What's on managers'minds this week

Published: 01/07/2004, Volume II3, No. 5912 Page 12

Mental health services are undergoing massive improvements, with new community-based treatments alleviating the need for service users to spend more time than is necessary in an inpatient setting.

That is the official line. But while mental health managers and chief executives warmly welcome recent initiatives, reality does not paint such a rosy picture. Although the number of early intervention and crisis resolution teams is steadily increasing towards the end-of-year targets - and assertive outreach team targets were met some time ago - managers are worried about uneven levels of service provision.

'We are establishing teams in the city areas but out in the country It is a different story, ' reports one Midlands mental health trust chief executive. 'There are not sufficient funds to put services in place across the whole area. Our commissioning primary care trusts are under considerable pressure to cut funding and new services are not appearing across the whole economy. Enough acute beds and specialist services alike are not being provided in different areas across our patch. It is a postcode lottery.'

With underfunding a historical reality for many mental health trusts, modern day service provision means incorporating cuts in services to help balance the books.

As monies for new teams are badged and cannot be spent on anything else, not having enough cash increases the pressures elsewhere in the service, as the Eastern region locality director puts it. He explains that as new teams are expected to reduce the need for in-patient provision, wards are closed or have their bed numbers reduced. Often the cash saved will help pay for new teams. But the ward closures can have a knock-on effect elsewhere.

One South East primary care trust mental health commissioner asks: 'How are we to get appropriate and adequate services across the county with no new money and a trust already in deficit?'

Managers feel they are being punished for the mistakes of the past, for inadequate budget arrangements and commissioning deals that are hangovers of long-gone health authorities.

Meanwhile, the headline targets such as those for crisis and early intervention teams must be met by the end of the year.

If no new money is available, staff must be found from somewhere, which means poaching from other community teams and inpatient wards, exacerbating recruitment problems. It is understandable that people move on, says one London director - new teams are sexy and attractive to those jaded by working in an underfunded team.

'Lower-grade nurses are the life-blood of inpatient settings but if they are good they want to move on. We do not have the money to have all upper grades staffing wards so we need lots of new people entering the system.'

Mental health has long been considered one of the most embattled parts of the heath service and these managers' experiences do not suggest that the situation is improving markedly. But what they are not prepared to tolerate is failings in patient care.

A particularly disturbing final word comes from a director who has worrying concerns about what increasing cuts could mean for patient and public safety.

'We are under huge pressure to discharge early and to bring back patients from private care, as it is too expensive. Clinicians are taking more risks than I believe they should. We are trying to manage people in the community who are high risk; both of suicide, and to the public, ' he says.