Transforming mental health services – at what cost?

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Transformation in health and social care is almost universally seen as positive. The NHS business plan for the next five years firmly stakes the future of the NHS on transforming care. As the pace of change increases and organisations clamour to join one of the successive waves of vanguards – is this confidence justified?

When it comes to transformation, mental health services have led the way. The sector’s shift from providing care in hospital to community-based care and the subsequent specialisation of community services to meet emerging needs offer some valuable lessons for other services. The sector has continued to transform services, but rising pressures in the mental health system and ongoing issues with quality of care raise questions about how successful recent transformation has been.

Despite their potential, an examination of transformation programmes in the mental health sector in our latest briefing paper, Mental health under pressure, highlights that the context in which they occur and their drivers have an important impact on outcomes.

It is clear from a review of mental health trusts’ strategic plans that a primary driver for transformation has been to reduce costs. The funding pressures on mental health trusts are evident, with 40 per cent experiencing a reduced income between 2012/13 and 2013/14 and again between 2013/14 and 2014/15. As one trust put it: ‘Traditional methods of making cost improvements have been exhausted and a new transformational approach is being taken to avoid significantly affecting the quality of the care we provide.’

The content and direction of many transformation programmes in mental health care reflect national policy, including recovery-focused care; a greater emphasis on the community; and an expectation that investing in care that supports self-management and prevention will reduce the pressure on acute services. However, there has been little recent national guidance on delivering these in practice or robust evidence in support of improved outcomes.

A report by The King’s Fund and the Health Foundation on supporting successful transformation highlights the time and investment needed to adequately support the development, implementation and evaluation of change and the need for funding to allow double-running of services during the transition phase. Despite the lack of guidance and evidence, the majority of trusts have embarked on transformation programmes at scale and pace with little or no dedicated funding for the process. Arguably this has resulted in trusts taking a leap in the dark.

It is unsurprising, therefore, that service changes have not always been successful at addressing key issues such as pressures on acute care, and, in some cases, have had a negative impact on care and resulted in a high levels of variation. And despite the changes, the pressure on inpatient beds remains and in most cases has increased. Many of the evidence-based models of care such as early intervention in psychosis and crisis resolution home treatment teams, once redesigned and reconfigured, are failing to deliver on the outcomes they are expected to. And while there have been a number of new developments, including recovery colleges and peer support programmes, evidence to support their wider implementation remains limited.

Faced with a choice between simply cutting services or reconfiguring care, many mental health trusts opted for the latter. While this has delivered cost savings in the short term – with the majority of mental health trusts in surplus at the end of the year – it has come at a cost to quality of care. 

It is too easy to lay responsibility for poor-quality care at the door of commissioners. Tasked with finding more efficiency savings and often with limited expertise in commissioning mental health – commissioners may be over-estimating the ability of mental health trusts to deliver further cost savings. However, there is a risk that trusts – through the ambition of their transformation programmes and the pace of change – support the expectation that high quality can be provided at lower cost.

Acknowledging the limits of transformation and the negative impact that decisions to manage cost have had on quality and outcomes may place trusts in an uncomfortable position, but an honest recognition of the relationship between funding, quality and service transformation may in the long run provide a more solid footing for investment in mental health services.


Julie Ann Racino

President and Principal,
Community and Policy Studies
Comment date
17 November 2015
For community mental health services, in the US, small new agencies were created in the 1970s to offer support services in homes and communities. This community development was the new wave of community support and community integration versus simply "deinstitutionalization" (successful when planned).

Deinstitutionalization often was a "dirty word" because it had hallmarks of transinstitutionalization, criminalization, dumping and homelessness. Its early 1960s success was release based upon medications (often considered effective for 70% of the clients).

However, in 2015, remarkable successes are described in Public Administration and Disability: Community Services Administration in the US (Racino, 2104).

Yet, the leadership of "community psychosocial agencies" (World Health Organization, Mental Health Development Programme) has been subjected to managed care plans as behavioral health. In most states, the agency's personnel were not educated or trained to offer these services, nor were they broadly recommended for homes and communities.

Qualified personnel are available to assist, but the mental health populations are often not aided by the criminal justice groups which often arrest. In addition, the hospitals in the US began going behavioral refusing to place qulaified mental health counselors in rehabilitation units.

For more information, start with which offer resources also on Person-centered planning in mental health.

Amit Shah

Co-founder and CFO,
Comment date
16 November 2015
One of the themes that we hear about time and time again is the access to a mental health expert at short notice, particularly for those living remote areas or too distressed to leave their homes.

Twealr helps to alleviate this by offering an online solution that enables users to reach out to experts in a timely manner. Plus it also offers a free Q&A service enabling users to reach out to and connect with other users struggling with mental health issues on an anonymous basis as well as post questions to experts.

Hopefully it is one step forward in solving the mental health crisis within the UK.

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