Leadership in Mental Health
A decade of austerity should spur on fundamental care reform
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’
But a report by the Nuffield Trust the same week warned that the NHS could face a “funding gap” of up to £54 billion by 2012/22 without real terms funding increases.
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.
Artifical divides
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.
Stark choices
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.
The mandate provides a historic opportunity for better mental healthcare
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.
Historic opportunity
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.
How public health can help the neediest parents
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.
Best start
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.
The new minister's agenda
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.
Parity of esteem
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.
Genuine 'co-production' now needs 'coming together'
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.
Securing equal mental health investment is still a big task
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.
Commissioning board must safeguard the future of secure care services
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.
On the road to Recovery
One of the most far-reaching commitments in the government’s mental health strategy when it was published last February was for Recovery to become the defining goal of mental health services in England.
While the idea of Recovery as an aim for mental health services has been around for a long time, making it the primary objective is another thing and the implications of this are considerable. Among those implications is the need for a big increase in the recruitment of peer support workers as vital members of the mental health workforce alongside traditional mental health professionals such as doctors, nurses and social workers.
Developing the role of peer support workers is one of the ten organisational challenges set out in the Centre’s Implementing Recovery. Through our work with the NHS Confederation’s Mental Health Network to support services to take on these challenges, it is becoming clear that peer workers can, with the right support, have a transformative effect on the organisations in which they work.
At an individual level, peer workers have unique insights into the issues that other service users face in making their Recovery journeys. They can also convey a sense of hope and opportunity for a life outside illness and, just as crucially, are able to use their skills and experience to earn an income from paid work.
Organisationally, just the simple presence of peer workers can spark many more changes, for example in the development of wider opportunities and in supporting people to make decisions about their lives and treatment choices.
One of the catalysts for this development was a visit to the UK in 2009 by Gene Johnson, chief executive of Recovery Innovations in Arizona, whose workforce includes large numbers of peer workers in many different roles at all levels of the organisation. His challenge to mental health services here was to be ambitious, be optimistic and above all be courageous in thinking about what people using mental health services can do.
Three years later and Gene Johnson is returning this month to speak at a conference organised by the NHS Confederation on the development of peer support workers in the UK. This has attracted a lot of interest. However, much has changed in that time. A number of mental health trusts and other providers are now beginning to offer paid roles for peer workers in clinical teams, supporting their development by establishing Recovery Colleges where the training can be based. These also provide service users with opportunities to work with staff on an equal basis to co-produce courses on living with mental illness and then deliver these to mixed audiences of staff and other service users.
Establishing Recovery as the defining principle of mental health services in England is not, however, all plain sailing. We are some way from reaching the tipping point from which progress is inexorable. Peer workers cannot simply be recruited as a form of cheap labour in tough economic times, for example. Nor should they become second class workers remaining subservient to more established professions. While there is no single “right” way to incorporate peer workers within the mental health workforce, there are plenty of wrong ways to do it and we need to be alert to them.
But that should not distract us from meeting the challenge we have been set. Mental health services across the UK have begun to move towards a Recovery focus. Growing numbers of peer workers are taking up new roles and Recovery Colleges are opening in a number of NHS trusts. The opportunity stands ahead of us to do something truly radical. If we take that chance, the difference it could make to the lives of many thousands of people and their families really could be really far-reaching.
Integrating mental health and substance misuse services
From the beginning of April, directors of public health will move from the NHS to local authorities at the start of a year of transition for the health system. As they move from primary care trusts, they will take with them a “ring fenced” budget that for the first time will include responsibility not just for health promotion and protection but also for drug and alcohol services.
Centre for Mental Health has been working alongside DrugScope and the UK Drug Policy Commission to examine what this transition, coupled with other aspects of the Health and Social Care Bill, might mean for people who have a “dual diagnosis” of mental health and substance use problems*. We have looked at what opportunities the new system might create to address longstanding barriers to offering this group of people adequate care and support and also at the risks the transition might pose.
Surveys suggest that some 75 per cent of users of drug services and 85 per cent of users of alcohol services experience mental health problems, while 44 per cent of mental health service users either report drug use or have been assessed to have used alcohol at hazardous or harmful levels in the previous year.
While there is ample government guidance and there are recognised pathways for supporting those with severe mental health problems alongside substance misuse issues, many such people do not receive integrated support. For the larger number of individuals with less severe mental health conditions alongside substance misuse problems, meanwhile, provision is less developed still. The current set of changes to the way health and substance use services are commissioned, funded, measured and held to account could result either in improved integration or in even greater fragmentation in the support offered to people with multiple needs.
It will be in the way the new system is managed and the new rules interpreted on the ground that the outcome will be determined in practice. Clinical commissioning groups and the Commissioning Board (at its various levels) will have the opportunity to work closely with Public Health England and Directors of Public Health to transform services for people with multiple needs, including those in prison. But there is also a risk that this group will be a priority for neither set of commissioners and that existing gaps in provision will be replicated in the new system.
Effective local and national leadership is likely to be crucial here. Health and Wellbeing Boards, for example, may offer a forum for joining up the commissioning of services for people with multiple service needs, including through pooled budgets. GPs can also champion improved support, especially for those whom existing single-issue services regard as ‘sub-threshold’.
Integrating support for mental health and substance misuse at all levels of severity is a challenge that existing systems have struggled to meet. The new health system has the potential to take steps in the right direction.
*Available at: Dual diagnosis: a challenge for the reformed NHS and Public Health England
Improving comorbity care is a key challenge for mental health
People with long-term physical conditions are the most frequent users of the NHS. Long-term physical illnesses affect some 30 per cent of the population of England, or some 15 million people. Mental health conditions, meanwhile, affect about 10 million of us. What is less widely acknowledged, and certainly less well managed, is the overlap between those two groups and the massive cost to the NHS of failing to treat mental and physical illness together among those who are living with both.
