Leadership in Mental Health
As clinical commissioning groups and NHS England take on their new responsibilities for real, the NHS mandate has become the key to ensuring that the new NHS commissioners make progress against the Government’s priorities for better healthcare in England.
‘Many of the objectives of the mandate require mental and physical health support to be far better integrated’
The mandate provides the vital link between the NHS and the public nationally, setting out what NHS England in particular will be accountable to the secretary of state (and Parliament) for achieving over the next two to three years.
As a briefing paper published by Centre for Mental Health this month shows, the objectives set out in the mandate cannot be achieved without a major focus on mental health for people of all ages throughout the NHS.
Following the government’s pledge to work towards “parity of esteem” between physical and mental health, the mandate includes a far larger number of commitments to improving mental health support than any of the operating frameworks that were its nearest equivalent in previous years. These include the expectation that NHS England and CCGs will continue to make progress on improving access to psychological therapies, not just for working age adults with depression but for children, older adults, people with long-term physical conditions and those with severe mental illness.
The mandate requires the NHS to make progress in securing employment for more people with mental health conditions and to offer more personalised support to people in mental health services, including through the use of personal health budgets. It also seeks to ensure the service looks beyond its conventional boundaries, for example to work with colleagues in public health to improve support for young families and to continue the nationwide expansion of liaison and diversion services in police stations and courts.
It sets some important new challenges to NHS England in improving access to mental health care and bringing greater parity to waiting times. This will take action on several fronts, from speeding up access to care in a crisis to bringing down waiting times for psychological therapies and other forms of mental health support.
‘In the everyday actions of commissioners and providers the separation and inequality between the two will be tackled most effectively’
Many of the objectives of the mandate require mental and physical health support to be far better integrated. From improving maternal mental health to taking action to address the 15-year mortality gap for people with a severe mental illness, the artificial separation of mental and physical healthcare will need to be addressed throughout the NHS. Nowhere in the 21st century NHS should a person’s mental health needs be neglected or professionals lack confidence in dealing with a patient’s emotional or psychological needs.
The mandate will not on its own bring about parity between mental and physical health in the NHS. It is in the everyday actions of commissioners and providers at every level of service that the separation and inequality between the two will be tackled most effectively.
It will require local commissioners to look at where they invest scarce resources to get best effect. It will require continued action to collect robust and useful outcomes data both for mental health services and for people with co-morbidity conditions. And it will require concerted leadership and sustained commitment from NHS England and CCG boards to challenge existing ways of working that stand in the way of parity and integration.
The Francis report today set out some 290 recommendations to protect NHS patients from neglect and poor care. The report’s recommendations reach across the health services, from the accountability of individual professionals for their own conduct to the roles of the national regulators, professional organisations and the Department of Health.
‘The report raises questions about the relationship between personal and corporate accountability’
Like all parts of the NHS, the report will have a major impact on mental health care. It will change the way mental health professionals and organisations work, as well as affecting the wider systems and processes in the NHS within which mental health services operate.
The report’s publication comes just weeks after the publication of the government’s report on the abuse of patients at Winterbourne View and the system failings that surrounded it.
Last week, the Care Quality Commission’s annual report on the use of the Mental Health Act reminded us that a significant minority of people who are detained in hospital compulsorily are not given the quality of care and support that we would expect to receive or indeed that the act requires.
Taken together, all three reports suggest while there has been genuine progress towards giving service users a bigger voice in their own care, in treating people with dignity and respect when they are in hospital, and in responding positively when things go wrong, we have a long way to go.
Too many people’s experiences of being in hospital are of losing power and control, of feeling bewildered and “done to”, and of not knowing what is happening to them. For detained patients, these painful experiences can be magnified many times without the active support of families, friends and advocates.
For mental health professionals, managers and leaders, the Francis report’s recommendations will create new duties and forms of accountability. Professionals and organisations will have higher expectations in the way they conduct themselves and tougher sanctions, including proposed new criminal offences, when things go wrong.
This will, and should, provoke debate about the balance between professionalism and regulation in the maintenance (and improvement) of standards in healthcare. It raises questions about the relationship between personal and corporate accountability when care falls below the proposed “fundamental standards”.
