This year’s HSJ100 highlighted the Mexican standoff between Simon Stevens and Jeremy Hunt over whether the NHS had enough money to deliver on its priorities – particularly A&E access and elective waiting times.
Well, appropriately for the time of year, HSJ has glad tidings for both men.
Today we report exclusively on the initial findings of the centrally funded Improving Access to Psychological Therapies programme, which brings mental health support to those with long term conditions. Analysis from the first cohort of patients to benefit to from the services is potentially a game changer.
The most robust findings, from Cambridgeshire and Peterborough Clinical Commissioning Group, show a 61 per reduction in accident and emergency attendance in the cohort of patients accessing the integrated IATP services – 61 per cent. Just let that sink in.
The impact on GP visits (down 73 per cent) and inpatient admissions (down 75 per cent) was even greater.
If this was not reason enough for the NHS to find every way it can to invest in mental health there is also growing evidence that poor mental health is an even bigger driver of cost to the NHS than age or chronic disease.
It is an argument that should convince even those whose focus is on the service’s bottom line. But contrast these findings with the decisions made on how to spend the £335m winter pressures cash announced in the budget – 95 per cent has been allocated to acute trusts, half of it to cut deficits.
The £18m given to mental health was close to an afterthought and, even then, various attempts were made to claw it back.
Increasing spend on mental health therapies at the expense of physical health services will be actively resisted
When the going gets tough, ingrained attitudes towards mental health persist among some influential people at the centre despite high profile commitments from the prime minister and health secretary. Time and again, siloed thinking dominates policy and, particularly, funding decisions: the delay in including mental health trusts in the global digital exemplars programme is just one example.
Indeed, HSJ choose not to mention mental health in the headline so as not too “put off” those who think it is irrelevant to the “mainstream” NHS.
At local leadership level, enlightened views are more common. This is not, necessarily, because trust chief executives are more altruistic – it has as much to do with self-interest. The competition among acute trusts for centrally funded programmes offering mental health interventions in A&Es and medical wards, such as psychiatric liaison services, is fierce and the outcry if they are withdrawn is great. Why? Because they work and the staff – driven to despair by not being able to properly care for obviously distressed patients – love them.
Unfortunately, this enlightened self-interest has not yet widely extended to acute trusts using their own money to pay for these interventions.
So, what do Mr Stevens and Mr Hunt have to do to make sure mental health gets the best chance to help rescue the NHS’s A&E performance.
First, make sure the funds allocated to mental health priorities in 2018-19 are protected from both raids and having additional demands loaded on them.
Second, find £50m extra in the next financial year to allow the staff being trained as therapists to be backfilled and therefore make sure the introduction of the programmes is not delayed by workload pressures.
Finally, they need to start accelerating their plans for mental health services which can impact on the emergency care system.
For example, the present intention is that by 2020-21 half of all A&Es will be covered by a liaison psychiatry service 24 hours a day, seven days a week. The ambition should now be to have the whole country covered by that date. The other milestones on the way to this target would have to be moved appropriately too. If workforce is a constraint on that – as it probably is – then the service must look abroad, as it is for GPs.
Twenty years from now it will be bizarre that acting on mental health was not first on the agenda when facing a demand challenge
NHS England should also speed up and broaden its plans to devolve mental health commissioning budgets to providers.
Doing all this will represent a risk. The early promise of the interventions may not be realised; increasing spend on mental health therapies at the expense of physical health services will be actively resisted and even portrayed as a “con” in some quarters of the media whose recent conversion to the need for better mental health services may be exposed as lip service.
But there are strong indications that mental health can have a more significant and rapid impact than fashionable approaches such as GP streaming or unknowns like the introduction of accountable care.
For mental health, such a sea change would not be the easy option it might appear. Those working in sector would have to accept that despite having finally won the argument that investing in mental health is justified for its own sake, the priority was now on helping fix someone else’s problem – and that neglected areas close to their hearts, such as services for those with personality disorders, would have to wait a little longer.
Twenty years from now – maybe even 10 – it will be bizarre that acting on mental health was not the first item on the agenda when facing a demand challenge.
The IAPT research is a clear call to the NHS to get ahead of the game.
The best test of whether the penny is dropping will be the information demanded by the increasingly powerful emergency care tsarina Dame Pauline Phillip. She should make it clear to trust chief executives and commissioners that mental health interventions must be treated as seriously and given the same priority as more traditional forms of demand management.
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