A report published this week by The King’s Fund and Centre for Mental Health sets out just how big a cost the NHS is paying for the artificial separation of physical and mental health among the 4.6 million people with a long-term illness that co-exists with depression, anxiety or dementia.
The report calculates that the excess cost of treating long-term conditions among this group is at least £8bn a year to the NHS alone. This is because for each person with a mental health condition alongside their physical illness the costs of treating the latter are 45 per cent higher than for someone with the physical condition alone.
Depression and anxiety are significantly more common among people with a range of long-term physical illnesses: depression is at least twice as common among those with cardiovascular diseases and those with diabetes, and it is extremely common among those with arthritis. People with COPD, meanwhile, are 10 times more likely than average to have panic disorder.
Outcomes from cardiovascular care are poorer for patients with co-morbid mental health problems, even after taking severity of cardiovascular disease and patient age into account. Studies have shown that cardiovascular patients with depression experience 50 per cent more acute exacerbations per year and have higher mortality rates. One study found that depression increases mortality rates after heart attack by 3.5 times while another found that patients with chronic heart failure are eight times more likely to die within 30 months if they have depression.
People with diabetes who also have co-morbid mental health problems, meanwhile, are at increased risk of poorer health outcomes and premature mortality. Co-morbid mental health problems are associated with poorer glycaemic control, more diabetic complications and lower medication adherence, and children with Type I diabetes are more likely to suffer from retinal damage if they also have depression.
The reasons for this excess mortality, morbidity and cost are complex but they include the reduced ability people with a mental health condition may have to manage their physical illness and a greater likelihood of health-damaging behaviour such as smoking. It should not, however, be seen as an inevitable cost.
While not all of the £8bn can be saved, improved integration can have a dramatic effect. The RAID liaison psychiatry service in Birmingham City Hospital, now cited in the NHS Operating Framework, saves the NHS some £3.5m a year in reduced hospital bed use. And outside hospital, collaborative care arrangements between primary care and mental health services, including psychological therapies, can improve the quality of support people receive at little extra cost to the NHS.
Improving the management of co-morbidity has already been identified by The King’s Fund as one of the top ten priorities for clinical commissioning groups to address as they take shape and begin to assume their new responsibilities. In taking on this challenge, commissioners will not just be able to achieve substantial cost savings but will also bring about dramatic improvements in the lives of some of the most vulnerable people in their communities.
The funding must be available to help achieve public health outcomes
This week, the first Public Health Outcomes Framework was published by the Department of Health. The framework sets out the measures by which the effectiveness of Public Health England will be judged from 2013 onwards. But concerns are already being raised about whether enough funding will be available to achieve these outcomes.
The framework includes many indicators that reflect the mental as well as physical health of individuals and communities. It includes existing measures from the NHS and social care outcomes frameworks such as employment and premature mortality rates for people with mental health conditions. And it adds new measures such as the proportion of prisoners with mental health problems and the emotional wellbeing of looked-after children.
While some of the new indicators are designated as “placeholders” for which robust measures are not yet available, and it is not yet clear how these measures will reflect differences in race, class and other equality dimensions, the inclusion of a range of mental health issues has the potential to bring about a sea change in the way public health professionals act to promote our emotional wellbeing.
The creation of a new public health system, and the move to local authorities for directors of public health, brings about a new opportunity to shift from a focus on preventing physical illness to an understanding of the many influences on our health and wellbeing. But with many local authorities facing major spending cuts there will be considerable pressure on public health budgets and tough choices about how they are spent.
Many items in the Public Health Outcomes Framework require attention to a range of factors that influence health. Domestic abuse, sickness absence and reoffending rates, for example, require a holistic view of health that not only take us beyond the artificial separation of physical and mental health but that also require directors of public health to exert influence over a range of public services such as schools, housing, the police and children’s services and indeed to engage with employers and communities.
Directors of public health can become major influencers in the communities they serve. They can exert a transformative influence on the risk factors for poor health, especially for the most marginalised and disadvantaged. They can help to achieve not just improvements in population health but also in rates of offending, homelessness and worklessness.
Making the Public Health Outcomes Framework an effective tool to measure the performance of public health services nationally and locally will not be easy. Many of the most important indicators need a lot of work before reliable data can be produced to support them. Others will be determined much more by the state of the economy and society than the day-to-day work of public health professionals. And if directors of public health find that they have insufficient resources to fulfil their potential, there remains the real danger that they will retreat to familiar territory and not take on this broader agenda. But the framework at least provides a starting point for a radical new vision of the role of public health professionals and their scope to help to bring about large scale social change.
What will 2012 have in store for mental health?
Mental health services and their partners face a challenging year in 2012. The introduction of payment by results in adult mental health care in England and the organisational changes taking place in the wider NHS are likely to create large-scale upheaval this year. Growing pressures on NHS budgets will also continue to affect mental health services, though hopefully not disproportionately. Alongside those pressures will be the increasing impact of cuts in local authority budgets, affecting not just social care but also housing and other key supports for people experiencing mental ill health.
Against this backdrop, it can be challenging to focus on improving the quality of care we provide or on the evident need to focus more effort on intervening early and integrating services across many different planes. While the Government’s mental health strategy has sent out a clear message in support of these objectives, there are too many competing priorities on the attentions on NHS leaders for that strategy yet to have taken effect on day-to-day decision-making.
With the new year inevitably comes talk of resolutions and new starts. Yet for mental health services in England new starts need to be accompanied by an awareness of what we do well already and are in danger of losing.
Early intervention in psychosis teams, for example, were developed under the National Service Framework for Mental Health and evaluations have shown the best of them to be highly cost-effective. Yet many of these teams are now being merged into generic community mental health teams and risk losing the distinctive approach that makes them so effective.
Likewise some assertive outreach teams are being cut at the very time that the creation of new and expanded diversion services for people in courts and police custody with mental health problems should be giving assertive outreach a vital role in sustaining support for people that other services find it hardest to reach.
