reporter Andy McNicoll gives his view on the factors driving serious failings in mental health care
Is England’s mental health system in crisis? There is mounting evidence that it is. At the sharp end – crisis care – frontline staff are routinely struggling to get people the emergency hospital care they need. If beds are available at all, and some days NHS trusts say there are none in the country, they are often hundreds of miles from people’s homes. The same is true of care for acutely unwell children.
Worse still, this is costing lives. People have taken their own lives just days after professionals tried to admit them to hospital only to be told no beds were available.
If this was any other health or care emergency it would be a national scandal. That it is going on at a time when government and NHS policy claims to be committed to ‘parity of esteem’ – equality – between mental health and physical health is at best baffling, at worst a disgrace.
Not just about beds
This crisis is not just about beds. The pressure on inpatient units is merely a symptom of a woefully under resourced mental health system that is bursting at the seams. Our mental health services are being forced to pick up the pieces from cuts to welfare, social care, housing and much, much more. Our emergency services – police and ambulance in particular – are, in turn, having to pick up the pieces from overwhelmed mental health services.
How did we get to this point? I have been trying to mull over what I believe I’ve learnt over the past two years of covering these issues, from talking to staff and spending time with teams. Mine is only one perspective on these problems – social workers, NHS directors, commissioners, police officers and people using services will all hold their own views and experiences – but it feels to me that a number of factors are at play here.
Mental health trusts
Most of my work looking at these issues over the last year has focused on NHS mental health trusts. Are they fully to blame for this crisis? Absolutely not. Are they partly at fault? Yes.
Many have closed beds during a period of rising demand. Several have made cost-driven ‘redesigns’ of services that have been sold to the public as improving care but in reality have masked deep cuts to the community and early intervention teams that can help keep people out of hospital. Few trusts have spoken out while the pressure and strain on their staff reached record levels.
Yet the reality is that trusts are to a large extent being backed into a corner. They can only invest the money that they are allocated by NHS commissioners. With mental health trust budgets falling by an average 2.3% in real-terms since 2011, a sector that was already underfunded has seen its lot worsen. The decision by NHS England and Monitor to impose a 1.8% cut to the tariff for mental health services compared to a 1.5% cut for acute hospitals in 2014-15 will cause more pain and put ‘parity of esteem’ further from reach.
If you are a trust and being pressured to make year-on-year savings by commissioners, closing NHS wards – which are hugely expensive to run – are one of very few ‘assets’ available to you to make substantial savings from.
Wards are not only being closed for cost reasons of course. The closures are also part of a well-intentioned drive to shift more care into the community. Most would agree that hospital environments should be a last resort and people should be treated at home where possible. But good community care can’t be done on the cheap and it feels like that’s too often what’s happening.
Evidence I gathered from trusts suggests that the bulk of cost savings from ward closures is often not diverted to community services. I found that, on average, budgets for community teams and crisis resolution teams – the services designed to keep people out of hospital – had flatlined or been cut in real-terms since April 2011. Referrals over the same period rose an average of 16%.
The figures I gathered on budgets didn’t cover other issues like the downgrading of experienced staff. Or the cuts to management posts that leave a void when staff need an experienced hand to turn to for advice in managing risky cases. The result? Risk-aversion can kick in and referrals get made all the way up the chain, ultimately increasing the pressure on crisis services.
Social workers and nurses in many crisis teams have told me they feel overrun. Often this is due to them trying to hit targets for the number of patients they see each day. It leaves little time to do meaningful crisis prevention work. Instead, dropping off someone’s medication and quickly checking they’re OK is as close to ‘intensive home treatment’ as some people get. Patients also report serious problems accessing services out-of-hours.
Concerns have also been raised over the pressure on community mental health teams, the services designed to help people manage their mental health at home. I reported how one trust’s risk register showed it its teams had ‘unmanageably high’ caseloads. When language like that is used in NHS trust board papers – usually the home of anodyne statements – the alarm bells should be ringing. High caseloads for these teams mean patients get seen less and the warning signs that someone’s mental health is deteriorating may not be picked up early enough.
Local authorities have also played a role in this crisis. Cuts to social care and housing have created problems discharging people who are ready to leave hospital, adding to the pressure on beds and delaying people from rebuilding their lives outside of institutions. Councils – themselves under pressure to make year-on-year cost savings – have also cut back on their contributions to child and adolescent mental health services and voluntary sector run mental health projects that can be key to crisis prevention.
