Which came first, the chicken or the egg – improving mental health care

Now it’s not often that two of my passions come together in the same place, but last week that was the case. It was the title of an article in the Nursing Times that caught my eye. Now I have to say that I am a not a regular reader of this publication, but the article’s title: ‘Solving the mental health nursing shortage presents a chicken and egg dilemma’ was somewhat intriguing. I will come back to the philosophical question embedded in the title later, but first the main thrust of the article was an exploration of the NHS Mental Health Implementation Plan which had been published just over a week earlier on 23^rd July.

It’s not surprising that its publication scarcely got a mention anywhere, there was a lot happening on that day. Boris Johnson won the race to become Leader of the Conservative and Unionist Party and UK Prime Minister and the spectre of a no-deal Brexit loomed large;  the boxer Maxim Dadashey sadly died following an injury he sustained in a fight a few days earlier, sparking yet another debate about banning boxing; Trump imposed a rule that takes 3.1 million people out of the food stamp programme (which provides free food to some 40 million Americans each day) on the basis that he has improved the US economy; and to some, most importantly, Jordan and Anna had a bust up on Love Island over his attraction to India (none of whom actually won the contest).   

    

It was a shame that it didn’t receive much attention. The plan sets out a framework for how NHS England will deliver on its commitments for the development of local, place-based mental health services. Readers might recall that the NHS Long Term Plan, in setting its ambitions for improved mental health care services talked about better 24/7 community-based crisis response services, greater liaison support to A+E departments, and the introduction of mental health nurses to work in ambulance control rooms. The NHS Mental Health Implementation Plan begins to put some flesh on these bones, along with a commitment from NHS England to a £3.4bn a year increase in funding, and funding that will be ringfenced for mental health care (well by 2023/24 anyway). Nurses and nursing feature prominently in the plan (see Appendix B for an indicative future mental health workforce), and that is rub number one… just where are these nurses to be found?

The Nursing Times analysis reveals that more than 4,000 additional mental health nurses will be needed over the next five years if the plan’s ambitions are to be achieved. Unsurprisingly, it is children and young people’s services where the greatest need for mental health nurses are said to be required. However, there is also recognition in the plan of the need to increase the number of mental health nurses to work in the community with those living with a severe and enduring mental illness. 

Given that we already have a massive shortage of nurses (and most other health care professionals) in the NHS, and for nurses this is estimated at now being over 40,000 vacancies in England alone, it’s difficult to see where the extra nurses are to come from. There is a possibility that the investment in mental health services might tempt some nurses who have left the profession to return, and despite Brexit, we might attract overseas nurses, but essentially it will require an exponential increase in student nurses to fill this gap. 

There are lots of problems with this. For a start, there are currently a lack of clinical placements in mental health services and universities will need to expand their mental health nursing programmes and then work hard to attract the students to fill the increased places, and that is rub number two. Whilst the plan might make working in mental health services more attractive, it will need significantly more mental health nurses than we currently have to develop and deliver the plan’s ambitions – it’s an example of the classic chicken and egg conundrum.  

   

Being someone who has long loved ‘all things chicken’ and a Doctor of Philosophy, I was tempted to revisit this chicken and egg conundrum, and I’m glad I did! The origin of the phrase, as far as I could find out was from the Greek philosopher and biologist Plutarch way back in the 1^st Century who discussed the famous problem in his essay ‘The Symposiacs’. Although Aristotle had discussed a similar dilemma hundreds of years before, it was Plutarch who articulated the question in its modern form. All chickens hatch from eggs, and all chicken eggs are laid by chickens. Whilst the ‘chicken and egg’ dilemma is essentially a metaphorical device, evolutionary biology provides literal answers. If one accepts the Darwinian principle that all species evolve over time, it’s possible to imagine that chickens had ancestors that were not chickens. And thus, the answer is the egg came first. 

The first amniote egg (the first hard-shelled egg laid on land) appeared around 312 million years ago, whereas all chickens, (and their eggs) descended from red jungle fowl and probably first appeared merely in the last 8,000 years. Mental illness has also been around for a long time. Katherine Darton’s ‘Notes of the history of mental health care’ says that in prehistoric times there were no divisions between medicine, magic and religion. She notes that evidence from Stone Age trepanning (cave paintings) shows a painting in France that portrays a strange being with human hands, feet and antlers who has been identified as a psychiatrist (or at least, maybe a witch doctor). I think I will stick with mental health nurses and chickens, but not necessarily in that order.