We know that this year, and more likely than not the next few years too, mental health services have to do their part to achieve savings in the NHS budget and make the whole system more efficient. Yet in doing this it is vital we follow the evidence of what will achieve sustainable savings alongside improvements in the service people experience.
The NHS has the comparative luxury of a longer timescale to make these changes than say local government. Unlike most councils, it can reinvest money from less effective interventions to those that have the potential to offer better value long-term. This may include the creation of new and expanded liaison psychiatry services in general hospitals and the development of improved employment support in mental health services. But alongside these necessary changes we should at the very least be maintaining what works already, supporting staff who are working well in effective services and offering what stability we can in the midst of the maelstrom we know is to come.
'Safe and secure housing is critical to the wellbeing of mental health patients'
Two recent reports have drawn attention to an issue to which mental health services too often pay insufficient attention yet which is fundamental to the health and wellbeing of every one of us. Having somewhere safe and secure to live is one of the basic requirements of human life. Yet too many people with mental health problems, and particularly those who end up in the criminal justice system, do not have somewhere to live and as a result their health suffers enormously.
An NHS Confederation Mental Health Network briefing, Housing and mental health, examined the many ways in which addressing people’s housing needs is critical to the success of mental health care. These range from broad questions about the importance of having somewhere settled to live to enable recovery and social inclusion to more specific requirements such as discharge planning and risk management.
Shortly after, a Centre for Mental Health briefing, A place to live, focused on the links between housing instability, mental ill health and offending. It showed that for too many people, poor mental health, a lack of somewhere to live and involvement in the criminal justice system reinforce each other. Figures from St Mungo’s, for example, show that 70 per cent of their hostel clients who have slept rough have a mental health need while 48 per cent of their clients were ex-offenders or had been to prison. Being in prison can be both a cause and a consequence of homelessness and mental ill health. And the impact of housing instability appears to be particularly dramatic among children: the Youth Justice Board having reported that 40 per cent of children in custody had already sought housing support, often from the ages of between 13 and 15.
In recent years there have been many different attempts to address the causes and consequences of homelessness, mental ill health and offending. Most resources, however, have remained in services that tackle single issues or at best two needs at a time. There are of course some outstanding exceptions to this rule. The Supporting People programme offers housing support to people with mental health conditions, learning difficulties, substance misuse problems or offending histories. Sadly, as a result of the programme’s budget losing its ring-fence at a time of extreme financial pressure on councils, many local authorities are now cutting their housing support budgets by up to 40 per cent. So one of the few means of supporting people with multiple needs to maintain their independence is being lost despite growing evidence of the need for this kind of intervention.
The Health and Social Care Bill could help to address some of these issues. By placing directors of public health in local authorities and boosting the role of Joint Strategic Needs Assessments, it could create better conditions for linking health and housing services. Yet without a requirement in the Bill to include housing services on Health and Wellbeing Boards, it will be up to local initiative to make those links work. And with mental health issues barely registering in the Government’s new Housing Strategy for England nor stable accommodation appearing as a major outcome for health services, there are few incentives from the centre to join up on the ground.
For mental health services, though, the evidence is clear. Failing to address people’s housing needs and aspirations is self-defeating. While the evidence base in this area is less well developed than in some others, taking action to form partnerships, to intervene early and to address multiple needs is among the keys to success in mental health care that can no longer be ignored.
The pressing case for linking physical and mental health
As the shadow NHS Commissioning Board begins work and the Health Bill continues its passage through Parliament, the changing architecture of the NHS continues to dominate the headlines. Alongside this process, however, we need to keep our eyes on bigger prizes, in particular to find ways of simultaneously improving services and becoming ever more efficient in the use of resources.
Nowhere is this more evident than in the interface between physical and mental health: a link that health services too often fail to make, at a high cost both to the NHS and to the people it serves. As a new report shows, if this interface is well managed, it is possible to improve the quality of care the NHS offers while also making substantial cost savings.
Psychiatric liaison services provide mental health care to people being treated for physical health conditions in general hospitals. One of the most well-regarded such teams is the Rapid Assessment Interface and Discharge (RAID) team at City Hospital, a large acute hospital in Birmingham which forms part of the Sandwell and West Birmingham Hospitals NHS Trust. The RAID service is provided by Birmingham and Solihull Mental Health NHS Foundation Trust and commissioned jointly by Heart of Birmingham and Sandwell PCTs. It offers comprehensive mental health support, available 24/7, to all people aged over 16 within the hospital.
RAID was launched in December 2009 as a pilot project, in succession to an already established but much smaller service. It offers a comprehensive range of mental health specialities within one multi-disciplinary team, so that all patients over the age of 16 can be assessed, treated, signposted or referred appropriately regardless of age, address, presenting complaint, time of presentation or severity. It operates 24 hours a day, 7 days week.
The Centre carried out an economic evaluation of an internal review of RAID with the NHS Confederation’s Mental Health Network and the London School of Economics and Political Science (LSE), and funded by the Strategic Health Authority Mental Health Leads.
Our report found that the service generates significant cost savings because it is able to promote quicker discharge from hospital and fewer re-admissions, resulting in reduced numbers of in-patient bed-days. These cost savings amount to at least £3.5m a year. Most of these savings come from reduced bed use among elderly patients.
By contrast, the incremental cost of RAID (i.e. the additional cost of the service compared with its predecessor) is around £800,000 a year. This means that the benefits of RAID are four times higher than its costs: even without considering other possible savings such as reductions in the use of institutional care for older patients when they leave the hospital. In other words, unlike most healthcare interventions, RAID actually saves money to the NHS as well as improving the health and well-being of its patients.
On a more fundamental level, though, what RAID demonstrates once again is that separating out physical and mental health needs is no longer sustainable in a health service facing rising cost pressures. It doesn’t make sense to patients and it doesn’t make business sense, either.