Consequences for all
These are not new issues, but with decision making in the NHS increasingly devolved to local organisations it is vital that everyone in the system is clear about where accountability lies and what to do when they are concerned about quality of care. As Robert Francis’ report acknowledges, any new system must have the support of the health professions and be clearly understood by patients and families.
The implications of the report are no more nor less applicable to mental health services as to other parts of the NHS. However, we will need to examine closely how any new arrangements intersect with those in place in social care, for adults and children alike.
‘A considered response to Francis should include a full assessment of what it will entail for mental health services’
Unless quality regulation and accountability are well aligned between the two systems, service users and their families will be left to negotiate a difficult path between them both. Mental health care extends well beyond NHS facilities to private and voluntary sector providers, prisons and police stations. Again, it must be clear how standards will be applied: how, for example, might any new system help to prevent more deaths of vulnerable people in custody?
The Francis report demands a considered and timely response. Service users, families and professionals need to know what it will mean for them. That considered response should include a full assessment of what any actions will entail for mental health services and their partners, inside and outside the NHS. How, for instance, can we ensure that the proposed new standards and the “duty of candour” will help to protect detained patients and those on community treatment orders?
The NHS has a lot of reflecting to do. It must balance decisive action with the avoidance of knee-jerk responses to a report with profound consequences for all of us. A mature response − with a clear sense of what it means for people with mental health conditions, their families and those who support them.
This month the NHS has been reminded from all directions of the scale of the financial challenge it faces. While much of the focus of debate about the NHS continues to be the structural changes that are now taking shape, the bigger question remains how the health and care system is going to cope with the financial pressure it faces in the coming years.
At the beginning of December, the chancellor’s autumn statement announced the government’s intention to continue to maintain health spending up to 2015/16 while most other departments are likely to continue to experience real terms reductions in their funding.
‘We have heard a lot about integration but too often it has been two dimensional’
In the shorter term, it warned, the NHS faces the prospect of cutting services or reducing the quality of care by 2014/15 as the prospect of making continued productivity gains begins to tail off − in other words, many of the more painless methods of saving money are going to be exhausted.
The challenges facing the NHS are to some extent much less acute than those of many other public services. Local authority budgets, the police and welfare spending are all falling much more rapidly. But taken together with social care, the NHS and its partners face the longer term trend of steadily rising demand as the population ages and chronic illness and disability take up an ever larger proportion of its funding.
Whether the scale of the “Nicholson challenge” is £15 billion or £54 billion, the implications for the health and care system remain much the same. Small-scale, one-off efficiency savings are not going to do the trick. The entire system has to reform itself, not so much structurally as in the way it supports people’s health, wellbeing and independence.
Artificial divides, be they between health and social care, physical and mental health, or primary and secondary care, need to be dismantled.
We have heard a lot about integration this year but too often it has been two dimensional and focused on only part of the picture. From the perspective of the service user, any form of dis-integration is unhelpful and sometimes disastrous.
One of the biggest forms of dis-integration in our system continues to be that between physical and mental health support. Yet this year the Centre for Mental Health reported clear evidence that up to 10 per cent of the NHS budget is spent on the extra costs of treating long-term physical illness caused by the coexistence of mental health problems.
‘A decade of austerity may in the end spur on some long overdue fundamental changes’
From having liaison psychiatry teams in general hospitals to better collaborative care arrangements in the community, much of this cost could be saved.
The first clinical commissioning groups to be authorised will begin to face some stark choices in the way they spend their money next year. Most are already grappling with these dilemmas as they consider how to cut costs.
Perhaps uniquely among public service commissioners, they do not have to make dramatic immediate cuts to their spending. They have the opportunity − the necessity in fact − to take their time; to reform patterns of service provision and established ways of working; to shape health services on a different footing.
A decade of austerity may in the end spur on some long overdue fundamental changes to our health and care system. To do otherwise is to risk the health and wellbeing of every one of us in the years to come.
Today the NHS received its first mandate from the government. The mandate, significantly ‘slimmed down’ from the draft produced for consultation earlier this year, offers a clear message from the start. Throughout, the ‘parity of esteem’ between mental and physical health is no mere rhetorical device.
