Abstract
Current status
Mental illness is common; at least one in four people will experience a mental health problem at some point in his/her life. Mental illness encompasses a variety of conditions; the majority of which are mild. However, every year, specialist teams in the NHS deliver care to over a million people with severe and enduring mental health problems.
Over the last 20 years, we have seen an overall reduction in the number of inpatient mental health beds (there are currently 30,000 inpatient psychiatry beds provided by 60 Mental Health Trusts [many but not all have Foundation Trust status]) and invested hundreds of millions of pounds in establishing hundreds of community mental health teams and home treatment teams throughout the NHS.
At present, nearly 11% of England’s annual secondary care health budget is spent on mental health. Unlike other NHS comparisons, the NHS spends a relatively higher percentage of total health budget on mental health, spending more as a percentage of spend than even the US system. This number excludes social supports and the physical health costs resulting from serious mental illness. In addition, launched in 2008, IAPT (Improving Access to Psychological Therapies) – providing access to psychological therapies for adults – is being expanded to provide psychological treatments for children and young people. In 2011, as part of ‘No health without mental health’, the government committed a further £400 million to improve access to talking therapies.1,2
The overall cost of mental health problems to England’s broader economy is estimated at £105 billion, and treatment costs are predicted to double over the next five years.
Despite this investment, there are repeated reports of long waits for people with mental health problems to be seen by specialist mental health teams. In addition, many mental health services do not meet the standards recommended by NICE. There are also problems in the lack of communication between different health and social care teams looking after the same individual patient. Institutionalisation is still the bias for the seriously mentally ill. Delayed discharge is the norm. Overall, the value that is delivered for mental health services by the NHS is unclear.
We do know that people with mental ill health and long-term conditions cost more on average per person per year, continue to use services intensively for longer, and impact on a wider range of other public services than those with exclusively physical health conditions. Mental ill health drives the use of acute care services, including repeated visits to Accident and Emergency departments, and many GP appointments. At least 25% of people in acute inpatient beds have a diagnosis of dementia (225,000 admissions in 2010, costing the NHS a total of £650m). This is likely to be an underestimate as mental health co-morbidities are frequently undiagnosed and not recorded. 3
Over the last two decades, researchers have made great strides in improving our understanding of what causes mental illness from a biological and social perspective. At a service delivery level, we have seen improvements in dementia care by targeting this on a condition specific basis. The National Dementia Strategy, published in 2009, set out a vision for achieving better awareness of dementia, early diagnosis and high quality treatment at whatever stage of the illness and in whatever setting – it also looked at stopping the prescribing of inappropriate medications for this group. 4
In contrast, the needs of young people with schizophrenia are fundamentally different to frail, elderly people with dementia. For example, employment for people with schizophrenia is currently between 5% and 15% and has fallen over the last 50 years even though many more people with schizophrenia could – and would like to – work. 5 In addition, people with schizophrenia die 20–25 years earlier as we fail to do a good job about caring for their physical health needs alongside their mental health needs. Similar premature mortality statistics are characteristic of all adults with serious and enduring mental health problems.
Opportunity exists to apply the drive that made such an impact improving dementia care for the rest of mental health conditions. The way to approach this is on a segmented approach based on people with similar needs.
How much better could mental health provision be?
At present, it is rare that explicit criteria are agreed to determine who is and who is not eligible for mental health services, even for admission to an inpatient facility. This lack of explicit guidelines leads to variation across the system about who receives what care and when. Most mental health trusts admit that there is variation in treatment approach for similar clinical presentations and that many individuals in inpatient facilities could be appropriately cared for in community settings. Examples from other health systems have shown that it is possible to provide more care for more people for the same amount of resources when an explicit approach to organising which patients are most appropriate for what intensity of care is systematically applied.
As a consequence of the variation, GPs struggle to access mental healthcare services for people, even when they are in crisis. Although some IAPT services have good recovery rates, many are failing to reach current targets meaning that most people have to wait weeks to be assessed and months to begin treatment. These delays are unacceptable. We have improved the wait time for people to be seen for routine medical and surgical appointments. Now we need to make sure we deliver the same quality of care for people with mental health problems.
A recent survey revealed that only 14% of people said that they felt they had all the support they needed when in crisis. This is not good enough.
When discharging people from secondary mental health services back to primary care settings, we need to ensure that primary care teams feel equipped to care for people with mental health problems. There are a number of ways to achieve this, including integration and co-location of mental healthcare professionals and open access appointments.
