Mental Health Matters: The murky business of aftercare

Murky business

An HSJ investigation suggests that the mounting cost of caring for people after they have been detained under the Mental Health Act is eating up an increasing proportion of mental health budgets for more than two thirds of commissioners.

This is the second time HSJ has delved into the murky world of section 117 aftercare, a little publicised service which supports patients discharged from hospital after being detained under the act.

I use the term “murky” because despite two separate freedom of information requests to all 209 clinical commissioning groups there is not enough information to definitively say exactly what is going on.

The first time HSJ requested data, only 75 CCGs provided data on their aftercare spend for 2015-16, with 97 saying they did not know how much they were spending.

But responding to HSJ’s most recent request, 150 CCGs were able to provide their aftercare spending for 2016-17. This included 60 which originally told us they did not hold the information for 2015-16.

The apparent increase in CCGs now monitoring S117 is welcome, but this still leaves more than a quarter which did not provide data or said they did not collect it.

Now, imagine a quarter of CCGs saying they did not collect data on the number of patients with cancer or the cost of their care? It would be a scandal.

Remember, people receiving aftercare are some of the most acute mental health patients in the system. They have been detained against their will because they are too ill to consent personally. Section 117 is their route back into the community that they were a part of until the state took away their liberty.

Section 117 is a vital service, but the lack of information about these patients begs a number of questions.

Who are these patients? We know the number of people being detained is rising, but is this simply more people being detained or the same people being detained more often? Is every patient getting the best care? Are we getting value for money?

The worrying lack of data suggests that at present answering these questions is impossible.

Because what we don’t know, we can’t prepare for.

Washed out to sea

But while the lack of information is a concern, what knowledge we have is worrying enough.

One CCG reported S117 costs rising from 5 per cent of its mental health spend to 30 per cent from 2015-16 to 2016-17, another reported a 5,000 per cent increase since 2013-14. These are admittedly outliers, but the trend shows that across the board it is increasing.

Our first investigation revealed the average cost of aftercare per CCG had risen by more than 50 per cent from 2013-14 to 2016-17. Our second reveals that for 54 out of 72 CCGs which provided data for the past two years, the cost of these packages has increased as a proportion of their total mental health spending.

This is worrying commissioning and provider leaders alike, because if aftercare costs keep rising as a proportion of mental health budgets then it is unlikely new cash promised for the sector will reach the areas it is intended, such as prevention and early intervention.

A large proportion of the £4bn NHS England has promised for the sector is to be fed into CCGs’ allocations. But if more and more of the pledged cash is being eaten away paying for aftercare packages, could plans to invest in prevention be washed out to sea?

Tides turning?

The government’s proposed scrapping and replacement of the Mental Health Act 1983 provides a unique opportunity to turn the tide.

It could allow ministers to work with the sector to look at who is being detained, how often, for how long and for what reasons. It could investigate how patients are placed into aftercare packages and how those packages are monitored.

At the moment, the guidance around S117 has been described as “ambiguous” at best and “inadequate” at worst. Mind have called for a national protocol to manage it and Rethink Mental Illness said it should be paid for separately from the new funding for the sector.

Scrapping the MHA could offer a change to get a handle on it, manage it better and improve care.

But the risk, flagged up by Rethink, is that the new Mental Health Treatment Bill is simply a cost cutting exercise rather than an attempt to improve care.