Amid the structural changes that can too easily distract us from the real purposes of the NHS, investing in good quality liaison psychiatry represents an opportunity not to be missed both to improve the care we offer to patients and to make the service more efficient.
Integration must not default to a box-ticking process
With the House of Lords debating the Health and Social Care Bill last week, the imperative of integration has reached an unusually high profile in health policy debate in England.
Like many other policy priorities, integration can be defined in all sorts of ways. It can mean joining up different services – most often health and social care for example – at one point in time and it can mean offering consistent care over time for people who need long-term support. It can mean improving links between primary and secondary care services within the NHS and it can also mean looking far beyond the NHS’s usual horizons to integrate with a range of other services such as schools, housing, employment and justice, to name but a few.
But integration for some can mean exclusion or fragmentation for others. Writing in HSJ last month, Chris Ham warned of “the wrong kind of integration”, for example when organisations come together but the professionals who work in them remain fragmented in their everyday practices, or when services integrate around specific conditions forgetting that many people with long-term health needs have multiple diagnoses – often including both physical and mental illnesses.
It is therefore crucial that integration does not simply become the latest buzzword in health policy fashion: a box-ticking exercise rather than a driving force for reform. Integration will all-too-easily be discredited if it is not sufficiently well understood or robustly implemented.
There are, nonetheless, opportunities with the reform process now under way to make integration in its fullest sense possible both within health and social care and across a range of other services. The Future Forum’s second work programme has focused on integration and may help to inform the design of the new system to give the best possible push in the right direction. This could have major implications for the way clinical commissioning groups and the Commissioning Board work and are held to account as well as giving health and wellbeing boards and their local authority hosts a bigger influence still in the way health services are planned and developed.
The Department of Health, meanwhile, is currently consulting on the potential of clinical senates and clinical networks to achieve integration within the health system. The potential for clinical networks in mental health is great. With the publication earlier this year of a cross-government mental health strategy, joined-up local and regional action to pursue its objectives is vital.
Clinical networks – if adapted to the needs of mental health services to offer equal voices to users and carers as well as a range of non-health services – could help to integrate support for people with mental health problems broadly and across a wide area. Mental health networks would particularly enable the joining up of services for people requiring more intensive support, for example those in secure services and those stepping down from them to supported housing. They would also support the development of new or expanded services such as police or court diversion, liaison psychiatry in acute care and psychological therapy services.
Above all of these influences, however, integration is dependent first and foremost on good quality relationships within and between agencies. With major structural changes taking place across the NHS and other public services, sustaining these relationships can be extremely difficult. But without them integration will continue to be a policy imperative without its most effective lever for change in place
Creating diversion will improve mental health screening throughout the judicial system
That mental health problems are widespread among the prison population in England and Wales has been known for some time. Mental ill health, combined with a range of related disadvantages in life, is the norm rather than the exception among people of all ages in custody.
What has been less well-known is that the same difficulties apply to those under the supervision of probation services. Yet new evidence produced by the University of Lincoln (Brooker et al 2011) has shown that rates of mental ill health among the probation caseload are very similar to those of the prison population, and as in prison much of this poor health is unrecognised, untreated and makes their rehabilitation all the more difficult.
The report’s findings are stark. More than a quarter of offenders in contact with probation said they currently had a mental illness. One in seven had a mood disorder and one in five had an anxiety disorder. Some eight per cent had a psychotic illness: about eight times the national average. About half had the symptoms of a personality disorder; more than half had the signs of hazardous or harmful alcohol consumption; and 12 per cent had the signs of serious drug misuse.
As worrying as the findings on the prevalence of mental ill health, the researchers found that 60 per cent of those with a mood or anxiety disorder were not receiving any treatment. Only half of those with a current psychosis were receiving any support from mental health services. And while 88 per cent of those with a drug problem were receiving treatment for this, the proportion getting help fell to only 40 per cent of those with serious alcohol problems. This latter finding reflects the very clear inequality reported last month in HSJ within prisons: that people who misuse alcohol get much less support from a range of services than those who use street drugs (Lewis, 2011).
These extremely high rates of poor health and untreated illness reinforce the need for urgent action to implement the government’s pledge to extend effective diversion arrangements to all police stations and courts in England and Wales over the next four years. Liaison and diversion services at their best are able to identify people at the earliest opportunity when they come into contact with the justice system. They are able to screen for a range of difficulties including not just mental ill health but drug or alcohol problems, learning disabilities and speech and communication difficulties: all of which may not just have affected their offending but which will have a big impact on their ability to cope with the justice system and their chances of successful rehabilitation.
Diversion services are then able to inform decision-making by the police and the courts, potentially avoiding lengthy delays for psychiatric reports later in the judicial process. And, importantly, good diversion services will ensure that the right forms of support are offered and that individuals whose lives can be complex and chaotic are properly linked with services before ‘letting go’ of them (Centre for Mental Health, 2009).
Some diversion teams are making a big difference and showing what can be achieved for relatively little investment. Services like MO:DEL in Manchester and the Youth Justice Liaison and Diversion pilots in six localities across England (and soon to be extended to 30 more) are leading the way in offering a proactive, robust and effective form of diversion.
The NHS now has the opportunity to invest in diversion services across England. These will deliver most value if they link to a wide range of community-based services so that the difference they make in a person’s life is most effective. If they achieve their potential, one of the most stark inequalities in health care can begin to be redressed even in these toughest of times for all public services.
References
Brooker, C. et al, 2011. An investigation into the prevalence of mental health disorder and patterns of health service access in a probation population.
Centre for Mental Health, 2009, Diversion. Available at http://www.centreformentalhealth.org.uk/publications/diversion.aspx?ID=593
Lewis, S., 2011 ‘PCTs urged to fill alcohol treatment gap in prisons’ HSJ Online, 30 August 2011
Learning lessons in mental health care from around the world
Earlier in July, the journal Nature published a worldwide “call for urgent action” in research into mental health. The article, Grand challenges in global mental health, is based on an international review of “the priorities for research in the next 10 years that will make an impact on the lives of people living with [mental health, substance use and neurological] disorders”.
