Wendy Burn discusses the findings and limitations of the recent review of community and mental health services by Lord Carter

Psychiatric / mental health unit

As a psychiatrist working in the community, the review of community and mental health services from Lord Carter comes as a welcome vindication of the experiences of mental health clinicians and wider teams. 

All of us working in front line community services know just how dedicated staff are to their patients and how hard we work. We also know what an uphill battle this can be with IT and administrative systems that just aren’t fit for purpose, with needless bureaucracy eating into valuable time that should be spent with patients.

Amidst great progress that has been made by the mental health sector, these might seem like small gripes, but they’re really not (I should know as I was elected by psychiatrists to represent them on these very issues!). Most importantly the knock-on impact they can have on patient care is huge. 

Lord Carter reiterates that inappropriate out of area placements should be eradicated by 2021

Mental health services desperately need more doctors, more nurses and more staff in psychology, psychotherapy, and other vital areas.  

And what’s more, better and kinder working conditions are absolutely necessary if we are to keep those we already have.  

Sometimes it feels that we are asked to count everything except the things that matter, things that matter like kindness to staff. That’s what we really mean when we talk about better working conditions.  

It’s remembering that people working all night need somewhere they can get a hot drink and food, somewhere to rest between calls, that they need to get home safe. It’s remembering that staff need to feel that they are listened to and that they are empowered to design and deliver changes that will improve services for patients.  

Report findings

A big part of this is ensuring that the unique skills of different members of staff can be used to greatest effect, and clinical staff. As part of his work, Lord Carter found that child and adolescent mental health staff spend on average just over 1 hour out of every five (21 per cent of their time) on direct patient care. This varies largely depending on administrative capacity in local trusts. 

“Administrative support teams have often been reduced as a cost improvement measure without sufficiently considering the impact on the clinical workforce”, the report finds. 

While Lord Carter’s report holds no magical solutions, there is much to praise in the report. Lord Carter rightly identifies some terrible instances of waste that happen to the detriment of patients all too often and where change is needed – namely the practice of sending patients far from their homes on out of area placements.

 Efficiency savings are not a panacea for the huge inequalities in access and funding between physical and mental health services

Lord Carter reiterates the recommendation of Independent Crisp Commission into Acute Psychiatric Care – that inappropriate out of area placements should be eradicated by 2021.   

He also endorses the approach taken by NHS England to commission the Royal College of Psychiatrists to specify care pathways to ensure that patients get the right high quality care at the right time. The report’s call for better data to track outcomes and money to the front line, provides a welcome answer to a long standing campaign by the Royal College of Psychiatrists.  

I’m sure that supporting and valuing staff, investing in the right digital and administrative support and implementing patient care pathways, could reduce reliance on agency staff and save money to be reinvested in community and mental health services.  

Lack of solutions

The billion pounds a year savings the report sets out makes a good headline – but the report is light on detail when it comes to how that is to be carried out practically. Policy makers should be in no doubt – efficiency savings are not a panacea for the huge inequalities in access and funding between physical and mental health services.  

Three months after the publication of Lord Carter’s interim report of his counterpart work into the operational productivity of acute hospitals back in 2015, 13 acute care collaborations “vanguards” were selected to make these recommendations a reality. These acute trusts were given an uplift of an additional £54.4m between 2016-17 and 2017-18.

 It would be unrealistic to expect mental health and community trusts to achieve the same efficiencies without a similar uplift in funding

The Royal College of Psychiatrists is keen to support the delivery of Lord Carter’s recommendations but it would be unrealistic to expect mental health and community trusts to achieve the same efficiencies without a similar uplift in funding and the time and space to properly implement these recommendations.

As Lord Carter rightly highlights, only a third of the people who need treatment for mental health problems are getting it. Just over a tenth of all NHS spending is allocated to mental health services and yet mental illness represents almost a quarter of the burden of disease in the population.

This inequality flies in the face of the founding principles of the NHS and in our 70th year, it is surely time to address that injustice.