From the outset, the mandate sets the NHS Commissioning Board and clinical commissioning groups the task of tackling the longstanding, and long outdated, disparity between mental and physical health support on the NHS.
This clear message is vital for the success not just of the government’s mental health strategy but also to make the NHS as a whole fit for the future.
Closing the gap
Joining up mental and physical healthcare, and giving each equal precedence, will increase the efficiency of the NHS by enabling it to respond to people as people instead of separating out their different diagnoses without reference to one another.
‘The task of delivering on the mandate now falls on the commissioning board’
To underline this point, a report published last week by the Centre for Mental Health and the NHS Confederation concluded that ensuring every hospital had an effective liaison psychiatry service could save the NHS some £1.2 billion a year.
The mandate makes a number of commitments that should help to make ‘parity’ more of a reality than it is today.
It makes integration a priority for all NHS organisations at all levels. There have been numerous debates about how to achieve different kinds of integration (such as between primary and secondary; mental and physical; health and social care) in a complex system. But for patients and service users, the daily reality is of services that are not integrated in numerous ways.
Genuine integration has to encompass all these elements, all working for the person, not just some joining forces in isolation from all the others.
The mandate calls on the board to make measurable progress to closing the health gap for people with severe mental illness, whose life expectancy now stands 15-20 years lower than average. It requires action to continue the national rollout of the Improving Access to Psychological Therapies programme to 15% of those who are eligible for it. And it sets the objective of improving the diagnosis of post-natal depression.
‘Making parity a reality is fundamental to the success of the whole NHS’
The mandate also sets longer-term ambitions for the NHS. These include the development of better means of addressing waiting times for mental health treatment and to consider how to create stronger entitlements and choices in this area.
Coinciding as the mandate does with the proposed changes to the NHS constitution, the need to enhance people’s entitlements regarding mental health treatment compared with those for physical health is starkly evident.
The task of delivering on the mandate now falls on the commissioning board. It has a historic opportunity to tackle some of the most dramatic inequalities in health and healthcare. The government, however, retains the crucial role of holding the board to account robustly for achieving on all of its objectives.
Making parity a reality is fundamental to the success of the whole NHS. We must now all work together to achieve it in every part of the country.
In last month’s HSJ, Duncan Selbie raised serious questions about the NHS’s record on public health and tackling the causes of ill health and health inequalities.
With public health directors moving to local government, and a new national agency in Public Health England to take the lead on prevention, there may be some who see the NHS’s obligations to promote good health as having been reduced.
The reality, however, is that while lead responsibility for public health will lie outside the NHS’s boundaries, health professionals and NHS organisations remain as key to improving our health and preventing illness as they have ever been. While councils will set the priorities for dedicated public health spending, GPs and the Commissioning Board with its various roles will be important partners without whom some of the most promising and effective interventions cannot be done.
‘Too often GPs and teachers do not know how significant a public health issue behaviour is’
A case in point is parenting. There is now clear and incontrovertible evidence that children with the most serious behavioural problems grow up to be among the most disadvantaged and unhealthy people in our communities.
One child in 20 has a severe behavioural problem while another 15 per cent have less severe problems; between them they go on to commit 80 per cent of crime during their lifetimes.
Feelings of stigma
Yet behavioural problems can be either prevented or managed using simple and inexpensive interventions. In most cases, evidence-based parenting programmes like Triple P and Incredible Years can in a short time support parents to manage their children’s behaviour and dramatically improve their health and life chances.
Such programmes, however, are not widely available. Where they are provided, they are not always targeted towards the families who need them most. And not all such programmes are run faithfully to the programme’s design by staff with the right skills to deliver them most effectively.
Key to the success of parenting interventions is the ability of universal health services to identify the families who could benefit from them and make referrals successfully.
Research shows that most parents who struggle with their children’s behaviour ask for help. Most often they ask their GP or their children’s schools. Yet too often GPs and teachers do not know how significant a public health issue behaviour is or what programmes exist locally to address it or how to refer in to them in a way that doesn’t make parents feel stigmatised.