It is, inevitably, an ambitious undertaking that illustrates above all the burden of ill health worldwide that is linked to the wide range of mental health problems. Depression alone costs some 65 million disability-adjusted life years (DALYs) while alcohol misuse accounts for 23 million and schizophrenia nearly 17 million.
The article is also a reminder that mental health conditions receive a much smaller share of research funds than their prevalence and their impact on people’s lives would merit. The total fund of research into mental health conditions is simply not enough to tackle the level of need that exists.
As a result, the authors set out their 25 top priorities for research into mental health, sorted into six groups. While some of the priorities were specific to the developing world, most are applicable to the UK and address some of the biggest challenges we face in improving mental health across society and in improving the lives of people affected by mental illness.
Some of the most important priorities focus on prevention and early intervention. They include reducing the ‘duration of untreated illness’ which we know for many conditions has a major bearing on both the speed and success of recovery, and tackling key determinants of poor mental health such as child poverty and abuse.
Other priorities focus on improved responses to the needs of people with mental ill health, such as better screening in primary care and improved community care. And there are major workforce issues such as improving mental health knowledge among all health professionals and increasing the role of lay health workers in providing effective treatments.
Global “grand challenges” can seem a long way from the real world of mental health care and support. Yet while they should be first and foremost a reminder of the pressing need for more research funding for mental health, they do point to some of the biggest issues we all face now in improving the quality of care people get in a time of scarcity of resources.
They also serve as a reminder that countries around the world can all learn from each other. While mental health care in the UK is widely regarded as being among the best in the world, we can still learn from the efforts of services in developing nations that are working in much more straitened circumstances, often without the elaborate exclusion criteria that we apply to people and the silos in which we work.
Will the bill halt the integration of vital services outside health and social care?
The much talked-about Health and Social Care Bill has now returned to Parliament with some very significant government amendments after its two-month ‘pause’. The bill’s lasting impact on the NHS has been the subject of heated debate and disagreement and will doubtless continue to be throughout its passage through Parliament.
What matters most about the bill, though, has at times been obscured or at least debated only at the margins. Changes to the way the NHS works are not, and should never be, ends in themselves. They are the means by which taxpayers’ investment in our national health service achieves the greatest possible impact on our health, wellbeing and quality of life.
The NHS was created as a key component of the post-war welfare state. It was seen as an economic as well as social good; a way of achieving the best possible value for money in the way health care is paid for and organised. And it was inextricably linked to the other pillars of the Welfare State, such as housing, social security and National Assistance (the forerunner of social care).
The Health and Social Care Bill will likewise have a big impact not just on the NHS but on the lives of the people who rely on it. And it will affect a range of other public services: not just social care but also employment, housing and criminal justice among others.
The importance of integration was one of the central ideas of the Future Forum report. The government’s amendments to the bill thus seek to enhance integration in the new health system. But they do so as if health and social care exists in a bubble.
Integration within health and social care is of course vital. This is not just the case for older people and those with long-term conditions but for people who fall between service silos, such as those with a ‘dual diagnosis’ of mental health and substance use problems whose care is too often anything but integrated.
But integration can apply successfully beyond health and social care. Good, safe and if needs be supported housing is often the key to hospital discharges, for everyone from frail older people to patients in secure mental health wards. Links between housing and health are just as important as those with social care. Yet Health and Wellbeing Boards are in danger of being constituted without their active involvement.
Health and Wellbeing Boards have huge potential to act as the ‘glue’ to bring together a range of local agencies to promote good health and support the most vulnerable and disadvantaged. But without genuine cross-agency involvement they may find it hard to break down the silos that prevent services working together to meet commons goals.
As clinical commissioning groups begin to form and local authorities take on their extended roles in promoting public health, it is vital that they take the opportunity to build effective relationships with other public services. Tackling the determinants of ill health, intervening early when people become unwell and supporting those with the greatest needs remain big challenges for the health system. Yet they are also where it has the most potential to contribute towards the wellbeing of society as a whole: its fundamental purpose.
While the bill gets debated in Parliament and eventually implemented in the world outside, it is vital that we stay focused on ends, not means, and on how best the NHS and its many partners can make a difference to people’s lives.
Time to change: challenging the stigma around mental health
Earlier this month, the NHS Information Centre published the latest survey of public attitudes to mental illness in England.
In many ways, the results were encouraging. They showed that public understanding about mental illness and attitudes towards people with mental health problems in recent years are improving.
Over three quarters of respondents, for example, agreed that ‘mental illness is an illness like any other’ while 72 per cent agreed that someone with a mental illness should have the same rights to a job as anyone else.
The survey has now been running since 1994. Between then and 2003, there was a noticeable hardening of attitudes towards people with a mental illness. High profile cases of homicide involving people who had been in contact with mental health services, coupled intense political debate about how dangerousness should be managed, have been widely blamed for this trend.
Since that time, there have been gradual improvements in attitudes, with answers to most questions showing greater acceptance of people with mental health problems as citizens with the same entitlements as everyone else in our society.
The upward trend is a great tribute to the efforts of campaigners who in recent years have sought to demystify mental ill health and tackle the prejudice and ignorance that have a huge impact on the lives of people with mental health problems.
But underlying the positive trend is a worrying truth: that fear of people with mental health problems and ignorance about mental illness are still widespread across our society. One person in six agrees that ‘locating mental health facilities in a residential area downgrades the neighbourhood’. This kind of fear is too often translated into action, bedevilling efforts to build new community services.
One in eight, meanwhile, agreed that ‘one of the main causes of mental illness is a lack of self-discipline and will-power’. Such myths translate all too easily into hostility towards people claiming incapacity benefits.
