COMMUNITY SPIRIT

Published: 21/03/2002, Volume II2, No. 5797 Page 18

In the next two years a host of targets will have to be met to achieve comprehensive and integrated mental healthcare.

Objectives are helpfully listed in The Journey to Recovery, the government's recently published vision for mental healthcare, which includes smiling pictures of the minister, the national director and the two job-sharing mental health leads. Is this a record?

By 2004, we will have 220 assertive-outreach teams, 335 crisis-resolution teams and 50 early-intervention teams, plus additional targets aimed at primary care, women-only services and suitable care for high-secure hospitals for those with severe personality disorders.

It is an ambitious list, and everyone would hope fervently the targets will be met.

The good news, according to a November press release, is that money already announced for mental health in the NHS plan is now earmarked for mental health. The press release goes on to describe in detail numbers of services and staff to be funded - for example, 22 early-intervention teams and 150 staff working in prisons. Nationally, progress towards early targets is promising.

Not such good news - on the Department of Health website - is that we are failing to meet the public service agreement to reduce emergency readmissions to 12.3 per cent by April 2002.

They stand now at 12.8 per cent.

Both good and bad news are part of the same story. There is overall progress, but success in some parts has led to problems in others. Crisis services undoubtedly reduce admissions, if not quite by the 85 per cent the press release suggested.However, a consequence is a concentration of severely disturbed persons on hospital wards, since those with relatively milder problems will have benefited from home care.

A more general issue is the neglect of continuing-care services in the NHS plan and this latest government vision. All targets are either at the entry gate - attempting to keep people out of hospital - or aimed at the risk end.We have forgotten continuing care for people leaving hospital or living a marginal existence in the community.

The root of the problem is a lack of system thinking. I strongly support early intervention, crisis resolution and assertive outreach, but many evidence-based teams thrown together do not make a comprehensive service.Mental healthcare is at risk of becoming unbalanced, as reflected in the strategy and funding.

The strategy's flaw is its neglect of mainstream services. It mentions hospital care, but says little about rehabilitation. Crisis resolution and maybe even services for severe personality disorders will be perceived as cutting-edge, while providing long-term support for long-term problems may be left for stragglers. A sign of this was a recent meeting with an assertiveoutreach team leader. A year ago his staff had deserted wards and community mental health teams;

now they were already moving on from his team to crisis resolution.

The main risk to the stability of the system is the CMHTs' role.

They are simultaneously under pressure to move towards general primary care support and to remain the specialist team looking after people with severe needs. I am struggling to understand paragraphs in government documents that aim to present a fudge as a constructive compromise.

Surprisingly, primary care trusts will be able to determine CMHTs' role unhindered by strategic objectives, in contrast to the powerful national directives and relentless performancemanagement of crisis and assertive-outreach services.

The specialist teams' sharp focus and the vagueness around core services is reflected in funding plans. The earmarked money will support the new specialist teams, and this is respected by commissioners, if somewhat creatively.

I do not know the fate of funding for existing core services. But nor, it seems, does anyone else. I hear from senior local sources that money is taken away from mental health services to balance deficits, sometimes caused by placements of forensic patients in private clinics, sometimes by pressures of acute sector waiting lists. The good achieved by the new funding is more than undone by cuts to essential services.

We are expected to put in place the most complex care model in the world within a couple of years, transforming obsolete forms of care in an underfunded system. Such vision is sufficiently challenging without threatening the mainstream services we will continue to rely on.

Rather than revisit failed past dreams, it might be more productive to invest in the NHS plan.Maybe it is time to propose ringfencing to achieve what government seems to accept as a priority, since mental health will always be vulnerable to raids from any sectors with urgent short-term needs, potentially destroying long-term plans.

Matt Muijen is director of the Sainsbury Centre of Mental Health.