Mental health services in the NHS: using reform incentives
Professor Nick Bosanquet
Henry de Zoete
Andrew Haldenby
October 2006
The Authors
Nick Bosanquet is Professor of Health Policy at Imperial College London. He
is a health economist who first carried out research on NHS funding in the
1980s for the York Reports sponsored by the British Medical Association, the
Royal College of Nursing and the Institute of Healthcare Management. He
has been Special Advisor on public expenditure to the Commons Health
Committee since 2000. He is a Non-Executive Director of a Primary Care
Trust in London.
Henry de Zoete has been
Reforms Health Research Officer since 2003.Andrew Haldenby has been Director of
Reform since 2005.Reform
Reform
is an independent, non-party think tank whose mission is to set out abetter way to deliver public services and economic prosperity.
We believe that by reforming the public sector, increasing investment and
extending choice, high quality services can be made available for everyone.
Our vision is of a Britain with 21st Century healthcare, high standards in
schools, a modern and efficient transport system, safe streets, and a free,
dynamic and competitive economy.
Reforms
previous reports on health include Investment in the NHS facing upto the reform agenda
(2006), Staffing in the NHS facing up to the reform agenda(2006),
Maternity services in the NHS (2005), The NHS in 2010: reform or bust(2005)
, Cancer care in the NHS (2005), The NHS in 2010 (2004), A Better Way, thefinal report of
Reforms Commission on the Reform of Public Services (2003),and
Why The NHS Needs Real Reform (2002).CONTENTS
Executive Summary
1. Introduction
2. Access to mental health treatment
3. Quality of inpatient care
4. Mental health and the social environment
5. Further problems with the current system
6. Recommendations
References
Executive Summary
Mental health is a central priority of modern health care. In terms of
disability adjusted life years, it imposes the second highest burden of
disease in Europe (only just behind cardiovascular disease).
But services are narrow and for the great majority of sufferers impose
unacceptable waits for treatment during which mental illness can become
entrenched.
Several organisations and commentators have concluded that the vast
majority of sufferers, suffering from common yet disabling disorders such
as depression and anxiety, may never see a mental health specialist. For
example:
-
The Healthcare Commission (2005) found that only half of people withdepression were receiving treatment and that people are waiting a
long time for appointments with psychiatrists and other mental health
professionals.
-
The OECD (2005) reported that patients have to wait six to ninemonths to access psychotherapy while conditions become more
entrenched.
Spending has increased since 1999-00 with the aim of developing a more
community focused service. But the funding has gone in quite a different
direction:
-
Between 1999-00 and 2003-04 spending on inpatient, outpatient andday patients services within the Mental Health Services Programme
Budget increased from £3 billion to £4.1 billion (real terms).
-
In contrast spending on community mental health nursing andcommunity mental illness nursing rose from £1.3 billion to £1.7 billion.
-
Numbers of short hospital stays have decreased while numbers of longstays have grown greatly. The number of patients whose duration of
stay is over a year has increased by 192 per cent between 1999-00 and
2003-04.
-
From 1999-00 to 2003-04 spending on inpatient care at constant pricesrose by £600 million (+27 per cent). The number of admissions fell
from 200,900 to 171,650 (-15 per cent). Thus real terms spending per
admission rose from £11,200 to £16,600 a rise of 48 per cent against
a background of increasing concern about the quality of inpatient care.
The whole programme has developed as a custodial model with high
levels of compulsory treatment rather than a health programme which
clients engage with voluntarily in order to achieve benefits. Funds are
concentrated on the 0.5-2.0 per cent of the population who suffer from
psychotic illness, yet the vast majority, suffering from common yet
disabling disorders such as depression and anxiety, may never see a
mental health specialist.
The lack of investment in community care is compounded by poor use of
modern effective drugs. We present new analysis of use of atypicals in
different SHAs and PCTs. Prescribing of atypicals as a proportion of total
anti-psychotics varies between 55-60 per cent in some SHAs to below 40
per cent in others.
In the absence of community care, the service operates with very high
levels of compulsory treatment. The number of detentions under the
Mental Health Act rose from 24,811 in 1987-88 to 46,003 in 1998-99. In the
most recent year 2003-04 there were 43,847 detentions. These figures
suggest that of adults over 65 admitted to hospitals, 40-50 per cent are
being treated compulsorily with the proportion nearing 70 per cent for
patients from ethnic minorities.
It is apparent that mental health services are excluded from the
mainstream of NHS policy and most importantly from the benefits
associated with the new reform programmes:
-
There were no targets for waiting times in mental health services whichare much longer than acute services. Even now the 18 week target
does not apply to non-consultant led services which are particularly
important in mental health services.