Even the fact that 72 per cent agree about a right to a job shows that over a quarter do not. And attitudes can be seen to harden the ‘closer to home’ questions are: only 25 per cent said they would trust a woman who had been in a ‘mental hospital’ as a babysitter.
These are not merely the views of a tiny minority of intolerant people. They are mainstream social attitudes with a long history. And they are not confined to older generations, either. A survey by YoungMinds last year showed that myths and misperceptions were just as prevalent among children and young adults. They found that mental illness is widely associated with violence and that half of young people are subject to verbal abuse when they are distressed.
The need for continued action to tackle these entrenched and ingrained prejudices and fears clearly remains. The Time to Change campaign has begun to bring about the kind of social change that will take more than one generation to bear fruit. That work will need to be sustained for some time to come, and with people of all ages, to achieve its full potential.
The government’s mental health strategy, meanwhile, rightly includes reduced stigma and discrimination as one its key objectives. Action to put that policy into practice should begin now. Restrictions on people with mental health problems serving on juries or sitting in Parliament need to be lifted as a matter of urgency. These symbolic acts of discrimination have no place in twenty-first century Britain.
Tackling stigma remains key to achieving so much more to improve the life chances of people with mental health problems. Concerted action at every level continues to be necessary to banish the blights of bullying and discrimination from people’s lives.
'Urgent action is needed to tackle mental health life expectancy inequalities'
For many years now we have known that people with severe and enduring mental health problems have a shorter life expectancy than those without. Recently published figures have for the first time given us a clearer picture of just how big the gap is and how serious an inequality in health this remains.
Researchers at the Maudsley Hospital in London found that on average a person with a severe mental illness can expect to die between 10 and 15 years earlier than average. For a woman with schizoaffective disorder, the gap is some 17.5 years. Men with depression, meanwhile, die 10 years younger than their peers and those with schizophrenia die 14.6 years earlier.
These are stark figures. They reveal a disparity in life expectancy that is as serious as any difference in the more often discussed dimensions of inequality in health such as wealth, geography or ethnicity.
As the researchers state, the largest part of this excess mortality is due to ‘natural’ causes rather than suicide. It reflects the overwhelming evidence that people with mental health problems have considerably worse general health than those without. It also suggests that the physical health care available to people with serious mental illness is inadequate to address their needs.
In the government’s mental health strategy, addressing the physical health of people with mental health problems is among its six key objectives. It notes that some 42 per cent of tobacco is consumed by people with mental health problems, many of whom would like to stop smoking if they had the right support.
The NHS Outcomes Framework (and alongside it the proposed framework for Public Health England) also includes measures of mortality under the age of 75 among people with a severe mental illness.
These are important steps forward but they will need concerted action to translate good intentions into everyday practice. For this, the whole of the NHS and the public health system need to get behind efforts to close the gap in life expectancy, and more generally to bring physical and mental health together much more effectively.
Smoking cessation efforts need to be tailored, for example, to the specific needs of people with mental health problems, many of whom will be using medication that might reduce their effectiveness. Advice and support to manage weight gain and encourage exercise will likewise be affected both by a person’s mental health condition and any medication they are prescribed for it.
Efforts to link physical and mental wellbeing need to start early in life and continue through to old age. Children with poor mental health are often the most at risk of taking up smoking or becoming overweight from a young age. In adult life, depression is associated with a far higher risk of a range of physical illnesses and makes it harder to manage or to recover from them. Promoting and treating mental health alongside physical health won’t just improve our overall wellbeing, it will also make the NHS more efficient and productive.
This is a big agenda for services that for too long have separated physical and mental health. We can no longer let a diagnosis of mental illness overshadow a person’s general health nor deny people with mental health problems effective support to improve their own health.
The shocking figures provided by the Maudsley must provoke us all into action so that we can begin to make them a thing of the past.
The benefits of employment support to mental health patients
The closure of most of the condition management programmes in the NHS this year is truly a great loss at a time when support into employment is more important than ever.
As HSJ reported last month, the end of Pathways to Work means that the condition management programmes that accompanied it – assisting people to manage their health condition in the context of their employment – have also disappeared in most places, to be replaced later this year by privately provided services for the new Work Programme.
Condition management programmes may have produced mixed evaluation results but for many people with mental and physical health problems they have provided a crucial link between health and employment support to give them the confidence to take up a job and manage their own health.
The Work Programme itself begins soon. Prime contractors for each region have now been chosen, each with its own supply chain of specialist providers for groups of people with particular needs. It is vital that the NHS is not shut out of this process, nor that health care providers shun the opportunity to help more of the people they work with into paid employment.
Over a million people in the UK are out of work with a mental health problem – most commonly depression and anxiety. Only about one person in eight using specialist mental health services is in paid employment.
Yet we know that helping someone to get a job can have a dramatic, positive effect on their health. Getting back to work can speed up recovery from many mental health conditions, from depression to schizophrenia, as well as benefiting our physical health. It also, over time, much reduces health care costs.
The NHS therefore needs to regard employment support as a health intervention and reach out to Work Programme providers to ensure that their efforts combine effectively. Unless health care – whether in the GP surgery or in specialist services – is integrated with employment support neither will be as effective as they should be.
For large numbers of people with mental health problems, welfare reforms are the biggest source of anxiety they face. The Work Programme arrives alongside radical changes to incapacity benefits and changes to housing benefit and disability living allowance. The impact of a Work Capability Assessment on a person’s mental health can be considerable, especially given the shortcomings of the WCA as it is currently constituted.
Despite the loss of many good condition management programmes, health services have lots to offer to the Work Programme. From offering Individual Placement and Support in mental health services to providing Fit for Work support to people in primary care, the NHS should be focused on employment as a key outcome.
The NHS and social care outcome frameworks both measure employment rates for people with mental health problems. NHS organisations that take this imperative seriously will bring huge benefits to their communities and the most marginalised people within them.
