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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 Reform’s 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 a

better 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.

Reform’s previous reports on health include Investment in the NHS – facing up

to 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, the

final report of Reform’s 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 with

depression 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 nine

months” 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 and

day 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 and

community mental illness nursing rose from £1.3 billion to £1.7 billion.

- Numbers of short hospital stays have decreased while numbers of long

stays 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 prices

rose 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 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.

- Services must now compete for additional funding without help from

compulsory targets. Many are losing funds to cover deficits in acute

trusts.

- Despite their use in acute services, choice and pluralism are a very low

priority 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 mental

health 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 two

pilot 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 the

community. There are many professionals at present who wish to do

this work but cannot do it because of rationed funding in the NHS.

- Make much more use of direct payment for patients who are

reaching the discharge/rehabilitation stage. Direct payment can be

used 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 sector

to accelerate investment. Such a partnership could bring about a

substantial 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 2006

Recently there have been some very positive reports and campaigns that have

emphasized the importance of improving services in mental illness. Lord

Layard’s 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 campaign

launched 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 Mental

Health Services by the National Institute of Mental Health – has set out very

clearly 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 didn’t 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.uk

recognise 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 is

evident 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 that

mental 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.5

King’s Fund

In their Independent Audit of the NHS under Labour (1997-2005), the King’s Fund

drew on previous research and stated that “there has been no shift in

performance, despite the extra resources” in mental health services. It noted

that 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 poor

performance 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), King’s 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 implementation

well 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 which

will see compulsory treatment being carried out forcibly in the community.

The King’s 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 compulsory

treatment, 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 in

England and Wales, King’s 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 within

the 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 much

more 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 finding

contrasts 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 justified

by 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 to

the House of Commons Health Select Committee increased in the last few years they have continued

to 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 found

that 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 important

sign 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 George’s 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 admissions—increasing 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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