-
Services must now compete for additional funding without help fromcompulsory targets. Many are losing funds to cover deficits in acute
trusts.
-
Despite their use in acute services, choice and pluralism are a very lowpriority for mental health services. There is no constructive long term
partnership with the private and voluntary sector. The current
relationship is based on spot purchasing; a model which is regarded as
delivering high cost and poor communication.
-
The postponement of the introduction of payment by results to mentalhealth services is a major blow. Payment by results and the national
tariff are major drivers for developing pluralism.
The new care model with its emphasis on early intervention, community
support, reduced admissions and much more help to return to
employment is clear enough. The key issue now is to make it happen in
this very difficult funding environment.
Here the reform incentives could be crucial. Those with a strong
preference for remaining with the monopoly model see them as highly
threatening. But choice, direct payment and pluralism offer the only
realistic way of making progress towards the new kind of care which is
there for the making. We would urge the following steps:
-
Develop a mixed economy of care in cognitive behavioural therapy(CBT) and other local preventive services.
It was notable that the twopilot schemes in wider CBT in Doncaster and Newham were not put
out to tender even though there would have been considerable private
and voluntary interest in providing for them.
-
Introduce direct payments for people needing therapy in thecommunity.
There are many professionals at present who wish to dothis work but cannot do it because of rationed funding in the NHS.
-
Make much more use of direct payment for patients who arereaching the discharge/rehabilitation stage.
Direct payment can beused for support in moving to accommodation, for employment skills
training and/or for activity which contributes to recovery.
-
Develop a strategic partnership with the private and voluntary sectorto accelerate investment.
Such a partnership could bring about asubstantial change in three years, especially as the change could unlock
some of the large property assets within the existing hospital system.
-
Introduce a much more active commissioner/provider relationship.To some extent mental health services have been the area which the
internal market forgot. Now joint commissioning with social services
supplies a chance for a more effective use of the new incentives. The
introduction of payment by results is essential.
It is now widely appreciated that mental illness is not simply a medical
problem it often raises a moral challenge of helping individuals to regain
independence. The compulsion of monopoly is the very opposite of this
independence. Choice and pluralism will enable a successful pursuit of
this goal of independence.
1. Introduction
Our aim in this report is to review the strategic outlook for improving services
for people with severe mental illness and to make some positive proposals for
ensuring that patients can benefit from the new agenda of choice and quality.
We write with a sense of great urgency. The Five Year Review of the National
Service Framework (NSF) conveys a somewhat favourable impression which
verges on wishful thinking. The difficult question of whether incremental
change a mixture of new teams and a propping up of the old acute services
can lead to the radical change in the quality and range of services which are
required is completely ignored.
There has been some progress in improving services which is covered in the
Five Year Review, in particular the starting of new teams and high levels of
patient satisfaction. However progress has been slow. A Healthcare
Commission Survey showed that 77 per cent of patients in mental health
services were satisfied with the service they received.
1 But such response,though welcome and a tribute to the dedication of staff, must be treated with
caution if the expectations of patients are very low.
There is a much clearer focus on social inclusion as the most important aim
for patients. Treatment outcomes may have improved through the
availability of new drugs and better support.
But will these produce real gains for patients in terms of life chances? Often
in the past patients have become career patients cut off from society with few
relationships and little access to opportunities in housing and employment. It
is the realistic potential of moving towards a real improvement in choices for
patients which adds some urgency to the search for a different model. The
opportunity is available:
There is a new generation of professionals often working as community
staff or ward managers who are moving away from the purely medical
model and have the confidence and expertise to help patients in more
short-term intensive treatment. There is in fact a new generation of young
leaders who are capable of managing new kinds of projects.
There has been an increase in the involvement of user and carer groups in
managing services. There is a much more active constituency for better
services than was the case a few years ago.
There has been an increase in the potential contribution of private and
voluntary providers. These providers are now offering more services and
there is the potential for moving beyond spot contracts for emergencies
towards a more strategic relationship with a greater range of providers.
The closer partnership with social services creates opportunities for
greater use of direct payments and of the mixed economy of care.
1
Survey of users of services, Healthcare Commission, September 2006Recently there have been some very positive reports and campaigns that have
emphasized the importance of improving services in mental illness. Lord
Layards report for the Cabinet Office in 2004 documented the gains from the
expansion of psychological therapies including Cognitive Behavioural
Therapy (CBT). In 2005, Rethink and the IPPR produced an excellent report
titled
Mental health in the mainstream. The One in One Hundred campaignlaunched in July this year has provided fresh impetus for a re-appraisal in
showing very clearly the continuing impact of schizophrenia on patients,
carers and society.
