Parity of esteem for mental and physical health services has been a key government goal for some years now – and there are several major pieces of policy that aim to work towards that goal. However, a report by the Commons Public Accounts Committee (PAC) has publicly questioned whether the government’s targets for improving mental health services and achieving ‘parity of esteem’ can be achieved in the timescales set out.
“Department of Health and NHS England have a laudable ambition to improve mental health services but, given the current pressures on the NHS budget, we are sceptical about whether this is affordable, or achievable without compromising other services,” the report said.
Coming from a Parliamentary Committee, these are strong words, although to many working in mental health services – or in receipt of them – they are likely to come as no surprise. However, the source also means they should be heeded by the DH and NHS England.
The report comes to five headline conclusions.
Firstly, it says that the aim of achieving parity of esteem for mental and physical health services will be very difficult to achieve.
While the PAC acknowledged that the introduction of waiting time standards for mental health treatment in three specific areas is welcome, it added that it is less clear how improvements in services will be paid for.
DH has previously announced £1 billion for mental health services over the course of this Parliament, but the money has not been ring-fenced: The report notes: “There is a risk that commissioners and providers, already under financial pressure, will have no choice other than to deprioritise other mental or physical health services if they are to meet the new standards.”
There has already been some evidence that money is not making it through to providers. In May, a report by the NHS Providers and the Healthcare Financial Management Association, ‘Funding mental health at local level: unpicking the variation’, revealed that only 52% of providers reported that they had received a real terms increase in funding of their services in 2015/16.
In addition, many providers didn’t expect this situation to change this year: only 25% of providers said they were confident that their commissioners were going to increase the value of their contracts for 2016/17.
The PAC report also criticises the level of information available to commissioners about the full costs and benefits of spending on mental health services, saying it is not good enough to support well-informed decisions about how best to use the limited available funding.
Additionally, the report queries NHS England’s aim of extending waiting time standards to other mental health services. “Given the pressures in achieving standards in the first three areas, however, it is not at all clear how easily or quickly standards can be introduced more widely,” it says.
The second conclusion is that structures are not in place to enable joined-up working across government to ensure the most appropriate action is taken to support people’s mental wellbeing.
The report says that while the 2014 Crisis Care Concordat has helped to ensure people with mental health conditions get appropriate treatment, and DH and NHS England have started “dialogue” with other departments on providing better integrated services, in general “systems for working across government are weak.”
As examples of this lack of integration, the report cites: how people leaving prison have no consistent way to access mental health services on their release; how counselling services are not available in all schools; how services to help people with mental health problems get back into work are not joined-up between the NHS and the Department for Work and Pensions.
Integration of services has been something of a ‘holy grail’ for years, and the report hints that it is still a distant aim, and likely to remain so, given the complexity of the individual services concerned. While “dialogue” may have started, it also means nothing has changed on the ground, and therefore the time when it will be achieved – if ever – is pushed further into the distance.
Thirdly, the report concludes that it is difficult for people to access the support they need because the way mental health services are designed and configured is complex, variable and difficult to navigate.
The report points out that there are many ways people can come into contact with mental health services, and there often follows a complex process of diagnosis, referral and treatment involving multiple staff in different health settings, making it difficult for people to access the treatment they need. These processes also vary from area to area.
Another conclusion highlighted is the dearth of information on numbers of mental health staff, and the lack of a plan to develop the workforce in order to achieve the goal of parity of esteem. The confusion over these issues was highlighted by Health Education England estimates that implementation of the waiting time standards will require a 7% increase in the number of mental health nurses by 2020, yet trusts expect their demand for them to fall. High vacancy rates in consultancy psychiatry posts and psychiatry training were also flagged, as was the high number of nurses leaving the NHS.
“Health Education England is now starting to develop a workforce strategy for mental health, the first since 1999,” the report says, adding, pointedly: “In the meantime, the Department has put new waiting time targets in place without a clear understanding of the workforce needed to achieve them.”
The final conclusion is another worrying one: that current structures, practices and payment mechanisms do not incentivise commissioners and providers to deliver high-quality mental health services for all who need them.
The report notes that there is a risk that, because there are only a small set of targets for a few mental health services, commissioners and providers will prioritise these at the expense of other services.
In addition, ‘block contracts’ are still the most common way of commissioning services, which pay providers a fixed sum regardless of the quality or timeliness of the services. They also lack transparency or give incentive for providers to improve services.