General practitioners, health visitors, midwives and mental health professionals are all ideally placed to identify families where behavioural problems are either emerging or already causing distress.
If they are aware of the support that is available and have the know-how to encourage parents to make use of it, health professionals can bring about a major improvement in the life chances of some of the most disadvantaged children in their communities.
It is in the relationships between the new public health system and the NHS, alongside their wider links with schools, housing providers and the police, that this major public health issue can be tackled successfully.
As the new systems take shape and learn to work together, providing parents with the support they need to give their children the best possible start in life can be a marker of what they can achieve and the difference they can make to the people they both exist to serve.
For the new minister responsible for mental health policy, there will be challenges and opportunities in equal measure. But what might (or should) his priorities be from this week onwards? And how will he achieve the ambition of putting mental health on a par with physical health?
The new minister benefits from the dedication of his predecessor, Paul Burstow, to creating and supporting a cross-government strategy, No Health Without Mental Health. The strategy sets out an ambitious agenda to improve mental health for all, tackle inequalities and radically improve the life chances of people living with mental ill health. Making it happen against a backdrop of organisational change and financial pressure, however, is another thing altogether.
So one big priority for the minister will be to see through the far-reaching change that the strategy requires: to embed mental health in the new public health system; to build the capacity of public services to intervene early; and to make Recovery the defining feature of mental health support in England. None of these will be achieved overnight but without government support the first steps to delivery will not be taken and the aspirations of the strategy will remain just that.
But the challenges (and opportunities) do not stop there. System reforms in the NHS have major implications for mental health services and the people who use them. The new commissioning system may stimulate creativity and innovation in mental health care commissioning but will all CCGs be able to demonstrate commitment to this and to work effectively with local authority partners? Ensuring that the Mandate places mental health on a par with physical health will be an important starting point, following which work is still needed to develop clear and robust outcome measures and to implement payment by results in a way that improves quality of care and promotes recovery.
Changes to public health and early years services create an ideal backdrop for enhancing mental health promotion and prevention work; but only with effective leadership from the centre to make these ‘must-do’ actions for local authorities.
Social care reform also needs to take mental health into account. The aspiration of a system that promotes independence is welcome but only if the new funding and legal arrangements encourage early intervention and support for recovery.
Finally, but perhaps most challenging of all, the minister can become a champion for mental health (and those living with mental illness) across government and in society more widely.
While public understanding of mental illness is beginning to improve, myths and misperceptions remain and discrimination continues to prevent people with mental health conditions from having a fair chance in life. National leadership to combat stigma and promote equality is as important now as it has ever been.
And as No Health Without Mental Health is a cross-government strategy, cross-government action to implement it is vital for success. This means linking with the Department for Education on schools; with the Ministry of Justice on prisons and probation; and crucially with the Department for Work and Pensions on welfare reform. The latter is causing especial concern with continued difficulties over assessments for a number of benefits and proposals to increase the use of sanctions with disabled people. These issues risk undermining efforts to improve people’s health and life chances.
The new minister for mental health will soon have a burgeoning in-tray. But it is a job that can make a difference to the lives of millions of people and address some of the starkest inequalities in health in our society.
Figures released at the end of July show just how big a task achieving that will be. Yet there are signs from outside the NHS that as a society we are starting to make some progress in improving understanding and attitudes towards mental illness and those who live with it.
The annual survey of investment in mental health services for working age adults showed that for the first time in a decade real terms spending on mental health services fell last year. The reduction was a relatively small one: 1% when compared with general inflation. Inflation in the NHS, however, tends to run much higher. And many people with mental health conditions rely on a range of services (for example for housing support, substance misuse and employment), many of which are also experiencing reductions in spending.
The publication last month of the implementation framework for the mental health strategy offered a reminder of the importance of investing in evidence-based approaches, in early intervention and in support for Recovery. On these issues the survey of investment provides a mixed picture. Spending on assertive outreach and crisis resolution services is falling but investment in psychological therapies and Early Intervention in Psychosis services is continuing to rise (if not at such a high rate as previously).