Ensuring security for secure mental health services
At the beginning of a new and very challenging financial year for the NHS, all health services are facing tough times ahead. Every pound spent will be examined for its cost-effectiveness.
While there are grave dangers in cutting health service provision thoughtlessly, it is right that we look critically at what we are spending now and where necessary find ways of using that money more wisely. Nowhere is this more the case than in secure mental health services.
Secure mental health services work with people who need to be detained under the mental Health Act following a criminal offence, either directly from court or as a transfer from prison.
There are about 8,000 secure beds in England, a few in high secure hospitals but most in medium and low secure units. A typical patient will spend about two years in secure care. The average cost of a year in a secure hospital is about £200,000 per person. Overall, secure services cost £1.2bn a year, or one-fifth of the NHS’s specialist mental health care budget, and throughout the last decade spending on secure care has risen more sharply than any other area of NHS mental health care.
Yet secure mental health hospital beds in England are being blocked by a lack of step-down and community services for people who no longer need to be detained.
And this is causing long delays in transferring prisoners who are acutely unwell.
There are a number of inefficiencies in the system. Many prisoners are assessed several times before being accepted in hospital, where there are high occupancy rates. But the main barriers to the system working better are a rigid risk aversion that requires all prisoners to go to high-cost high or medium secure units and a lack of less costly rehabilitation services for people who no longer need so much security.
We need to focus instead on creating step-down services and intensive community support. People leaving secure care still need a lot of support but even very intensive community care costs much less than a medium secure bed.
A resident in a secure mental health unit recently told us: “I was given an absolute discharge at my last tribunal seven months ago, but due to the lack of a suitable community placement, I am still in a medium secure hospital. It costs nearly £4,000 a week to fund my stay in hospital, which is about £100,000 so far, compared with around £600 per week in the community.”
To facilitate this reform, we need to change the way secure services are commissioned. Currently primary care trusts pay for a fixed number of beds each year, often commissioned on their behalf by regional specialist commissioning groups. As a result, PCTs lack incentives to invest in alternative provision.
Instead we recommend that the commissioner – which may in future be the NHS Commissioning Board – pays for a whole package of care for someone, from end to end, and focuses not just on maintaining people safely but also on helping them to recover better lives, for example to get stable accommodation, paid work and a good family life.
Secure beds will always be a necessary part of the mental health system and a vital therapeutic alternative to prison for people with acute and severe illnesses. But we must ensure people do not languish there and in so doing prevent others who need urgent care from getting a bed.
Prioritising mental health commissioning is brave, but it's also sensible
HSJ recently told us that “brave” GPs in Brighton had chosen mental health as their first priority for commissioning.
The decision to focus on mental health care is indeed a brave one. But it is also one that makes a lot of business sense for any GP consortium, big or small, urban or rural, anywhere in England.
Mental health issues account for 23 per cent of all GP consultations and will figure in many more. Mental health services account for one pound in every eight the NHS spends, making it by far the biggest single programme budget.
Commissioning of mental health services has been widely criticised, not always fairly, but with some justification. Some primary care trusts in the past cut mental health care budgets to balance their books, most notoriously when many acute trusts overspent following the arrival of the tariff system in 2005. There is doubtless a risk they will do the same again in the absence, for now, of a tariff for mental health care.
So why not focus on mental health first? What other area could be considered more deserving of GPs’ attentions nor more important in terms of the overall health and wellbeing of the people they serve?
There are, of course, a lot of concerns about the ability of GPs to commission for mental health. A Rethink survey last year found that few GPs feel confident in their ability to commission mental health services.
Mental health services come with added complexities: they cannot all be parceled up into short, discrete ‘episodes of care’. Specialist services are provided jointly by health and social services, often with the involvement of voluntary and community organisations, especially to reach those for whom mainstream services are not enough.
Many people with mental health difficulties have a range of other needs, for drug and alcohol misuse for example, for help into employment or with welfare benefits. And children and young people’s mental health services are often run separately, on quite different lines with different partners such as schools and child protection services.
These are some of the factors that make commissioning mental health care a complex task. But there are plenty of opportunities to do it better and in so doing improve the mental health of the community as a whole while raising the life chances of those with mental health problems.
The government’s mental health strategy set out some of those opportunities: to invest for the first time in public mental health activities such as parenting support for vulnerable families; to build up a full range of evidence-based psychological therapies for all who need them; and to give everyone who uses mental health services the right support to get into paid work.
Brighton has its advantages in this regard, of course. It has a unitary council and if the GP consortium is coterminous with the local authority it makes a lot of the new arrangements easier to manage: a director of public health for the one area, a single Health and Wellbeing Board, many more opportunities for pooled and place-based budgets.
So are Brighton’s family doctors brave to take on mental health so soon? Maybe. But maybe the truth is they are just doing the right thing and in doing so, setting an example for many others.
Early intervention is rightly at the heart of new mental health strategy
The government’s much-anticipated mental health strategy, No Health Without Mental Health, was published earlier this month with a major, and very welcome, focus on improving services for children.
While there has been intense debate about how precisely the government’s pledge to expand psychological therapy provision will be funded, the strategy and its attendant supporting documents at last give mental health policy in England a much-needed sense of direction and purpose.
One of the key themes that emerges clearly from the strategy is that of intervening early. The evidence in almost all areas of mental health is indisputable. Mental health problems are widespread, they affect people of all ages, and the longer they remain hidden, stigmatised and untreated the worse they become and the greater the losses people experience in all areas of their lives.
Early intervention really does have to start early. Parenting support for young families, including before birth, can make a dramatic difference to the emotional health and long-term life chances of our children.
The expanded health visitor workforce as well as midwives, GPs and other health workers will have a crucial role to rebalance post-natal care to focus as much on children’s and their parents’ mental as well as physical wellbeing.
As well as early in life, early intervention can also mean acting quickly when people first become unwell.