2 The recent review Ten High Impact Changes for MentalHealth Services
by the National Institute of Mental Health has set out veryclearly how services need to be improved.
It is now widely appreciated that mental illness is not simply a medical
problem it often raises a moral challenge of helping individuals to make
choices and to live independently. Mental illness often means that people
cannot function as independent human beings and recovery must mean that
they regain the ability to live independently and to make choices. This is why
rehabilitation through access to employment and housing opportunity is so
important. In pursuit of this goal of independence it is surely logical that
patients would be offered an increasing amount of choice as their recovery
continues. The compulsion of monopoly is the very opposite of the
independence and choice which is central to recovery. Where improvements
have occurred they have been painfully slow.
We need to take a realistic look at whether the services as currently modelled
can really deliver security and choice. There seems to be an increasing
paradox that choice and pluralism are required for acute services but are a
very low priority for mental health services. There has been a failure to define
a constructive long term partnership with the private and voluntary sector.
The current relationship is based on spot purchasing; a model which is
regarded as delivering high cost and poor communication.
The continuing model of state provided monopoly is very different from the
mixed economy of care in social services and has probably made joint
working more difficult. There has been a postponement of the introduction of
payment by results to mental health services a major blow as reform needs
to be sped up not slowed down. By postponing payment by results trusts
who worked hard to prepare for its introduction have been left dismayed and
trusts who didnt have essentially been rewarded for their failure. Paymentby
results and the national tariff is also a major driver for developing
pluralism in mental health provision.
The ingrained mindset of commissioners at all levels below the Department of
Health seems to be that the NHS family provides the totality of (health)
care. The third sector, whether profit or the so called not for profit, is seen as
peripheral to main stream thinking. To some extent, this is driven by the
Department of Health since Key Performance Indicators either tend not to
www.oneinonehundred.co.ukrecognise such expenditure with non-NHS providers or at worst, negates
against it.
There were no targets for waiting times in mental health services which are
much longer than acute services. Even now the 18 week target does not apply
to non-consultant led services which are particularly important in mental
health services. Many services such as CBT are unavailable because waiting
lists are so long that they have been closed.
There seems to be a compulsion to stay with the present model rather than to
use the reforms fully. In many ways a cultural gap is opening between acute
services based on choice and pluralism and mental health services which are
still a monopoly.
In this paper we set out the case for using the new reform incentives much
more actively: far from being a threat to better mental health services they
offer hope of more rapid progress and a more creative adjustment to an era of
likely low growth in spending.
Some argue for a choice of treatment rather than a choice of provider. The
reality is that state monopoly services move so slowly that the only way to
ensure a choice of treatment, as well as reasonable access times and good
quality environments is to create a choice of providers.
We need to look for new and innovative ways to get more rapid progress in
terms of improved service particularly when there are many signs that mental
health services will lose priority for funding compared to acute services.
Previous reports have given us a list of many fine aspirations but how will
we actually make them a reality? It is significant that after seven years of the
NSF the Government has announced a new special allocation of £130 million
to remedy the most basic deficiencies in accommodation for people with
serious mental illness.
3 But there is little evidence that the funding for this isevident locally. A recent report from the Sainsbury Centre for Mental Health
has noted that mental health trusts tend to faces lower funding increases than
the NHS as a whole and face financial difficulties due to deficits in other parts
of the service.
There is of course considerable capital and new buildings within the
independent sector that could be used immediately to treat NHS patients
therefore negating the need to spend what is unnecessary public sector
capital.
£130 million investment for mental health, Department of Health press release, 20 October 2005.Under Pressure: the finances of mental health trusts, Sainsbury Centre for Mental Health, July 2006.
2. Access to mental health treatment
Access to specialist mental health services and psychological treatment
The burden of mental illness is great. The NHS Improvement Plan includes
estimates of the disease burdens, which show that mental ill health is second
only to cardiovascular disease in disability adjusted life years (see Table 1).
