People with mental health problems lose out in the NHS. That’s the case powerfully made in a new report published by the London School of Economics (LSE), which argues that underinvestment in mental health care represents ’the most glaring case of health inequality in our country’. I would particularly recommend the report to everyone working in or with clinical commissioning groups (CCGs).
The argument is a strong one. Mental health problems are far more common than generally appreciated, pervasive in their effects, and all too often go untreated – only a quarter of those experiencing depression or anxiety receive treatment, according to the most recent national survey data.
Those who do receive support often face much longer waits than would be considered acceptable in other clinical areas. Despite the success of the ‘improving access to psychological therapies’ programme, the dramatic drop in waiting times seen elsewhere in the NHS between 2002 and 2010 was not mirrored in mental health. The NHS Constitution gives patients the right to be seen within 18 weeks, yet the majority of people with depression or anxiety still wait for more than six months (often much longer) for psychological therapy.
The LSE report rightly highlights childhood mental health as a particular concern. More than half of all mental health problems start in childhood or adolescence, and access to effective forms of treatment and support for children is limited. Worryingly, there are signs that funding for child and adolescent mental health services is under serious pressure, particularly where services are jointly funded by local authorities and the NHS.
So what role can CCGs play in addressing these problems? The impact of poor mental health is seen on a daily basis in primary care, so it is to be hoped that CCGs put improving mental health care among their highest priorities. There are several things that every CCG leader should know.
First is the scale of the problem. Mental health problems account for a quarter of the overall burden of disease in the UK – more than any other disease category – and have a similar effect on life expectancy to smoking.
Second is the extent to which poorly treated mental health problems drive up costs in other parts of CCGs’ commissioning budgets. Our previous work on long-term conditions and mental health has suggested that between 12 and 18 per cent of all money spent by the NHS on long-term physical health conditions is linked to poor mental health. If we add the costs related to medically unexplained symptoms, mental health problems cost the NHS at least £10 billion each year in physical health care costs alone.
Finally, CCG leaders should know that improvements can be made without incurring additional net costs. For example, integrated psychological support for people with long-term conditions can pay for itself by bringing down the costs of physical health care. Another example is early intervention in psychosis teams, which have been estimated to deliver £10 in savings to the NHS for every £1 invested.
A first step for CCGs should be to work with member practices to explore how the interface between mental health services and primary care can be improved. Proposals from the Royal College of General Practitioners to include a mandatory mental health rotation in GPs’ training is an important step in the right direction. But there is much that CCGs can do more immediately. Investing in mental health and building stronger connections between mental health professionals and primary care would be a significant achievement for CCGs, and one with a compelling economic and clinical basis.
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We are where we are in health and social care because of the relentless pace of socio-economic development. Mental health problems arise at all stages in the journey towards socio-economic prosperity, when barriers are faced, escape from the journey is sought through drugs or alcohol or when the plateau of plenty is reached and emptiness kicks in - or the next project is landed leading to mental exhaustion. Add to that the effect of spiritual isolation, multi-media invasion of privacy, cultural differences and personal pressures and it is amazing that sanity can be measured at all. But it can be quantified in terms of monetary value, work hours lost, GP appointments for associated health conditions, etc. In an attempt to save money by saving the undiagnosed ill, we must simultaneously look towards investment in strategies for healthy living, finding out what makes people happy and offering more of it.
I can only agree with this analysis. Interestingly, of course, while it is quite right to say that we need more investment in mental health to tackle the huge amount of untreated mental disorder across the UK, we do actually spend a considerable amount on mental health care - in England, PCTs (largely) spend some some £12 billion annually, compared to around £8 billion for heart problems and £6 billion for cancer.
However we also know that both NHS and local authority mental health services are under huge pressure, and many are facing cuts, both as a result of the recession and public service spending cuts, and the Nicholson 'efficiency savings'. As an example, one service user wrote to me last month: ". In my town they have closed two centres for the treatment of mental health problems which has affected me. Out of working hours there is now no one I can contact if I have a mental health crisis, who knows my case. The CPN and Psychiatrist I see are excellent, but there hands are tied by lack of money, they are only at work during working hours and 5 days a week and are under tremendous pressure".
Clinical Commissioning Groups need to be clear, as the King's Fund suggests, on the benefits of better integrated physical and mental health care (improving the physical health of people with mental health problems is a key outcome for the Government) and on the latest and best evidence of cost-effective interventions, as set out in NICE guidelines. But they also need to think outside their clinical silo - what will improve mental health is mentally healthy homes, schools, workplaces and community environments, which means working very closely with Health and Wellbeing Boards and embracing the public health agenda.
