Large-scale changes to mental health services are a ‘leap in the dark’ and are having a negative impact on patient care, according to a briefing published by The King’s Fund.
The briefing, Mental health under pressure, reveals that the sector is under a huge amount of strain, with about 40% of mental health trusts experiencing a cut in income in 2013/14 and 2014/15. This is in marked contrast to the acute sector, where more than 85% of trusts saw their income increase over the same period.
It also reports widespread evidence of poor quality care, with only 14% of patients saying that they received appropriate care in a crisis, a 23% increase in out-of-area placements for inpatients in the year up to 2014/15 and bed occupancy rates routinely exceeding recommended levels.
The briefing also revealed that the need to reduce costs has driven large-scale transformation programmes aimed at shifting demand away from acute services towards recovery-based care and self-management. This has seen a move away from evidence-based services in favour of care pathways and models of care for which the evidence is often limited. There has also been little formal evaluation of the impact of these changes.
One example cited in the briefing is the merger of specialist crisis resolution home treatment teams and early access to psychosis services into generic community health teams. Evidence suggests that these teams are often unable to provide the level of support required by patients, reducing quality of care and increasing pressure on inpatient beds.
Worryingly, the King’s Fund briefing found that, as their financial situation deteriorates, many trusts are considering a further wave of large-scale changes, which could further destabilise services and reduce the quality of care for patients. It calls on the sector to focus on using evidence to improve practice and reduce variations in care, but says it is essential that this is underpinned by stable funding, with no more cuts to budgets.
Helen Gilburt, fellow, (mental health) policy at The King’s Fund and author of the report, said: “Historically, mental health services have often been the first to see their funding cut, so many trusts felt forced to look at what savings could be made through transformation programmes to pre-empt this. Trusts looked to move care from the hospital to the community, focusing on self-management and recovery. Few would dispute the intention and rationale for this – the problems arise with the scale and pace of the changes, which lack the necessary checks to evaluate their effectiveness and the impact on patient care.
“Mental health trusts now need the security of stable funding, supported by a national focus on evaluating the changes to date, improving practice and reducing variations in care.”
Stephen Dalton, chief executive of the Mental Health Network, welcomed the report: "It exposes the institutional bias that exists in the NHS and local authorities when it comes to funding for mental health. Much of this is well known to policy makers and politicians and despite the rhetoric about giving equal importance to physical and mental health this hasn't translated into any new money. On the contrary, funding for mental health services has gone down. Many commissioners of NHS services don’t have the capacity to do the right thing and fund what works. If this government is serious about prioritising mental health they need to ensure new funding gets directly to providers of care and not channelled through layers of bureaucracy where it is lost."
Brian Dow, director of external affairs at Rethink Mental Illness, agreed that funding was crucial: “This largely comes down to the question of whether support is being designed around the needs of people with mental health problems, or is it about being driven by attempts to cut costs and find the cheapest way forward.
“There’s no doubt that lack of funding in recent years has had a detrimental impact on mental health services and the support people with mental illness are getting.
“The danger of these ‘transformation programmes’ is that on the ground it could mean a very different outcome for someone who, for example, has schizophrenia and is in the midst of a crisis, hearing voices telling them to harm themselves.
"In some areas there are currently specialist crisis teams with trained professionals who know how to support this person through an incredibly terrifying ordeal. Instead of this, the risk is that there will be a watered down version of this support, and the mental health professional who happens to be on call may not be sufficiently well trained to take on the crisis as effectively. This adds even more concern, especially as only 14% of people say they had received appropriate care in a crisis situation.
“It’s true ‘transformation’ needs to take place, but into a mental health system that is fairly funded, evidence-based and has parity with other health provision.
“There are many opportunities to transform the mental health system to focus on properly funded, high-quality, community care. While these changes can potentially save money; decisions must focus on providing the most appropriate care for the people who live with mental illness every day.”