Table 1: The Burden of Disease in Europe
Cause Disability adjusted life years Per cent
Cardiovascular Disease 33,381 21.8
Mental Illness 31,080 20.3
Injuries 22,707 14.8
Cancers 17,642 11.5
Digestive Diseases 7,087 4.6
Infectious Diseases 6,823 4.4
Respiratory Diseases 6,416 4.2
Musculoskeletal Diseases 5,304 3.5
Sensory Organ Disorders 4,150 2.7
Respiratory Infections 3,891 2.5
All Other Causes 14,631 9.5
Total 153,111 100.0
Source: The NHS Improvement Plan, Department of Health
Spending on mental health services has risen within the UK over the past five
years. However, the majority of resources are being concentrated on the
minority of patients who are regarded as high risk in terms of violence. Many
groups of patients who are in urgent need of help and where the social
returns would have been positive have great problems of access. The Review
completely fails to provide evidence on the quality of service for people
where illness is not a major risk to others. The whole programme has
developed as a custodial model with high levels of compulsory treatment
rather than a health programme which clients engage with voluntarily in
order to achieve benefits. There is currently a concentration of funds on the
0.5-2 per cent of the population who suffer from psychotic illness, yet the vast
majority, suffering from common yet disabling disorders such as depression
and anxiety, may never see a mental health specialist.
Waiting times for therapy services in the community are now far longer than
for most treatments for physical illness. The Five Year Review reported some
growth in the numbers of psychologists and therapists but there seems little
chance that such waiting times will reduce at any time in the future. Some of
the worst experiences of waiting for example in child psychology services
where the waiting was so long that the client was no longer a child may
have been reduced: but waiting times are such that for many clients the
services may become completely irrelevant.
Targets for reducing waiting times have not been applied to mental health
services. This may have meant less attention and a lower priority from
funding organisations. It has certainly reduced the sense of urgency about
reducing waiting times especially for psychological therapies.
The Department of Health project for Graduate Mental Health Workers was
an imaginative initiative that where implemented and understood could have
had a huge impact on primary mental health with a subsequent impact across
the whole systems, for example through faster return to work following
depression. Unfortunately, the Graduate Mental Health Workers were rolled
out too late in the process without sufficient understanding by the majority of
commissioners and providers as to their role.
Several organisations have previously noted the poor performance of mental
health services in England despite their high and growing importance. In
particular, these reports highlight that many patients are not being seen by
specialist mental health services, and where referrals are taking place, waiting
times are long.
Healthcare Commission
In its report,
State of Healthcare 2005, the Healthcare Commission said thatmental health services fall short of national standards despite the fact that
one in six adults requires some sort of mental health support. It found
serious problems with:
Access. Only two thirds of community-based crisis resolution teams
operate 24 hours a day and fewer than half of people who receive mental
health services reported that they had access to crisis care. It also found
that only half of people with depression were receiving treatment, only 8
per cent had seen a psychiatrist and only 3 per cent had seen a
psychologist. This was despite strong evidence that both drugs and
psychological treatments could provide real benefits to people with
mental health problems.
Waits. It said that information on waiting times for mental health care is
not collected nationally but that there was evidence to support the claim
that people are waiting a long time for appointments with psychiatrists
and other mental health professionals.
Variations in care. It also reported serious problems with variations in
care across the country noting that the National Service Framework for
Mental Health found significant differences in PCT spending on mental
health care, including a widening gap between the North and the South.
Inequity. The Commission noted that some disadvantaged groups are
more likely than others to fail to receive services.
In September this year the Commission published its first national review of
adult community health services. Assessing the 174 Local Implementation
Teams (LITs) who are responsible for ensuring community services it
found that only just over half of were rated as excellent or good.
Mirroring its previous report it found poor access to out-of-hours crisis care
and accommodation. Only 50 per cent of people had access to talking
therapies and in 20 per cent of LIT areas this figure was significantly lower.
5Kings Fund
In their
Independent Audit of the NHS under Labour (1997-2005), the Kings Funddrew on previous research and stated that there has been no shift in
performance, despite the extra resources in mental health services.
It notedthat there had been little improvement in star ratings for mental health trusts
and that one summary of inspection reports found that the majority of trusts
face significant challenges with a high use of agency or locum (that is
temporary) staff, long waits for children and teenagers to be seen by a
specialist, long waits for psychological therapies, and problems in getting
patients in and out of acute inpatient care.
OECD
In its latest
Economic Survey of the United Kingdom, the OECD noted poorperformance in mental health services and the effect this had on people
suffering from mental illness:
Today, patients still have to wait for six to nine months to access
psychotherapy while conditions often become more entrenched .
Using a combination of medication and cognitive behavioural therapy,
most people suffering from depression can be helped to a point where
they can work most of the time, and having something meaningful to
do is in itself a help.