However, NHS England says that it is undertaking an ‘open-book’ exercise with clinical commissioning groups (CCGs) to better understand how much commissioners are spending on mental health services.
These conclusions flag up once again concerns that have been mentioned in previous years and plainly haven’t been addressed. There is also implicit criticism of the DH – that, essentially, it has trumpeted the aim of parity of esteem, without first making sure if it was achievable.
Given the critical nature of the report, it is somewhat surprising that its recommendations are brief, and largely to do with collecting data.
That said, the information that would be available if the following recommendation is acted on would make for interesting reading. That is, that that DH and NHS England should:
Collect the cost and performance data needed to understand what the baseline position is in terms of the mental health services currently being delivered, and the money being spent
Calculate how much money it will take to achieve their ambitions and how best to prioritise the money available to get the best results
Be clear about the outcomes that services achieve.
The Committee recommends that that approach be adopted for the start of 2017/18.
The report also requests that DH, NHS England and Health Education England collect the data needed to estimate the workforce required to achieve parity of esteem between mental and physical health. By the start of 2017–18 it should a plan should be in place for supplying that workforce.
Taken together, action on these recommendations will give a more revealing picture of current mental health services – and how much is needed to ensure that parity of esteem is achieved.
More immediately, the report recommends that NHS England and NHS Improvement should accelerate work being done to incentivise CCGs and providers to improve mental health services and outcomes, including by developing better payment mechanisms, for implementation by April 2017.
Costs and funding
Behind the headline conclusions and recommendations, the PAC report give some more in-depth findings.
In terms of funding, the report notes that in 2014-15, DH gave NHS England £97.4 billion for all NHS services. However, NHS England directly commissioned just £3.7 billion of mental health services, and CCGs an estimated £7.9 billion – just 12% of the NHS budget. Most of the spending is on staffing.
Again, it emerged that there is limited data available on spending on treatment for different mental health disorders. The Centre for Mental Health called for real-time data on what is being spent on what.
In terms of spending on drugs, CCGs spend about £400 million through prescriptions by GPs – a total expected to rise by 4% in 2016/17. But this spending is not visible to a mental health trust as it appears in GPs’ prescribing budgets. In the context of the £11.7 billion spent on mental health, the cost of drugs represents a small proportion, because almost all drugs are off-patent.
NHS England said it has commissioned an independent panel to assess the extent to which CCGs are using money appropriately to improve mental health services, adding that focusing on funding is a proxy for the availability of high quality services and the outcomes they achieve, and that more of the funding needs to be linked to the outcomes that services achieve.
DH admitted that the widespread use of block contracts makes it difficult to judge if money is being well spent. However, NHS England and NHS Improvement are working to replace block contracts with either a proper capitated budget, under which a provider would be responsible for the local population, or funding would be attached to the episodes of care themselves.
DH and NHS England allocated £120 million additional funding to support the access and waiting times programme over 2014/15 and 2015/16. But this amount is small, and it was acknowledged that commissioners will mostly use existing budgets to improve services.
Worryingly, only 52% of mental health trusts said that they had received a real-terms increase in funding in 2015/16, according to evidence from NHS Providers. NHS England accepted that in some parts of the country the money is not getting through. In other areas some of the money is going to other parts of the mental health system such as independent providers, GPs and liaison psychiatry services in A&E departments, rather than to mental health trusts.
NHS England also admitted that cost overruns in acute hospitals had ‘crowded out’ what would have been investment in mental health services and primary care. However, this year it expected to adjust spending in acute hospitals to free up funding for mental health. Although later in the report the NHS admitted that if there continues to be unbudgeted overspending in the acute sector, there may have to be ‘a rethink’.
While £1 billion has been earmarked to implement the mental health taskforce recommendations over the next five years. NHS England said this money would not be provided evenly over the coming years, but with most coming in 2018/9, 2019/20 and 2020/1.
NHS England also pointed out that mental health services will have to find the same 2% efficiency savings as other parts of the NHS will.
The PAC also challenged DH and NHS England on whether estimates of the cost of meeting access and waiting time targets were accurate. NHS England said projected figures were only estimates, and should be treated as such. NHS England admitted that “the need on the ground already outstrips the budget and, while increased funding meant that more people would be able to access services in future, demand will still outstrip even the expanded budget in 2020”.
This would seem to indicate that NHS England does not believe that there is enough funding to achieve stated policy aims.