Councils are also responsible for making sure local areas have sufficient numbers of Approved Mental Health Professionals (AMHPs), the group of mostly, but not exclusively, social workers that carry out Mental Health Act assessments. Longstanding concerns have been raised about the fact that the AMHP workforce is both ageing and shrinking, yet at least one local authority has let their AMHP numbers reach what the Care Quality Commission described as ‘too few AMHPs to provide a safe service’. This should not be happening.
I have heard officials downplay problems with crisis care as limited to ‘parts of the country’. I may be wrong but based on what I hear from social workers and AMHPs I do not believe that to be true. I actually believe the reverse to be the case – that the majority of mental health teams, particularly crisis services, are under severe pressure.
This does not mean practice is always poor or mental health trusts are not doing good bits of work. I’ve heard of some good projects launched by trusts to try and curb bed pressures by boosting community support and alternatives to admission. I also know that staff are often doing a pretty incredible job in impossible circumstances, I’ve seen it firsthand. The point is that too often this is all being done despite the system’s failures. There is too much firefighting.
Over the past two years I have spoken to staff, particularly AMHPs, from various parts of England. The stories I’ve heard are similar – good, highly-skilled people feeling ground down by not being given the support and resources to do their jobs properly and safely. The national AMHP survey and research by The College of Social Work has highlighted similar issues.
A national problem should demand national action. This government has said plenty of good things about mental health. Its commitments to parity of esteem and introducing access standards for mental health are a genuine step forward from its predecessors. In Norman Lamb and his predecessor Paul Burstow, the sector has had two extremely engaged ministers who have introduced policies that I’ve heard referred to as some of the best mental health policies this country has ever seen.
But, and it is a huge but, the government’s positive statements on mental health are seriously undermined by two major issues.
The first is that for all the good aspirations in the government’s policy documents, most have not been met with any resource commitments to help make them a reality. Soundbites and ‘challenges’ to services to improve care cannot address systemic failure.
The government’s ‘crisis care concordat’ – its flagship policy to address crisis care failings – sets out standards of crisis care that few would argue with. Local areas will sign-up to it with enthusiasm, but without the resources to make it happen, or the threat of sanctions for not delivering it, its chances of success feel limited.
It is worth remembering that in 2012 this government launched a ‘concordat’ to address the fallout from the Winterbourne View care scandal. Last week, Norman Lamb told the Health Service Journal that – two years on – the scheme has been an “abject failure”.
The second major issue undermining the Department of Health’s mental health rhetoric is wider central government policy. Welfare cuts are frequently cited by mental health social workers as among the most challenging part of their work. The bedroom tax was a major factor in the caseload of one team I spent time with. Meanwhile the coalition’s Health and Social Care Act has devolved responsibility for services from the government to NHS England. The result has been what feels like a gaping hole in the accountability for services.
And so it is that we have a situation where the lead minister for mental health can say that real-term cuts of 2.3% imposed by commissioners on mental health trusts “completely conflicts” with government policy but NHS England say the same cuts represent mental health trusts “delivering better value”. It would be laughable if the situation facing patients and staff wasn’t so serious.
This passing of the buck is happening at local level too. We have reached a point where a social worker alerted a minister, NHS commissioners and a mental health trust to the fact teams feel unable to operate safely and legally, only for all three parties to tell him they broadly share his concerns; yet weeks later staff at the trust say the problems are worsening and they are now considering industrial action.
I appreciate the solutions to all of this are likely to be incredibly complex. I know projects like street triage (which has received some funding) and improved CQC inspections may have some impact. However, the lack of investment to tackle the underlying problems in the mental health system – despite evidence of unsafe care – is striking. When we had an acute A&E crisis last year, the government found more than words to address it and stumped up £500m to help hospitals cope with overwhelming demand and improve community services.
One thing that needs to stop is the lack of ownership of these issues at the highest levels. The back and forth between the Department of Health and NHS England that has emerged when serious problems with care are highlighted is insulting to the social workers, nurses, doctors and others that get up every day to put themselves in increasingly difficult and risky positions because they cannot get the resources they need to work safely. Most importantly, it does a disservice to the people who use the services and their loved ones. They all deserve better