Yet, in Britain only one in five persons suffering from severe
depression gets the chance to see a psychiatrist. For some, this is
because they themselves do not seek or wish treatment, but in most
cases it is because of capacity shortages so that general practitioners are
left with the responsibility of treating the person. Patients have to wait
for six to nine months to access psychotherapy while conditions often
become more entrenched.
Postcode rationing of new therapies
There is a backlog of unfinished business in ensuring that patients can get
access to new therapies. There has been much discussion about the role of
different drug therapies but now NICE has supplied definitive guidance.
Health watchdog highlights gaps in community mental health care,Healthcare Commission, 29 September 2006.
Independent Audit of the NHS under Labour (1997-2005), Kings Fund, March 2005. Economic Survey of the United Kingdom, OECD, 2005.Here we present the facts about the level of compliance with NICE
recommendations.
The Technology Appraisal by NICE estimated that in England and Wales
there are 210,000 individuals who are potentially eligible for treatment with
atypical anti-psychotics. Of these 30 per cent were estimated to be in the
treatment resistant group who would not use the first line therapies. NICE
estimated that some 60 per cent of remaining patients should move to the
newer therapies, which would involve use by some 80,000 patients.
Our study follows a recent review of postcode rationing in the use of new
anti-cancer drugs.
Some of these recommendations began implementationwell before the recommendations on atypicals. The report by the National
Cancer Director showed considerable concern about the differences in access
to new therapies. Our study shows that there can be similar concerns in other
areas. Indeed the differing rates of prescribing in mental health seem
somewhat larger than in the case of cancer therapies. During a period of
increased concern about the implementation of NICE recommendations this is
the only set of NICE recommendations that affects patients with severe
mental illness.
We have made a detailed examination of each individual Primary Care Trust
in all of the Strategic Health Authorities. PCTs are now assessed by the level
of implementation of this and other NICE guidelines. Performance levels are
shown in Table 2 below with Grade 5 representing the highest level of
implementation.
Table 2: Performance levels in take up of atypicals. 2004-5
Grade 1 Under 35 per cent
Grade 2 35.9 per cent to 43.5 per cent
Grade 3 43.5 per cent to 54.6 per cent
Grade 4 54.6 per cent to 60.0 per cent
Grade 5 More than 60 per cent
We summarise data on the current percentage of atypical prescribing as a
proportion of total anti-psychotics prescribed in each individual PCT in
England and prescribing levels within SHA areas.
There are nine SHAs where on average prescribing levels are in the 54.6-60.3
per cent range, thirteen in the 3rd grading between 43.5 and 54.6 per cent and
four in grade 2 with atypical prescribing between 39.5 and 43.5 per cent and
one with prescribing well below 33.9 per cent (data was available from 27 out
of 28 Strategic Health Authorities). The range in 2004-5 was from South West
London with 60.7 per cent to Trent with 33.9 per cent.
We can identify the 30 PCTs, which were top and bottom performers. Of the
last 20, 14 are in the East Midlands and East Anglia. There is only one of the
Review of variations in the usage of cancer drugs approved by NICE,National Cancer Director, 2004.
bottom 20 PCTs (East Surrey) in the South East. In contrast 16 of the top
performing PCTs are in the South East or the London area and only four
Airedale, Coventry, North Tyneside, Newcastle and Central Cheshire are in
the North or the Midlands.
These results are even more striking given that atyipicals are hardly new and
they are not really that expensive in the context of other modern medication
as well as having a significant positive effect in terms of value for money
across a whole systems approach.
Greater community based care
The lag in use of new therapies is one indication of the challenges facing
mental health services. But there are other signs that mental health services
are having great problems in moving towards a more personalised
community based model of care. Any move towards higher spending on
community teams is taking place against a background of additional
spending on hospitals.
Table 3: The Mental Health Services Programme Budget
(£ million 2003-04 prices)
Inpatients Outpatients Day patients
Community mental health nursing
Community mental illness nursing
1999-00 2,257 408 362 534 740
2000-01 2,513 448 369 561 845
2001-02 2,601 521 339 515 862
2002-03 2,767 674 354 541 937
2003-04 2,857 882 316 640 1,033
Increase +600 +474 -46 +106 +293
Percentage increase
+27 +116 -13 +20 +40
Source: Public expenditure on Health and Personal Social Services, Department of Health
Memorandum to the House Commons Health Select Committee, 2005
Thus from 1999-00 to 2003-04 spending on inpatient care rose by £600 million
(27 per cent) even though the number of admissions fell and serious concerns
remained about quality.