As mentioned, the greatest cost in mental health services is staff, but there are often also skill shortages. Several reports have highlighted this issue, including a PAC report in May on managing the supply of clinical staff that concluded that to align with financial plans, trusts’ workforce plans had consistently understated how many staff they would need.
Additionally, the National Audit Office (NAO) has reported that there is a considerable discrepancy between numbers of staff that local providers estimate they will need and Health Education England’s forecasts. Trusts forecast, for example, that their demand for mental health nurses will fall while Health Education England estimates that implementing access and waiting time standards will require the number of mental health nurses to rise by 7%, from 39,000 in 2014 to 42,000 by 2020.
The Royal College of Nursing also said there was a disconnect between workforce planning and service design, adding that it was unclear how national forecasts would meet the increase in demand by 2020.
In response, DH said that, through Health Education England, it is preparing a new workforce strategy for mental health, which will be ready by the end of the year.
DH also noted there remains a concern that, while Health Education England can train adequate numbers of mental health nurses, the health system has struggled with the rate at which nurses have been leaving the NHS over the last few years. But, with funding largely set out for the next 4 years, trusts and CCGs can have more confidence in recruitment, the DH said.
People’s experiences of mental health services
The report notes that only about 25% of people estimated to need mental health services have access to them. Access also varies depending on where someone lives. For example, the NAO found that in 2014–15, the proportion of people able to access psychological therapy within six weeks of referral varied from 7% in one CCG to 99% in another.
The fragmented nature of mental health services is also highlighted; Mersey Care NHS Foundation Trust said that there were about 19 different routes by which people could be referred to the trust for treatment. In response, DH said that everyone in primary care should have a named GP who is responsible for the oversight of their care. In secondary care, there should be a lead individual who is responsible for ensuring that person’s care is co-ordinated.
Some evidence in the report warns against prioritising certain services at the expense of others. This is in the light of targets only covering some mental health services, with the worry that attention and funding will be focused on those, with others neglected. DH emphasised that targets were part of a wider package of incentives to change behaviour that included oversight by NHS England and regulatory activity by the Care Quality Commission.
The Centre for Mental Health also emphasised that in working towards the goal of parity of esteem, inequalities in mental health services also had to be tackled. For instance, people from Africa and the Caribbean, as well as people who are lesbian, gay, bisexual or transgender have poorer experiences of mental health care.
DH pointed to the taskforce report recommendation that some form of ‘equalities champion’ should be appointed to make sure that the issue continued to be given prominence.
In terms of children and young people’s mental health, NHS England acknowledged that there had been huge geographical inequalities across the country. For example, compared to a national average of about 11 in-patient beds per 1,000 children, there had been five in the southwest. NHS England said that it had increased the total number of beds, and committed to increasing capacity in places where there was still under-provision. It also said that it is connecting local CAMHS with in-patient units in the same area to try and help flows of patients and ensure there are as few out-of-area placements as possible.
Finally, in terms of criminal justice, NHS England said it was rolling out liaison and diversion services to try and identify people with mental health issues before they enter the criminal justice system. It currently covers half of the country, with the aim of total coverage by 2020.
When asked why prison leavers are not directly referred to the NHS, NHS England admitted that it would make sense to have a referral system, but said that many prison leavers are reluctant to engage with services.
The PAC report paints a varied picture of mental health provision in England, and suggests that a postcode lottery is still very much in effect. It also calls into serious question whether the government’s aim of achieving parity of esteem for mental and physical health services can be achieved in the timescale set out.
There is an implication that the government has been quick to talk up its aims of achieving parity of esteem, but without first having put in place the systems and mechanisms to be able to achieve them.
It seems that without significant funding – additional to the £1 billion over the course of this parliament that the government has already committed – the government’s aims will not be realised.
The PAC report also highlights that some of the changes required to achieve parity of esteem will take much longer than the government – and others – may like. For instance, services are still mainly being commissioned via block contracts and that is an approach that will take many years to unpick, meaning that it will take a long time for new commissioning models to be put place. Increasing the number of mental health nurses will also take time.
However, in their responses, there seems to be some acceptance, from DH and NHS England, of the issues the PAC highlighted and, in some cases, promises of strategies to address them. If the DH and NHS England accept the report’s recommendation and act on them, then we will at least have a better picture of the scale of the challenge to put mental health on a par with physical health – however, we will be little closer to actually achieving it.