversities with their hard work, determination, tenacity and the right skills.