Early intervention in psychosis teams, set up under the National Service Framework for Mental Health, have shown that not only does reaching out to young people experiencing psychosis for the first time benefit their health but it also increases their chances of getting into employment and building the lives they want for themselves.
We now need to learn from what these teams have achieved and extend this approach to other children and young adults – for example those who end up in the justice system for lack of support from other services. And of course we need also to avoid making short-sighted cuts to existing early intervention teams in the face of financial contingencies in the NHS.
Intervening early can also be applied to the 1.3 million people who work for the NHS, too. Every year, one worker in six will experiences a mental health difficulty. Only a minority either seek or receive treatment. The NHS can, and should, show leadership to other employers by promoting the mental health of its own staff and helping supervisors and line managers to respond positively when staff become unwell.
The government’s mental health strategy presents a compelling vision for promoting the mental wellbeing of the whole population and improving the lives of people who experience mental ill health. Making it happen in an environment of funding cuts across public services – and especially in local government – will not be easy.
But it is a challenge we must not neglect.
We need to foster a culture in which our mental health needs really do have ‘parity of esteem’ to our physical health, where discrimination to those with mental health problems is as unacceptable as racism and sexism, and building on these foundations where intervening early is the norm, not the exception.
'Alcohol misuse is the most daunting of public health challenges'
At the start of the year, which will see the creation of Public Health England as well as far-reaching changes to the NHS, the size of the task each faces in relation to alcohol misuse is staggering. Almost a quarter of the adult population of England are hazardous drinkers, while six per cent of us are dependent on alcohol. Some three-quarters of incidents of domestic violence are linked to alcohol misuse as well as half of assault cases and 63% of woundings.
The cost of alcohol misuse is some £23bn, more than £3bn of which is borne by the NHS. Yet neither health nor drug treatment services are responding adequately to the needs of offenders who misuse alcohol. A window of opportunity to help them to manage their use of alcohol is missed and the risk of further offending is not mitigated.
As with many other health issues, prevention is key and the management of problems should be stepped: from basic advice to those with the least serious issues to more specialised responses to those whose problems are more serious or entrenched. Yet for offenders who misuse alcohol, the responses at all of these levels are woefully inadequate. The absence of support is evident at all levels of need and all stages of the justice system, from first contact with the police to release from prison. The problems of alcohol management for offenders was all too clearly bought to focus during the New Year’s Eve riots in West Sussex.
Offenders have told us that their alcohol problems have been ignored by frontline workers to the extent that some are forced to lie about or exaggerate illegal drug use to get any kind of help. Health and criminal justice commissioners struggle to find common ground on which to fund joint services, hindering the development of effective responses to meet different levels of needs. There are examples of excellent local initiatives, many of them led by enterprising individuals or user groups, but many exist on a shoestring.
We need action on at least three fronts. Alcohol should have parity with illegal drugs in the provision of services to support offenders. We need a range of responses, from ensuring that all health and justice frontline workers are skilled in identification and basic advice to supporting people on community sentences with an alcohol treatment requirement as an alternative to prison.
Health services need to work with the police, prisons and probation to achieve this, building alliances with community and voluntary organisations that have developed creative responses to need and listening to the views of offenders about the support they require.
Finally, we need a renewed focus on prevention. Minimum or unit pricing and regulation of the night-time economy are important ways of reducing risk and preventing offending that should not be overlooked for their potential to improve public health.
Alcohol misuse should no longer be a label for exclusion from health services. The NHS has a key role in reducing the devastating impact of alcohol misuse and offending on all who are affected by it. Instead of picking up the pieces, health services can take the lead and cut the costs to individuals and communities alike.
Mental health in 2011: challenges and opportunities
After a year of political and policy change in 2010, the New Year will bring major challenges and opportunities for mental health services.
Like all public services, the NHS faces a big challenge in being able to cope with leaner times than it has enjoyed for many years. Mental health services will not be immune to that challenge, and nor should they be. While we must not see a repeat of recent years when mental health services were especially hard-hit by NHS spending pressures, there is much that mental health can do to improve its own productivity and to contribute to the efficiency and effectiveness of the NHS as a whole.
The time has come for real progress in taking forward the international evidence on recovery. We should see commissioners and providers placing experts by experience at the centre of local mental health service delivery and a real shift in the balance of power towards the people who use services and their families.
We should also see more progress on offering evidence based interventions for people with mental health problems to gain employment and keep it. Implementation of Individual Placement and Support (IPS) and building closer relationships between the NHS and the new Work Programme are vital to achieve this goal.
Diversion teams should be available to all police stations and courts to identify people with mental health needs and ensure they get the support they need from whatever services are required. This should always take into account the very different and emerging mental health needs of children and young adults.
Alongside these major changes to mental health practice, the NHS can do much more next year to improve its response to people with mental health difficulties. Effort is still needed to reduce unnecessary psychiatric bed use (in secure as well as general inpatient services) and out-of-area placements. Extending the availability of psychological therapies to people with long-term physical conditions and medically unexplained symptoms could massively improve many people’s quality of life, while improving physical healthcare for people with mental health problems could help to close a gap in life expectancy that remains unacceptably wide.
As well as looking at how we can improve mental healthcare now, we must think long term and put more investment into children’s mental health and wellbeing. Simple, cost effective parenting interventions for children with early behavioural difficulties result in better mental health and wellbeing and enhance the wellbeing of communities.
To give leadership and direction to meeting these challenges, I hope that 2011 will bring a high impact government mental health strategy that will set an agenda of promoting mental wellbeing for all, improving the lives of people with mental health problems, and tackling stigma and discrimination wherever they stand in the way of equality.
Making this real will require sophisticated commissioning and disinvestment in services with poor outcomes to focus on what matters most to the people who use services in a public spending downturn. This may be difficult against a background of changing commissioning structures but remains vital to meet the challenge of making mental healthcare more productive and effective in the years to come.
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