Lack of money is frequently highlighted as a key barrier to providing high quality care in mental health, with bed pressures, access to services and poor patient experience being associated with inadequate funding, writes Helen Gilburt
There is a common view that mental health services have been underfunded in comparison with physical health services. As a survey earlier this year by NHS Providers demonstrated, this has led to a lack of confidence in the sector that this situation will change, despite promises of parity of esteem.
‘Around 40 per cent of mental health trusts experienced a reduction in their income between 2012-13 and 2013-14 and 2013-14 and 2014-15’
A King’s Fund review of trust annual reports shows that around 40 per cent of mental health trusts experienced a reduction in their income between 2012-13 and 2013-14 and 2013-14 and 2014-15. This is in marked contrast with the acute sector, where more than 85 per cent of trusts saw their income increase over the same periods.
With this in mind, mental health trusts have embarked on transformation programmes to implement large scale changes to services, workforce and corporate infrastructure. These programmes have been based on creating integrated care pathways, shifting demand away from acute services and delivering care focused on recovery and self-management.
While the mental health sector has often been at the forefront of transformation in the past, these changes have been driven by the need to reduce costs, and have often resulted in a move away from evidence-based services. This represents a leap in the dark. Shining a light on how practice has changed shows worrying signs that in many cases this appears to have had a negative impact on patient care.
Community services have been a focus for these changes. Almost a decade after their introduction as part of the National Service Framework for mental health, and despite growing evidence of their effectiveness, specialist community services such as early intervention in psychosis services (EIPs) and crisis resolution home treatment teams (CRHTs) have been remodelled, integrated into standard care or decommissioned by providers.
The impact of this is increasingly evident. CRHTs and EIPs have been cornerstones of providing quality care and play an important role in preventing relapse and managing inpatient bed capacity, but access to these services and their effectiveness has been compromised. Examining the operation of CRHTs, UCL’s CORE Study found that, among the 75 teams surveyed in 2014, there was no single area where average performance could be rated as ‘good’ in relation to best practice. At the same time, evidence suggests that within EIPs, access to many NICE recommended treatments is limited.
The workforce changes associated with service redesign, including the closure of inpatient wards and merging of community services, has also had an impact on quality of care. NHS England has highlighted a lack of staff and inadequate skill mix as a key barrier to implementing the new access standards for early intervention in psychosis, reporting that no service currently has the capacity to deliver the new standards to more than 50 per cent of new first episode cases by April 2016.
Our review of trust strategic plans shows that more than half of mental health trusts have undertaken, or are in the process of implementing, radical transformation programmes as a means of reducing costs. The example of Norfolk and Suffolk Foundation Trust provides a stark reminder of the risks associated with undertaking whole-system transformation at scale and pace.
‘More than half of mental health trusts have undertaken, or are in the process of implementing, radical transformation programmes as a means of reducing costs’
To pre-empt increased financial risk and deliver efficiency savings, the trust engaged in delivering a vision of implementing recovery-orientated care. Its trust service strategy outlined large reductions in staff, changes to skill-mix requirements and service reconfiguration including a reduction in acute beds and a redesign of the way that services are delivered.
In 2015, the Care Quality Commission rated the trust “inadequate” and placed it in special measures. The trust’s own analysis found that there was insufficient evidence to support the rationale for change and workforce skills requirements, and that the timescale had been too limited to consider all the factors required to successfully implement change. The trust’s board have said that in future financial decisions will not impact on quality of services.
It is important not to dismiss this as an isolated example as the ambitions of Norfolk and Suffolk are mirrored in the strategic plans of a large proportion of trusts engaging in similar programmes.
The picture is not wholly negative. Some changes have resulted in positive outcomes, such as an increased focus on primary care, and there are examples of providers who have taken a more incremental approach to service development and improvement. Understanding the pressures in mental health is as much about how trusts spend money and there is a need to focus on using evidence to improve practice and reduce variations in care.
However, as the financial situation of mental health trusts deteriorates, with growing numbers of trusts falling into deficit, providers are signalling the need for further transformation. Unless mental health trusts can have confidence that their funding is secure, there is a risk of initiating another wave of changes which fails to learn the lessons to date and further compromises the care of the patients they serve.
Helen Gilburt is a fellow in health policy at The King’s Fund
Mental health under pressure can be downloaded at www.kingsfund.org.uk/mentalhealthpressures