MUST TRY HARDER

The reforms to mental health services promised in the NHS plan and national service framework continue apace, but years of underfunding have left a troubling legacy. Emma Forrest reports

When the national service framework for mental health came out in September 1999 it built on pledges made in the NHS plan, which had mental health as one of its top-three priorities.

Together with the mental health policy implementation guide, launched in 2002, its mission was to give mental health services the targets that would help them shape the face of modern, NHS-provided mental health services.

'The NSF and the NHS plan are the two most influential policy documents in the lifetime of anyone working in mental health, ' says national director for mental health Professor Louis Appleby, who recently wrote a five-year review of progress on each of the NSF's seven standards, plus a study of finances in mental health services.

So have the principles and targets outlined in the NSF been achieved?

Much progress has been made. But read the whole Appleby report and it becomes clear that more needs to be done.

On new models of care, for instance, improvements in developing new teams have sometimes been only a partial victory, with not enough staff in place to function at full capacity, or to a level recommended by the 2002 guide.

And when it comes to improving the lives of carers by offering more support, or improving the experiences of service users from black and minority ethnic communities, Professor Appleby acknowledges there is still much to do (see box, page 4).

At the heart of many of these issues is the finance. Professor Appleby says mental health is enjoying its biggest ever single increase in proportional spend. 'I can't find an equivalent time of spending on this scale, and I personally know that other services are not enjoying increases of that sort of amount. I had been worried about the money but it is a bigger increase than I expected, ' he says.

But historical patterns of underspending on mental health persist and in some areas, particularly in the North, significantly less is spent per working adult on all mental health services.

There are also signs that some money has been spent on the wrong things, such as agency and locum costs, or out-of-area treatments, when the NSF and NHS plan were in part designed to reduce the need for such measures.

Here Professor Appleby blames primary care trusts, and the review is damning on PCTs' failure to commit to improvements.

'Although the national picture on mental health is positive, it is not positive enough. And this is ultimately because many PCTs, faced with their own financial pressures, have not given sufficient priority to mental healthcare in comparison to other priorities such as access targets and waiting lists. In a devolved system of commissioning, there is very little earmarking of money allocated, and spending on mental health has been left to local organisations to argue over.

'More could have been done. They have made the funding of acute trusts a priority and continued the historical underfunding of mental health that created the problems that we are now grappling with.' He adds that strategic health authorities and the Department of Health have failed to make it clear that mental health is just as important as access and waiting targets. 'Officially, all priorities are equal but some are more equal than others.' In addition, there are real fears that the increases enjoyed by mental health funding may stop. 'It will be hard for some people to accept that priority status has been fulfilled if spending on mental health does not at least keep pace with spending on the NHS as a whole, ' says the review.

'Lack of transparency around funding is still one of the biggest obstacles, ' says Rethink director of policy and campaigns Paul Cory. 'And it looks like spending on mental health may be about to fall behind, which raises questions about the government saying it is putting mental health first.'

Teamwork

The review also examines the need to set up new teams to provide care earlier, and help people receive care without having to go into hospital.

Services were also set up to meet the needs of those who are hard to reach, through assertive outreach teams.

The result so far is a mixed picture. Although assertive outreach targets have long since been met, those on crisis resolution and early intervention teams have not. Professor Appleby points out that the most up-to-date figures on team numbers are still being assembled, but he admits even those teams that have been established do not always meet guidelines on how the teams should be staffed and run (see 'The good news', left).

'If you think where we started from, the increase in the workforce is quite extraordinary.

The service is signed up to deliver these targets and that is an important step. In the past, we have not always had the commitment of everyone in the field, but having all local delivery plans accepting the targets was a critical step, ' he says.

Mr Cory is concerned that funding for new services has had to be found through the closure of others. As staff for new teams have often been found by poaching them from other teams (see 'What's not so good', left), service users in need of long-term, low-key services are neglected.

'Though services may be very good in the early years, there is no support for later, when a user has stabilised but has lost social contacts - their job, friends and family. Their appointments with their community psychiatric nurse are likely to have been reduced and the day centre they visit closed down. They will have to be acutely ill to be able to access services, ' he says.

'Although providing such services are important, we cannot leave behind long-term care. Otherwise we will be establishing the forgotten generation of the future.' Maggie Cork, chief executive of Leicestershire Partnership trust and chair of the National Mental Health partnership, agrees that social exclusion is a vital issue.

'Treatment might be vital but having a job and decent accommodation to live in are just as important, ' she says. 'Some of the issues that underline recovery are about basic human rights and there is only so much specialist trusts can do;

PCTs and local authorities have to have a role.' Managers say too many groups are still isolated from accessing care at the point where it might prevent them from getting very ill.

'We serve a very ethnically diverse area, and we are recruiting workers from similar cultural backgrounds so as to improve engagement with the community, ' says a director of nursing at one London trust. 'But there are other people we are not reaching: young white men, for example, who live on sprawling estates, are out of work, and feel increasingly isolated. The first contact we usually have with them is when they turn up on one of our wards, desperately depressed.'

Professor Appleby recognises that there are areas where work has barely begun. In addition to listing priorities for the next five years, his review emphasises that as the NSF was for adults of working age, as much now needs to be done for older people, children, adolescents and people with learning disabilities.

Services also need to be developed for those who fall between the gaps, such as the children of people suffering from mental illness or young adults who develop dementia.

'It is important to say that things are certainly better than they were. But the advances that we have seen in heart disease and cancer have not been seen in mental health, ' says Mr Cory, who believes improving mental health service provision is not enough of an issue for politicians to make them force through reforms.