Although there are some examples of best practice when young people transition from Child and Adolescent services (CAMHs) to Adult Mental Health Services – too often there is huge disruption to their care at a time when individuals are at their most vulnerable from a neurodevelopmental perspective. Too many young people are lost from services at this juncture only to later present in crisis that could have been avoided. 6
Despite investment in community mental health teams throughout the NHS, many people continue to be seen year after year in outpatient clinics by consultant psychiatrists. Recent analysis has shown the majority of consultant psychiatrist-led outpatient appointments are for follow-up and monitoring purposes. 7 These could be delivered by other healthcare professionals in community settings. At present, different models of mental healthcare delivery run in parallel, sometimes delivering duplicative care for the same people. This is not consistent with the evidence on recovery, does not deliver value for taxpayers’ money and is confusing.
For those who are acutely unwell and at risk enough to themselves and/or others to require inpatient mental healthcare, there is often a lack of communication between the inpatient ward and primary care. On the inpatient wards themselves, the majority of decisions still take place during once or twice-weekly consultant psychiatrist-led ward rounds. This results in patients waiting several days for appropriate senior assessment, medication and treatment plans to even begin. More than 50% of those in an inpatient setting are readmissions. As such, a great deal is known about these individuals that could enable crisis stabilisation in a community setting eliminating the need for any admission at all. As a consequence of poor coordination and a bias toward institutionalisation, average lengths of stay for people on inpatient mental health wards in the NHS today approaches 40 days. Aside from isolated innovations, such as the Triage ward model, few mental health providers are proactively measuring and driving down inpatient lengths of stay. 8 Examples of best practice internationally, from both Europe and America, reveal that, for the same intensity of care, it is possible to improve outcomes with lengths of stay less than half as long. 10 To achieve this will require delivering the same care at weekends as during the week, with daily rather than weekly reviews of how people are doing by senior clinicians.
The way we have set up payment systems in the NHS for mental healthcare does not incentivise providers to improve the velocity and coordination of patients through the system of care. Too often Home Treatment Teams, which provide an alternative to inpatient admission by seeing patients in their own homes, are declared ‘full’. 11 Community resources must be seen as part of a continuum of care available to support crisis stabilisation and supported discharges, rather than being run as yet another parallel set of services.
We know that a small proportion of people drive a significant amount of the overall spend on healthcare. While many of these are older people, others have multiple mental and physical health long-term conditions and do not engage well with primary care services. This group of people often experience fragmented care and poor outcomes from an early age. Opportunity exists to organise care differently, including social services, for this group of individuals, who are often well known to local services yet no single team has overall responsibility or accountability for coordinating their care and improving their outcomes. The acute sector, under payment by results and foundation trust status regimes, even has distorted incentives to increase the volume of inappropriate care for this cohort.
There is a need for a step change in how we measure and pay for mental healthcare in the NHS. While a national tariff for commissioning mental healthcare is currently being developed which clusters patients based on their level of need, this does not go far enough. 12 Measuring care and outcomes in mental health is often put in the ‘too difficult’ box yet capturing data on whether people have homes to live in, jobs to go to, appropriate medication, financial stability and social interactions are possible for other conditions so why not for people with mental health problems too.
Where we have experimented with personal health budgets, these have proved popular – giving more choice for people with mental health problems over who provide their care. Yet spread in the use of personal health budgets is not currently occurring at the scale and pace it deserves. 9
Summary/call to action
Although frontline clinical teams are extremely busy, we do not currently measure the outcomes or the difference that the care provided makes to individuals with mental health problems and their families. It transpires that some of our most intensive specialist mental health teams are not currently caring for the most unwell people who would benefit from them most.
When people have multiple physical and mental health problems, we do not routinely share information on care plans, medication, risk assessments and outcomes between the different health and social care professionals involved in looking after the same patient. Siloes exist between physical and mental healthcare in the way teams are organised and the way care is paid for. Social care is overtly excluded. This leads to poorly coordinated care, poor experience for individuals and their families, and unacceptably worse outcomes overall.
The existing mental health system does have the potential to improve the care it provides with the same resource available. To achieve this requires a rapid upscale in mental health commissioning expertise and delivery models that recognise the importance of mental health in affecting physical health conditions, especially for individuals with multiple chronic physical and mental health conditions. Opportunity exists for the NHS to partner with both the voluntary and private sectors, tapping into international expertise to implement data-driven models of best practice.