‘Hips, knees and eyes’ funding focus ‘not fair’, says medical leader

Adrian James also said future leaders must tackle bed and workforce shortages, while upcoming inquiries into poor care must allow people to speak openly without fear. 

Forensic psychiatrist Dr James, who has led the royal college since 2020, handed over the presidential reins to South London and Maudsley Foundation Trust’s Lade Smith earlier this month.

Slow progress on parity and closing access gap

NHS England CEO Amanda Pritchard has called the minimum investment standard for mental health “non-negotiable”. However, in an interview with HSJ, Dr James said mental health services are often missing out while “big chunks” of government money are allocated to reduce waiting lists. 

He said: “The [covid] recovery plan that was negotiated with the government really was about your hips, knees and eyes, in spite of big voices – one of them mine – saying, ‘what about the mental health backlog’. At that point, we didn’t get any extra money.”

Government allocated the NHS £44bn in its 2021 spending review, including £5.9bn to tackle the elective backlog, but nothing was specifically identified for mental health.

Dr James said just 14 per cent of NHS funding is spent on mental health, despite it accounting for 23 per cent of the public health burden, adding: “I think we are still on track to have fairer funding, but even the government would say right now it’s still not fair enough.”

Investing in shrinking mental health waiting lists would help close the access gap and achieve parity of esteem, he said, progress on which has been too slow.

“The access gap has closed a little, with the last big adult mental health survey showing one in three people with a mental illness getting evidence-based treatment, up from one in four,” he said.

“While that’s good, I don’t know if there’s any other branch of medicine where people would be cheering from the rafters to say what a great thing that is.” 

He said where services have received targeted investment, such as perinatal access and psychiatric liaison in acute hospitals, significant coverage has been achieved: “If you invest, you really get something back – but overall we’ve got 1.4 million people on waiting lists and that’s just not good enough.”

Areas with the biggest access gaps, Dr James said, include intellectual and learning disability, alongside autism and ADHD services, with 140,000 people waiting more than 18 weeks for treatment in March 2023.

Although £1bn was invested in general adult and older adult psychiatric services before the 2019 long-term plan, Dr James added: “If you spoke to most general adult and older adult psychiatrists, they would say it’s taking a while for that money to be very visible on the front line.”

Not enough beds

Under Dr James’ leadership, RCPsych has raised the plight of patients placed hundreds of miles from home, with the number of “inappropriate” out of area placements in April 2023 rising to levels beyond that seen during the omicron outbreak in January 2022.

Asked if he believes inappropriate OAPs will ever be eliminated, given repeated failures to meet an April 2021 target, he said it is possible but boils down to getting the basics right: staffing and bed numbers.

“There should always be [inpatient] services locally… in combination with good community services, so that admission only happens when it’s absolutely necessary,” he said.

“Our community services are not good enough to allow that to happen in every part of the country. There are pockets where you probably do need extra beds [despite a long-term national policy emphasis on reducing them]. But there is always that argument – a very real one – that beds cost more money, and there is only a finite pool of staff.”

He added: “If we kept our workforce and supported them better, had a full range of inpatient and community services, so we didn’t need to admit people, we could prevent admissions and undoubtedly we could solve this.”

OAPs will be investigated by a new national probe, while 2,000 deaths in Essex will also be examined through a landmark statutory inquiry into mental health services.

On the latter, Dr James said “it is very clear that things went very badly wrong” and there “needs to be accountability”.

But he warned: “If you make it statutory, people won’t necessarily speak openly… it depends on the way the inquiry is brought about, if it is in the spirit that we really want to learn from it… that’s got to be a good thing. The evidence base around people being able to speak without fear is that people do speak, and you get better improvement for patients.”

Dr James, who will continue his clinical work and remain on the NHS Race and Health Observatory board, used his valedictory address to warn racism “wrecks lives” in the health service, adding problems linked to it include pay gaps, disparities in disciplinary processes and a “glass ceiling” for doctors from ethnic minority backgrounds wanting to progress into management positions.

A Department of Health and Social Care spokesman said: “More people are getting help with their mental health than ever before. We’re spending an extra £2.3bn a year by March 2024 to expand and transform mental health services so an additional two million people can get mental health support.

“We’re investing more than £400m to improve mental health facilities including eradicating dormitories, plus £150m to build new mental health urgent and emergency care services.”

An NHSE spokesperson said:  “Mental health services are committed to ending inappropriate [OAPs] as quickly and as safely as possible for patients – with local areas determining how many beds they need in line with local demand.

“The NHS is right to ensure patients get the support they need earlier, with new models of care allowing adults and older adults to have greater choice and control over their care, reducing the need for people to be admitted to mental health inpatient settings.”