The state of mental health provision in the 21st century
For too long mental illness has been something of a hidden injustice in our country, shrouded in a completely unacceptable stigma and dangerously disregarded as a secondary issue to physical health.’
Prime Minister Theresa May, 9 January 2017, unveiling plans to transform mental health support.
Mental health care has come a long way from the institutionalisation of patients in psychiatric hospitals. However, it still does not enjoy parity of esteem with physical healthcare in our health system.
Mental health care accounts for nearly a quarter of NHS activity, but receives only 11% of spending. According to The King’s Fund, 40% of mental health trusts in England received a real terms decrease in their operating income in 2015-16.
More recently, The King’s Fund found that, despite 85% of mental health trusts receiving increases to their income in 2016-17, funding for acute and specialist physical healthcare continued to grow more quickly, increasing the gap in funding between physical and mental health services.
Non-consultant led mental health services are exempt from the 18-week ‘referral to treatment’ waiting time rule, enshrined in the NHS Constitution. This means people with mental health problems can be left without treatment or support when they most need it. The CQC recently reported how one child had been waiting 18 months for treatment. It is therefore welcome that NHS leaders have recognised the need for a radical upgrade in mental health services.
In 2016, the independent Mental Health Taskforce published the Five Year Forward View for Mental Health, a strategy for improving mental health services. The Taskforce identified three strategic priorities:
A seven-day NHS: making sure that mental health crisis care is available 24 hours a day, seven days a week.
An integrated physical and mental health approach: making sure that care for people with both physical and mental health needs is joined up and that one is not treated in isolation or to the detriment of the other.
Improving prevention: enabling people to lead fulfilled and productive lives and providing support at key moments in life, for example, during childhood or when people are out of work.
As we publish this report, NHS England is two years into its implementation plan for the Five Year Forward View for Mental Health.
This plan sets out an ambitious programme of work to improve mental health services, with the aim of ensuring one million more patients are receiving high quality mental health care. However, the recent CQC report, The state of care in mental health services 2014 to 2017, based on evidence from its inspections, shows the challenge the NHS has to overcome in order to deliver the strategy.
This report reinforces the CQC’s findings. While 74% of NHS services were rated as good or outstanding, 25% required improvement and a further 1% were rated inadequate. CQC identified several areas of concern from their inspections:
- Safety concerns over antiquated premises, unsafe staffing levels and poor management of medicines.
- Persistence of restrictive practices, including locked mental health wards, staff on acute wards lacking the skills to anticipate and de-escalate violent situations, and the over-use of physical restraint.
- Poor access and lengthy waiting times for specialist services and a lack of 24-hour crisis care.
- Poor clinical information systems which hinder care co-ordination and information about risk not being available to all staff involved in a patient’s care.
The CQC also monitor how NHS organisations use the Mental Health Act 1983. Its most recent report showed there has been no improvement in respect of problems it had identified in previous years including:
- Patient involvement in care plans.
- Taking the patient’s views into consideration.
- Consideration of patient need or the least restrictive option for care.
- Discharge planning.
- Patients not being informed of their legal rights.
These concerns are additionally worrying given the increasing use of detention under the Mental Health Act 1983. 63,622 people were detained under the Act in 2015-16, a 9% increase on the previous year.
In 2017, the government appointed an independent review,led by Professor Sir Simon Wessely, to examine the way providers currently use the Mental Health Act 1983, and how it affects patients, professionals and the public.
The review is looking at the reasons behind the rising use of the Act, the disproportionate number of people from black and minority ethnic groups detained under the Act, and processes that are out of step with a modern health system. The review is due to publish its findings in autumn 2018.
A common thread running through both the Five Year Forward View for Mental Health and CQC’s state of care report is workforce challenges. The scale of the problem is underlined by The King’s Fund report on staffing in NHS mental health services, which found there has been a 13% reduction in mental health nurses between 2009 and 2017, with inpatient care losing nearly 25%. Almost 10% of all posts in specialist mental health services in England are vacant.
The Five Year Forward View for Mental Health set out the need for a costed, multi-disciplinary workforce strategy to ensure the workforce has the right number of people with the right skills.
The complaints we have included in this report demonstrate how patient care and safety is jeopardised by these workforce challenges.
They show clinical staff ill-equipped with the skills to manage potentially violent situations, being expected to work double shifts leading to exhaustion, and clinicians having to treat conditions they have no experience of.
Unless these workforce challenges are addressed it is difficult to see how the transformation of mental health care, envisioned in the Five Year Forward View for Mental Health, can be realised.