Secure mental health services, meanwhile, continue to grow and to account for almost £1 in every £5 we spend on mental health care.
The survey of investment focuses particularly on services for working age adults and there is a separate survey of services for older adults. The position of funding for child and adolescent mental health services (CAMHS) is not included in the survey but what evidence we have suggests that reductions in spending are occurring in several regions of England, especially to lower tier services (i.e. those with a greater emphasis on prevention and early intervention).
Spending reductions are not unique to mental health services of course. But mental health care already experiences a yawning gap between its share of the burden of disease and its share of health care spending, and news that a mental health services tariff is still some way from being ready makes it vulnerable to further ‘salami slicing’ from commissioners.
Far from the coalface of NHS commissioning, however, last month saw Channel 4’s enlightened and enlightening series of programmes aiming to dispel some of the longest standing myths about mental illness. From Jon Richardson’s exploration of OCD to the appearance of people with a range of mental health conditions across the channel’s programmes, ‘4 Goes Mad’ was an imaginative and thought-provoking way of tackling prejudice and dealing with the crucial issue of disclosure at work.
One of the series’ central messages - that people with mental health conditions can work and should not be denied the chance to do so - is one many NHS Employers have yet to fully heed. If the NHS is serious about ‘parity of esteem’, its employment policies and practices should be as much a part of the process as its spending decisions.
The framework sets out a number of actions for organisations ranging from mental health service providers and commissioners to schools, employers and the criminal justice system. For each it identifies how they might take action now to help to bring about the change needed to achieve better mental health for the whole population alongside better life chances for people with mental health conditions.
The role of the framework is not to supersede the strategy but to give organisations a starting point in translating the vision into reality; the first steps towards achieving the strategy’s ambitions in an environment of structural change, system reform and immense financial pressures on public services.
Unlike most documents produced by government, the framework is a genuine ‘co-production’ between it and a range of independent organisations, including Centre for Mental Health. As a result, it brings together a range of perspectives and understandings about what needs to be done to bring about change in people’s lives. It aims, ultimately, to leave no one in any doubt about their responsibility for the strategy as well as offering very practical suggestions for how to make a difference in their localities.
Achieving the strategy’s six objectives remains, of course, a major challenge. To take just one objective, improving the physical health of people with a mental illness and vice versa, we are only at the beginning of a long journey towards integration and better outcomes for the half a million people with a severe mental illness whose life expectancy is dramatically reduced and the four million with long-term conditions alongside depression and dementia.
Nonetheless, there are signs of a shift in understanding and expectation. The draft NHS Mandate now places a clear obligation on the Commissioning Board to place mental health on a par with physical health. Both Sir David Nicholson and Duncan Selbie have pledged the Board and Public Health England respectively to do their part to implement the mental health strategy at national level.
Many localities are also taking the initiative. Dorset County Council has a member ‘champion’ for mental health who works across the council and with local health services and employers to promote equality. Some clinical commissioning groups are making plans to improve local mental health services while local authorities are investing in parenting programmes despite the spending pressures they are facing.
Successful application of the mental health strategy will depend on both national and local action, with a range of services cohering and supporting one another to achieve more than any could do in isolation. The framework offers ideas about practical steps that can help to trigger bigger changes over time. In practice, though, what will make it work is people: coming together, championing change, building relationships and doing things differently.
The Health and Social Care Act earlier this year included a new requirement on the secretary of state for health to give equal prominence to physical and mental health. This week, a report published by the LSE has reminded us of quite how big a task this is.
The report, How mental illness loses out in the NHS, notes that mental ill health accounts for 23 per cent of the ‘burden of disease’ in the UK yet it receives just 13 per cent of NHS funding. At a total of £14bn a year, spending on mental health care is of course a major cost to the health service. Yet to put that in context mental ill health represents almost half of the total amount of illness among working age adults, three quarters of whom never receive any treatment for it.
The cost of failing to deal with mental ill health vastly outweighs what we currently spend on mental health care. The NHS alone spends some £8bn extra treating long-term physical conditions among people with co-occurring mental health problems and another £3bn on treating people with ‘medically unexplained symptoms’, many of whom may have an underlying psychological need. Mental ill health among the NHS workforce costs the service another £1bn.