At one and the same time, people who want quite inexpensive out-patient mental health services are complaining about cuts in such services, and different people (with full mental capacity) who don't want mental health services are being chased about the country, by people determined to deliver them unwanted in-patient mental health services non-consensually and after detaining them without charge or trial for thought crimes.
Am I the only person able to see an obvious solution to the problem of a supposedly "under-funded" mental health industry, which has far too much money to waste, in the perception of those trying to avoid the industry, by fleeing to "safe houses" provided by surviving mental health refuseniks?
The mental health industry will remain too expensive as long it refrains from operating as nothing more than a useful, demand-driven market-place, and insists instead of doubling as a thought police service, tracking down dissidents, and meting our cruel and unusual punishments, in ways that are not justiciable.
There are also efficiencies to be gained in treating lower level mental health problems, but the oppportunity is being lost by uncertainty over budgets and funding.
A service piloted in the West Midlands over the past 3 years supports the conclusion that APPROPRIATE early intervention leads to improved outcomes for patients, reduced cost, AND more efficient working for GP's.
It was found that patients repeatedly presenting with symptoms of mild or moderate depression due to non-medical causes can be more effectively treated at low cost by specially trained advisors, instead of by repeated visits to the GP’s surgery. In one sample of 521 such patients referred by their GP to the service, 379 (72%) exited the service with reduced depression and with a completed (or in some cases ongoing) plan to deal with the underlying cause of their depression. None exhibited more severe depression following the service, and most were successfully discharged from the service within 3 to 6 weeks, after a maximum of 6 meetings with their advisor.
This produced a positive outcome for an otherwise moribund cohort of patients and removed them from surgeries, improving GP access for other patients. The service also reduced the cost of intervention by approximately 38% compared with the cost of allowing the same patients to continue visiting their GP, even if only for the same number of meetings (the greater likelihood being that they would have visited their GP more often, for appointments likely to exceed 10 minutes).
However, despite strong evidence that the service is cost-effective, the perverse outcome has been that budget cuts mean the PCT is unable to continue funding the service, and these patients are now returning to their GP’s waiting rooms. Whilst individual GP's acknowledge the value-add of the service, they remain unwilling to pay for it from their own budgets, even though it directly benefits them by saving time, and benefits their patients by resolving their issues.
Rightly or wrongly, GP’s believe the onus for providing this service falls either upon outgoing PCT's or incoming CCG’s, and not upon themselves.
As a MH service user with frequent admissions I am at the stage where I feel quite literally bounced between services. The Crisis services in my area can't respond out of hours unless you can get to A&E.I am currently deemed at being at very high risk of suicide (full risk assessment done this week) yet in the next 2 weeks will lose both my Care Co-Ordiantor and my Psychiatrist of 7 years without replacements. My GP is excellent but cannot support my level of need and has stated this in writing. The Trust therapy services have wait lists of over 1 year and have just told me that without a Psychiatrist taking clinical responsibility they won't now assess me. The only voluntary sector therapy service with low cost therapy has just assessed me as being too high risk for them to support.
So too unwell to get the help I need to manage life yet not unwell enough to warrant support at CMHT level. 19 admissions in 8 years, recently detained under the MHA, multiple crisis contacts and diagnosis of Bi-Polar with psychosis.
So when Personal Health budgets finally arrive in my area I will use it to go to Dignitas.And the Trust and NHS get to make an overall saving.
The Mindfulness Based Cognitive Therapy (MBCT) 8 week course is NICE-recommended for depression under CG23 2004 and CG123 2011, but so few courses are commissioned that the waiting on the NHS is thousands of years, whereas there are many providers in the third sector. They should be invited to bid, so that the waiting time can be reduced to 18 weeks. For details of how this could work, see sectco.org
We need to stop the false dichotomy between 'physical' and 'mental' health problems, which are used by staff on both sides to protect their resources and push patients from pillar to post. I have recently come across numerous cases of people in a range of acute hospital settings with serious psychological problems (often presenting as extreme agitation and challenging behaviour) - referrals for such patients to psychiatric liaison services are fraught with difficulty and often result in little, if any, support. A recurring complaint from the acute hospital staff struggling to manage these patients is that their mental health colleagues won't touch them with a bargepole until they've had every last blood test, scan and investigation known to man to exclude 'organic' causes. Even if there is an organic cause - so what!? - dementia is an organic condition, but that doesn't mean mental health services don't get involved! In one case I dealt with the stubborn refusal of the liaison psychiatrist to offer even a scintilla of advice about medication resulted in the patient being inappropriately over-sedated by a general physician who didn't know what else to do. Records written in acute hospital notes by psychiatric liaison staff frequently make pointed reference to concerns about the fact that the person's condition might be 'organic' - which means, reading between the lines, "probably not our problem - whew!". The pressure on resources, on all sides, means that clinicians try to put patients into artificial boxes that don't really exist - but anyone with half a brain knows that physical and psychological problems are invariable inextricably inter-linked. The irony is that, at the end of the day, this almost certainly costs the NHS more money, leading to delayed and/or poor quality assessments and treatment decisions. We need to accept that patients are more complex than this - services should be prepared to work together collaboratively, recognising that mental and physical problems often go hand in hand. I think it's called 'person-centred care'.