It is worth noting that with the possible introduction of the Mental Health Bill
(having previously been shelved in March 2006, Patricia Hewitt has said a
new streamlined version will be introduced as soon as parliamentary time
allows
9) there could be an increase in the use of non-residential orders whichwill see compulsory treatment being carried out forcibly in the community.
The Kings Fund has stated there will probably be a year-on-year increase in
the number of people on orders as they become part of the mental health
Oral answer to a written parliamentary question, 18 July 2006 col 150.system and their effectiveness for some patients is demonstrated.
While this raises concerns about the liberty of patients who are given compulsorytreatment, it indicates that there will be further movement towards
community based rather than acute based care.
Data for inpatient length of stay shows that much of the increased spending
on hospital care has been used to fund patients staying over a year (see Table
4 below). There has been some success in reducing short admissions under a
year but this has been in line with the general reduction in all stays between
1999-00 and 2003-04.
Table 4: Number of patients by duration of stay
1999-2000 2003-04 Number increase or decrease
Percentage change
All durations 200,900 171,650 -29,250 -15
Under 1 week 45,640 38,260 -7,380 -16
1 week 1 month 82,230 65,410 -16,820 -20
1 month 3 months 50,500 43,750 -6,750 -13
3 months 1 year 19,400 14,290 -5,110 -26
1 year 2 years 1,770 5,540 +3,770 +213
2 years 5 years 940 1,970 +1,030 +110
5 years 10 years 240 1,030 +790 +329
10 + years 110 370 +260 +236
Duration unknown 170 1,020 +850 +500
Source: Public expenditure on Health and Personal Social Services, Department of Health
Memorandum to the House Commons Health Select Committee, 2005
The number of patients whose duration of stay is over a year has increased by
192 per cent between 1999-00 and 2003-04. Clearly hospital spending has
become somewhat more concentrated on a relatively small group of longer
stay patients. The balance of funding would be even clearer if it were possible
to take full account of the funding of patients in the private sector. Most of
these are medium stay patients who may not be fully counted in admission
statistics to NHS units. While the intention has been to develop a more
community focused service the funding has gone in quite a different
direction.
A Question of Numbers: The potential impact of community-based treatment orders inEngland and Wales, Kings Fund, 2005.
3. Quality of inpatient care
The quality of inpatient care has been rated as low by numerous surveys
most recently by the Sainsbury Foundation and above all in a powerful report
by the Mental Health Act Commission.
The service does not operate withinthe same framework of compulsory standards as the Commission for Social
Care Inspection (CSCI) sets for long term care in the private sector. If there
had been the same rigour of outside inspections against defined standards for
NHS facilities as the private sector, a number of them would have been closed
down for failing to meet standards. Even where the physical environment
has been improved there is often little positive about the day-to-day
therapeutic regime with extended periods of inactivity and boredom.
The Mental Health Act Commission Report
In Place of Fear provides muchmore definitive evidence on the state of inpatient care than has been available
before. It is of great importance because it is based on unique access to the
actual conditions in wards all over England. Presenting a picture of great
difficulties with staffing, quality of care and rising risk it must cause deep
disquiet. The Department of Health response has been a new programme for
improving the built environment for inpatient care. We would see this as a
totally inadequate response to the depth of the crisis revealed in the report.
In an audit of mental health and learning disability wards the Healthcare
Commission found that 23 per cent of respondents reported sharing wards
with members of the opposite sex when they did not want to.
12 This findingcontrasts with Government figures showing 98 per cent compliance with
guidance on single sex accommodation by mental health trusts.
From 1999-00 to 2003-04 spending on inpatient care at constant prices rose by
£600 million (+27 per cent). The number of admissions fell from 200,900 to
171,650 (-15 per cent). Thus spending per admission in real terms rose from
£11,200 to £16,600 a rise of 48 per cent against a background of increasing
concern about the quality of inpatient care.
The service is operated with very high levels of compulsory treatment. The
number of detentions under the Mental Health Act rose from 24,811 in 1987-
88 to 46,003 in 1998-99. In the most recent year 2003-04 there was 43,847
detentions. Few of these detentions are of elderly people. But what these
figures show is that of adults over 65 admitted to hospitals 40-50 per cent are
being treated compulsorily with the proportion nearing 70 per cent for
patients from ethnic minorities.
Some of this compulsion may be justifiedby risk but some of it reflects the difficulty of getting patients to accept
treatment on a community basis.