At the same time, of course, the NHS is being asked to make savings of at least £15bn over five years. As the LSE report argues, investing wisely in improved mental health support – particularly for those who currently receive little or no attention – could help the NHS to reduce its overall costs while improving health and quality of life for people of all ages.
The largest current area of NHS mental health spending is on services for working age adults with severe mental illness. Many of these services are under considerable financial pressure, with the requirement to make savings affecting both their immediate and their long-term plans.
At the same time, many mental health trusts are taking important steps to become more Recovery-oriented in the services they offer. Recovery Colleges, for example, are now opening in a number of trusts across England, offering a very different approach to the way service users (and their families) are supported to build lives outside illness. As a briefing paper published this week by the Centre and the NHS Confederation notes, Recovery Colleges can bring about far-reaching changes to mental health services as well as to the lives of the people who learn (and teach) in them.
The current cost pressures on the NHS and the movement towards Recovery have entirely separate, and quite different, origins. Yet their coincidence in time carries major risks as trusts take steps to enhance their Recovery orientation while also being required to cut existing services; all at the same time as many service users are being reassessed for their benefit entitlements and finding themselves worse off financially, too.
These are challenging times for mental health services. Exciting new opportunities lie ahead in achieving the objectives of the government’s mental health strategy – such as extending access to psychological therapies, refocusing on Recovery and developing liaison and diversion services. Yet financial pressures continue to weigh heavily on these developments and threaten to blunt their impact and undermine their value.
The LSE’s reminder of the extent to which we still under-invest dramatically in mental health comes as a timely reminder that we need to be bolder in making the case for more and better mental health support, when and where it is needed, offering the kind of services people want.
Secure care accounts for almost one-fifth of NHS spending on mental health services in England. They include the three high secure hospitals as well as about 7,000 beds in medium and low secure units and a handful of community forensic services.
When the Commissioning Board takes over responsibility for specialised services in April 2013, commissioning secure care will be a major part of its remit. Getting this right will be a huge challenge and needs careful attention now to design a system without the blockages that beset it today.
People awaiting transfer from prison to hospital in a crisis are still having to wait for weeks and sometimes months for a secure hospital bed: a move that outside prison would normally be expedited within a few hours. And there is growing evidence that many patients spend considerably longer in hospital than they need because of difficulties in arranging discharges back to prison or into the community.
The encouraging news is that the way secure services are commissioned is already changing. While full-fledged payment by results is unlikely to emerge for another two years, this year the Department of Health is offering CQUIN incentives to providers that use the new clustering tool for secure care in order to begin the journey.
Payment by results systems do not in themselves guarantee improvements in service quality or outcomes for service users. Indeed in some cases they can disadvantage some groups of people, and we need to be watchful of this throughout the NHS. Nonetheless, these first steps towards PBR for secure services are to be welcomed.
Currently, secure services are commissioned using block contracts, top-sliced from PCT budgets and managed by specialised commissioning groups at a regional level. With beds purchased in advance, at a cost of £150,000 a year for low secure and more for the higher tiers of security, the system militates against the commissioning of timely and effective pathways through services, particularly when it comes to move-on accommodation and community-based services for those who no longer require inpatient care. This is exacerbated further by a lack of robust outcome measures, a high level of risk aversion in decision-making and an absence of clear guidance on the role and purpose of low and medium secure services. The result is a system that is high-cost with little evidence of value for money.
The potential for secure care to boost the life chances of some of the most vulnerable people in our society is considerable. Many service providers are exploring ways of adapting the Recovery approach to their environment. Others are developing move-on accommodation or integrating prison and secure care teams to facilitate faster transfers in a crisis.
To achieve consistent progress across the country, however, the Commissioning Board will have to get a grip on secure care commissioning as an early priority. It will need to redesign the system to pay providers for the outcomes they achieve, backed up with robust information drawn from service users’ experiences and clear guidance about the respective roles and expectations of medium secure, low secure and community services. This will take time to achieve, but concerted action now could help to create a system that is better at managing cost, speeding up admission and discharge, and creating good outcomes.