HSJ’s fortnightly briefing covering safety, quality, performance and finances in the mental health sector.

At first glance, the recently published implementation guidance for mental health appeared to finally be a solid attempt to address the balance between community and inpatient care.

Headline figures showed the majority of the £2.3bn promised to mental health has been allocated to community based mental health services – the biggest chunk to adult community mental health services. 

Credit where credit is due, NHS England does seem to have listened to the criticism that community mental health services for those with serious mental illness were ignored under the Five Year Forward View for Mental Health and is attempting to put that right.

The implementation guidance also makes it clear clinical commissioning groups can expect closer scrutiny over exactly where and on what they are spending their mental health money.

However, as is common to high-level planning documents, no baseline spend was given for any of the 11 service areas.

For community mental health, it is likely the national commissioner doesn’t actually know how much is spent. Gaining this knowledge would require unpicking block contracts and looking into inconsistent financial coding.

A quick read of this Commons public accounts committee paper also shows just how little NHSE claim to know about baseline budgets for children and young people’s mental health service spend.

Remember that £1.4bn promised to CYP mental health services in 2015? The MPs found dodgy spending data means we’ve no idea how much of this has actually been spent.

Without an accurate or even rough baseline spend, we’ve no real way of evaluating the significance of the £975m promised to the community. It certainly indicates a mindset shift at the centre, but will it tip the scales towards prevention in the community? Or will it just fill the hole left by decades of financial neglect?

Greater transparency of the starting point is required. Even the overall 2018-19 spend on mental health has been difficult to confirm. In January, NHS England quoted a spend of £8.9bn for the financial year, but, in its dashboard, £12.15bn is used.

About those beds

Interestingly, funding for inpatient services and beds was almost non-existent within the guidance. Just £41m was reserved for increases in staff who offer therapeutic interventions within inpatient units.

Questions about capital aside – we know those have been reserved for the spending review – it was surprising NHS England seemed to assume there would be no funding for growth in beds. 

The commissioner has instead rested its plans on areas improving community services and reducing length of stay. Both of which, in theory, should release some money for inpatients and reduce demand.

This may cause concerns for some providers, who’ll be aware mental health is seriously lacking in the bed department.

With the reality of rising demand on inpatient beds, maxed out bed occupancy, and stubborn levels of out of area placements, should we be a little worried by the commissioner’s assumption?

The guidance also does not cover the future of specialised services, beyond the plans for provider collaboratives to take on the budget. With no commitment to either grow or shrink this budget, and no indication of an increase in specialised mental health beds for the NHS, this could become a point of contention – public scrutiny over the NHS’ reliance on private inpatient units for specialised services is growing, after all. 

Before I’m hung drawn and quartered, community mental health is absolutely the right area of focus. However, it seems a bit naïve to think, over the next five years, we will not need any increase in beds.

Demand is unlikely to decrease, and history tells us the NHS has not got a great track record on delivering community service improvements.

That being said, with more money being pumped into community mental health, the system does now stand a better chance.

In other news… we have a new prime minister and, if his views on how the mental health crisis can be cured with work are anything to go on, perhaps we’re right to be cautious about how the sector will fare under the new government. 

Mental Health Matters is written by HSJ’s mental health correspondent Rebecca Thomas. Tell her what you think, or suggest issues she could cover, by emailing her in confidence at rebecca.thomas@wilmingtonhealthcare.com or by sending a direct message on Twitter.

Join us at the HSJ Transforming Mental Health Summit (28-29 November 2019, Hilton Leeds) as senior peers from across the NHS, local authority and wider mental health service delivery landscape to discuss the remaining challenges as we reach the end of the Five Year Forward View. Register your interest here: http://bit.ly/2KbYAzJ