In a long term perspective mental health services have been associated with
high levels of compulsory treatment and even though numbers have not
In Place of Fear, Eleventh Biennial Report 2003-2005, The Mental Health Act Commission, 2005. The National Audit of Violence (2003-2005) Final Report, The Healthcare Commission, 2005. Public Expenditure on health and Personal Social Services, Department of Health Memorandums tothe House of Commons Health Select Committee
increased in the last few years they have continuedto rise in relation to a declining number of new admissions. The great majority of longer term
admissions still involve compulsion.
4. Mental health and the social environment
The OECD has noted the growing importance of mental health and in
particular its effect upon the economy. It notes that a growing number of
incapacity benefit claimants receive it due to reasons related to mental health.
In its latest
Economic Survey of the United Kingdom the OECD stated:In the 1980s and early 1990s, disability benefit recipients were more
likely to have had problems with joints and muscles than to have
mental and behavioural disorders. But now people with mental and
behavioural disorders dominate, their number having grown to a
million incapacity benefit recipients today, five times the number in the
mid-1980s . The magnitude of this change raises a large challenge
for the health service about how to better help this group with
treatment and rehabilitation.
The below chart is taken from
Economic Survey of the United Kingdom 2005:It is vital to assess how new aims, incentives and policies could benefit users
to the mental health services. There is a serious danger that mental health
services will be left behind in this period of change of the whole of the NHS.
The Social Exclusion Unit has also produced a landmark report on mental
health and social exclusion, which sets out new policy options for better
rehabilitation and for reducing stigma.
Trust and PCT managers in the mental health services are going to have to
make sure that mental health services can take advantage of the new policies
and incentives in a reformed health service.
Economic Survey of the United Kingdom, OECD, 2005.Mental health and Social Exclusion, Social Exclusion Report, Social Exclusion Unit, Office of the
Deputy Prime Minister, 2004.
5. Further problems with the current system
There has been mixed success in attracting young doctors into psychiatry and
many posts remain unfilled or filled by locums. The Royal College of
Psychiatrists has set out a clear and positive strategy covering standards,
communications and structures. Among the aims in communication are those
of increasing collaboration with other healthcare professionals and
developing shared organizational goals.
There has been some success in attracting more young people into nursing
courses for psychiatric nursing but there may be little success in retaining
them to work in the NHS. According to internal health authority reports staff
gaps remain large with 13 per cent of nursing posts unfilled on inpatient
wards and 22 per cent in the London area. The NHS now faces a more
competitive labour market for such staff with competition from the social
services and from the private sector.
Mental health services have been associated with continuing levels of social
stigma. In fact social attitudes to people with mental illness appear to have
worsened over the past four years with surveys showing higher levels of rejection.
As the NHS enters a period in which patients have more power through
choice mental health services start with a history of little choice. Choice
should play a role for everyone; even during severe illness there may be
choices which are relevant for patients and carers. For the
discharge/rehabilitation stage choice surely becomes highly relevant. There
have been some real gains in terms of the greater role of user groups but there
is still a long way to go to offer choice in type or location of services in
housing access or employment rehabilitation.
The use of resources has shown little movement towards more spending on
housing or employment access. Nor has there been much development of
psychological therapies. Such programmes, which could provide pathways
to recovery, have attracted very little of the additional funding which the
service has gained over the past three years. Unfortunately, the Government
is (still) not joined up across agencies such as housing, social services and
health regarding Key Performance Indicators.
For the future, services are now in the position of competing for additional
funding without help from compulsory targets. Already according to local
NHS reports some mental health trusts such as in Sussex are receiving
increases of 5.5 per cent a year which are below the likely level of cost
increases. Many are losing funds to cover deficits in acute trusts. A policy
brief published by the Department of Health alongside Mental Health
Strategies
2005-06 National Survey of Investment in Mental Health Services foundthat Strategic Health Authorities have reduced their investment from the
Mental health and Social Exclusion, Social Exclusion Report, Social Exclusion Unit,Office of the Deputy Prime Minister, 2004.
agreed investment baseline for 2005-06 by £16.49 million, a reduction of 1.9
per cent.
Reductions come at a time of increasing costs and are an importantsign of how providers are swinging away from mental health services.
Mental health services are to face a period of slower growth in spending with
much unfinished business. It is difficult to see how trusts can both improve
acute care and invest in new services.
Policy Briefing, NHS investment in mental health services (2005/06),Department of Health, 2006.
6. Recommendations
The Five Year Review presented an optimistic picture of progress but as
funding restrictions increase it may be even more difficult to improve the
quality of inpatient care and care programmes for patients with the whole
range of severe mental illness. It is also very hard to see how with current
policies it will be possible to meet the 18 week target for access to
psychological and other therapies in the community. We should explore
options which would bring results for patients much faster.