'The cancer czar dragged the prime minister onto cancer wards and got Mr Blair to talk up the reforms in cancer services, ' he says. 'It would be nice to see Professor Appleby going on a tour of psychiatric units with the prime minister.'

THE GOOD NEWS

There has been a 25 per cent increase in psychiatrist numbers and a four-fold rise in the use of anti-psychotic medications, which have fewer side effects and are often preferred by patients. 'But there is still local variation around their uptake, ' says national director for mental health Professor Louis Appleby.

There are about 500 new specialist teams - early intervention, crisis resolution, home treatment, assertive outreach - in place and the target to establish assertive outreach teams has long since been met.

A national suicide prevention strategy has been published. Suicide rates, including among young men and inpatients, have fallen.

WHAT'S NOT SO GOOD

Poor commissioning by PCTs 'A lot of PCTs do not have a good grasp of what modern mental health services need, ' says Professor Appleby. 'The main predictor of current spending is still historical spending, rather than allocation.' This is perpetuated by PCTs failing to buy into mental health reforms.

High vacancy rates These persist across the workforce, particularly in patient care. Although targets have been met, not all new teams meet the desired model of 24-hour care.

In 2003, it was estimated that 62 per cent of crisis resolution teams provided 24-hour cover, while only 30 per cent of assertive outreach teams did, although 70 per cent provided evening and weekend cover.

'Evidence from the US and Australia, where many of these models originated, stress that it is critical to keep caseloads low and get the staff numbers right, and That is not happening, ' says Rethink director of policy and campaigns Paul Cory.

He adds that there is increasing anecdotal evidence of new teams being staffed by creaming off the best talent from more established services.

'The staff left behind, those in traditional settings, can quickly become demoralised, ' he warns.

'If you look carefully at the breakdown of spending it is quite candidly expressed that some services have been funded by diverting finance from others, ' says National Mental Health Partnership chair Maggie Cork.

The review also reports that progress on the recruitment of 1,000 graduate primary care workers - outlined in the NHS plan as vital to improving mental healthcare - has been 'slower than expected'.

Mental health promotion

Although the National Institute for Mental Health in England has launched a five-year plan to reduce stigma and discrimination around mental health, further investment in mental health promotion at local level is still lacking.

Spending in England seems to lag behind countries with established mental health promotion campaigns.

THE NEXT FIVE YEARS

Appleby's priorities

Black and minority ethnic service users

'The needs of black and minority ethnic communities is the area where there is the greatest need and yet the least has been done, ' says national director for mental health Professor Louis Appleby, who identifies this as the single biggest programme of work needed to be done by the Department of Health.

Delivering Race Equality, which was published early this year, aims to put a stop to this. Its 10-year programme of targets includes reducing the number of black men on inpatient wards - they are currently massively over-represented - and compiling a census of the ethnic background of patients for the first time.

Primary care

About 60 per cent of mental health problems are dealt with in primary care.

Professor Appleby wants the mental health of the 'wider community' to be the focus of more attention.

This goes hand in hand with the need to promote mental health issues and reduce the stigma faced by those suffering from a mental illness.

Proposals on community mental health are expected to be produced by Professor Appleby this month. 'The NHS plan set out what specialist services should look like; now we have to do the same with primary care, ' he says.

As much attention needs to be given to the physical health of service users as their mental health. There are high mortality rates for long-term conditions such as heart disease, diabetes and smoking-related disease in mental health service users.

Access to psychological therapies

Waiting lists for these therapies, also known as 'talking' therapies, remain long in many places. The review outlines the need for more primary care and frontline staff to be trained in them, a broader range of providers to be found and greater access to selfhelp tools.

Inpatient wards

On the same day as Professor Appleby released his five-year review, which health minister Rosie Winterton announced£30m of funding to be spent on inpatient wards.

Professor Appleby believes the image of inpatient wards as 'squalid' is outdated, but admits there are still some in use that are inappropriate for the care of people in distress.

He wants all unsuitable wards to be eradicated and new models of inpatient services - such as crisis admission and specialist treatment - to be further developed.

Improving technology

The quality of data collection and technology services in mental health is often so poor it cost many trusts at least one star in the 2004 ratings. Many in the service feel the sector has been left behind by the national programme for IT.

'We must build on the national IT programme pilots in mental health - we have to improve in this area, ' says the review.

Dual diagnosis

This means those who have a diagnosis of mental illness and a drug or alcohol addiction. The review outlines the need to establish teams dedicated to working with dual-diagnosis patients, better working between community drug and alcohol and mental health teams and more training for staff in managing and assessing drug misuse.

The prevention of drug misuse in inpatient wards and working to prevent people with severe mental illness from using drugs is also noted.

'There is guidance available on this but it is a challenge to services and it is right to identify it as an area worthy of concentrated effort, ' says Ms Cork.

HAS SPENDING INCREASED?

WHAT THE REVIEW FOUND

In the first three years after the national service framework was published, there was a 19 per cent increase in spending in real terms on mental health.

By the end of the third year, this had amounted to an extra£843m. The year 2003-04 saw a further increase of 2.2 per cent.

Key points

Professor Louis Appleby's review sets out progress on mental healthcare reform, and future priorites.

Spending is higher than ever, but there is still a lack of transparency around funding.

More must be done to meet the needs of black and minority ethnic communities.

Find out more

The NSF for Mental Health: five years on Delivering Race Equality

www. dh. gov. uk