Much of the guidance and the KF's own analyses recommend greater use of self help groups and peer support to facilitate self care, sustain the benefits of self management interventions and facilitate shared decision making but the new AQP tariffs are focused on 1:1 professional treatment. Mutual aid is a low cost but not free effective complement to 'wrap around' these packages of care with proven savings for services and improved quality of life for patients but it requires specialist support (JRowntree Foundation and the National Programme for Improving Health and Wellbeing). Where is the provision for this?
I agree with Sue Neal-we need a holistic approach. People are people and do not fit neatly into one box or another. We need a 24/7 patient centred and patient led mental health service that provides quality and measurable outcomes. Patients with mental ill health need step up and step down care rather than sticcato services when it suits the provider
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However we also know that both NHS and local authority mental health services are under huge pressure, and many are facing cuts, both as a result of the recession and public service spending cuts, and the Nicholson 'efficiency savings'. As an example, one service user wrote to me last month: ". In my town they have closed two centres for the treatment of mental health problems which has affected me. Out of working hours there is now no one I can contact if I have a mental health crisis, who knows my case. The CPN and Psychiatrist I see are excellent, but there hands are tied by lack of money, they are only at work during working hours and 5 days a week and are under tremendous pressure".
Clinical Commissioning Groups need to be clear, as the King's Fund suggests, on the benefits of better integrated physical and mental health care (improving the physical health of people with mental health problems is a key outcome for the Government) and on the latest and best evidence of cost-effective interventions, as set out in NICE guidelines. But they also need to think outside their clinical silo - what will improve mental health is mentally healthy homes, schools, workplaces and community environments, which means working very closely with Health and Wellbeing Boards and embracing the public health agenda.
Am I the only person able to see an obvious solution to the problem of a supposedly "under-funded" mental health industry, which has far too much money to waste, in the perception of those trying to avoid the industry, by fleeing to "safe houses" provided by surviving mental health refuseniks?
The mental health industry will remain too expensive as long it refrains from operating as nothing more than a useful, demand-driven market-place, and insists instead of doubling as a thought police service, tracking down dissidents, and meting our cruel and unusual punishments, in ways that are not justiciable.
A service piloted in the West Midlands over the past 3 years supports the conclusion that APPROPRIATE early intervention leads to improved outcomes for patients, reduced cost, AND more efficient working for GP's.
It was found that patients repeatedly presenting with symptoms of mild or moderate depression due to non-medical causes can be more effectively treated at low cost by specially trained advisors, instead of by repeated visits to the GP’s surgery. In one sample of 521 such patients referred by their GP to the service, 379 (72%) exited the service with reduced depression and with a completed (or in some cases ongoing) plan to deal with the underlying cause of their depression. None exhibited more severe depression following the service, and most were successfully discharged from the service within 3 to 6 weeks, after a maximum of 6 meetings with their advisor.
This produced a positive outcome for an otherwise moribund cohort of patients and removed them from surgeries, improving GP access for other patients. The service also reduced the cost of intervention by approximately 38% compared with the cost of allowing the same patients to continue visiting their GP, even if only for the same number of meetings (the greater likelihood being that they would have visited their GP more often, for appointments likely to exceed 10 minutes).
However, despite strong evidence that the service is cost-effective, the perverse outcome has been that budget cuts mean the PCT is unable to continue funding the service, and these patients are now returning to their GP’s waiting rooms. Whilst individual GP's acknowledge the value-add of the service, they remain unwilling to pay for it from their own budgets, even though it directly benefits them by saving time, and benefits their patients by resolving their issues.
Rightly or wrongly, GP’s believe the onus for providing this service falls either upon outgoing PCT's or incoming CCG’s, and not upon themselves.
So too unwell to get the help I need to manage life yet not unwell enough to warrant support at CMHT level. 19 admissions in 8 years, recently detained under the MHA, multiple crisis contacts and diagnosis of Bi-Polar with psychosis.
So when Personal Health budgets finally arrive in my area I will use it to go to Dignitas.And the Trust and NHS get to make an overall saving.
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