The realistic outlook for these services is one in which there is an unusually
large gap between funding and expectations. The gap exists in acute services
but not to the extent which is now present in the mental health services. The
main service changes required are for building up capability for early support
in CBT and other community based services and for moving towards care
programmes with access to housing and employment for people with severe
mental illness. The new services have to be developed over a time of new
scarcity in funding indeed when many trusts may expect falling funding in
real terms. The reputation of the services is of great inflexibility and difficulty
in shifting resources. The record of increased spending on a diminishing
number of hospital patients supplies some evidence on this together with
numerous critical reports by outside agencies.
However the service also has some new strengths with a new generation of
managers and professionals with a highly positive approach compared with
the old guard. The wider use of new anti-psychotic drugs are improving the
treatment process for many patients so that patients feel better and
rehabilitation becomes a realistic option earlier for more patients. There are
also many new young staff in nursing, psychology and medicine who have
started to work in the services.
There are opportunities to use joint commissioning with social services to
draw on the social service experience of identifying new customer needs and
using public private partnership to design new services to meet them. There
should also be gains from the new Foundation Trusts with greater ability to
use investment to develop new services.
The funding outlook is at best one in which funding will remain constant in
real terms and it is more likely that many Mental Health Trusts will find their
funding shows little increase in cash terms over the next three or four years.
This is already happening to some large trusts such as the South West London
and St Georges Mental Health Trust.
The new care model with its emphasis on early intervention, community
support, reduced admissions and much more help to return to employment is
clear enough. There is certainly a lot more consensus around this model than
was previously the case. The key issue now is to make it happen in this very
difficult funding environment.
Here the reform incentives and systems could be crucial. They are often seen
as highly threatening with a strong preference for remaining with the
monopoly model: but choice, direct payment and pluralism offer the only
realistic way of making progress towards the new kind of care which is there
for the making. We would urge the following key first steps.
1. Develop a mixed economy of care in cognitive behavioural therapy
and other local preventive services. It was notable that the two pilot
schemes in wider cognitive behavioural therapy in Doncaster and
Newham were not put out to tender even though there would have
been considerable private and voluntary interest in providing for
them.
2. Key use of direct payments both for people needing therapy in the
community. This would help to develop the supply of services. There
are many professionals at present who wish to do this work but cannot
do it because of rationed funding in the NHS.
3. Make much more use of direct payment for patients who are reaching
the discharge/rehabilitation stage. Patients can be offered much more
choice and can be empowered to follow their own preferences and
interests. If the health services are to help the moral issue of how
people can re-establish themselves as free and independent individuals
with a job, a home and a friend as was well put by a dynamic
chairman of a London Mental Health Trust we must surely give them
more choice and more responsibility. Of course carers and their
professional supporters are going to be involved in most cases in these
choices but patients can start to decide on their own futures. Direct
payments can be used for support in moving to accommodation, for
employment skills training or for activity which contributes to
recovery. It can also be used for paying for support outside hospital.
4. Use of direct payments can be accelerated through joint management
with social services. There is already great support for the policy in
social services and experience in using them.
5. Develop a strategic partnership with the private and voluntary sector
to accelerate investment. The public/private partnership is one which
is still based around spot purchasing rather than about a framework
for pluralism. Through such partnership it would be possible to
replace many of the existing hospitals with new care centres which
would serve the new model of care. These new centres would include
inpatient care but on a much shorter stay basis and they would provide
much greater privacy and much more continuous support. Some of
these centres would be provided by voluntary and private providers
within common standards for quality. With such a strategic
partnership it would be possible to bring about a substantial change in
End of the prozac nation more counselling, more therapy,less medication to treat depression,
Department of Health press release, 12 May 2006.
three years, especially as the change could unlock some of the large
property assets which are within the existing hospital system. The new
generation could design the services to fit the new model of care and to
reflect the greater power of patient choice.
6. Introduce a much more active commissioner/provider relationship.
To some extent mental health services have been the area which the
internal market forgot. Now joint commissioning with social services
supplies a chance for a more effective use of the new incentives. The
introduction of payment by results is essential and it is one sign of the
recoil to monopoly that the introduction has been postponed yet again.
More active commissioning is already achieving significant results in
demand management through reducing admissionsincreasing even
more the requirement for flexibility and care programmes in the
community. This action plan is already being followed in a number of areas such as
Telford and Peterborough and supplies the only realistic chance of bridging
the large gap between aspiration and funding.
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