Trust finances raise concerns about the future of the Mental Health Taskforce recommendations

Funding is never far from the headlines in mental health. The government’s commitment to parity of esteem between physical and mental health care has led to a whirlwind of activity over the past couple of years, but as the focus on mental health grows there is widespread recognition that without greater parity of funding, improvements in access and treatment are unlikely to be realised.

Mental health trusts provide about 80 per cent of all mental health care. Our 2015 briefing outlined the financial pressures that those trusts are experiencing. For the first time in a decade funding for mental health (adult and older people’s services) fell in 2011/12. Data from 2013/14 and 2014/15 shows that around 40 per cent of mental health trusts continued to experience year-on-year cuts to their budgets (see Figure 1).

In 2014, NHS England backed up its ambition to achieve genuine parity of esteem by 2020 by outlining an expectation that clinical commissioning groups (CCGs) would increase mental health spending in 2015/16 in real terms by at least the same proportion as each CCG’s allocation increase. However, one year on, analysis of mental health trust annual accounts demonstrates that 40 per cent of trusts have in fact seen reductions to their income.

Figure 1

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The failure to increase funding for many mental health trusts comes despite assurances from NHS England that almost 90 per cent of plans submitted by CCGs for 2015/16 reflected the mandated increases. NHS England has maintained that investment in mental health cannot be equated with the revenues in mental health trusts as some services are provided by other organisations. However, given that mental health trusts provide a large proportion of mental health care, and with little evidence that demand for these services has fallen, it seems likely that for many CCGs, overall spending on mental health has been lower than planned.

This raises serious concerns. Many of the recommendations from the independent Mental Health Taskforce, published earlier this year, call for increased investment in core mental health services. The implementation plan that accompanied the taskforce report demonstrates that many funded programmes, such as vital improvements to crisis and acute care, will be included in CCG baseline allocations, or through centrally allocated funding from NHS England that will be switched to CCG baseline allocations at a later date. Experience with previous initiatives, including the Improving Access to Psychological Therapies programme, highlights the challenges of getting funding to the front line of care, with an evaluation led by the London School of Economic and Political Science attributing the failure to scale-up services as planned to commissioners not using available funding for the intended purpose.

The disparity between planned investment in mental health and actual investment could be attributed to a number of factors, including the need to tackle deficits among NHS providers, which have been largely concentrated in the acute sector (see Figure 2).

Figure 2

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Although many mental health providers did not see an increase in income during 2015/16, the majority of acute providers did (see Figure 3). Future plans continue to reflect an emphasis on managing the financial pressures in the acute sector with almost all the sustainability and transformation funding being used to tackle acute sector deficits, an approach that could backfire given that the number of mental health trusts in deficit is increasing (see Figure 4).

Another key issue is the difference in payment systems. Mental health providers continue to be paid predominately through block contracts. These not only fail to reflect increases in demand, which must be met by the provider, but are also more vulnerable to cuts which can impact across the range of services that the contract covers.

Figure 3

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Figure 4

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How mental health trusts have maintained their financial performance for so long despite having their income cut is an important question. Our own analysis highlighted provider-led service transformation as an important factor in this but also raised significant concerns about the impact this has had on quality of care. Workforce transformation has featured as a key aspect of many of these plans, with significant reductions in the number of experienced nurses. This trend looks set to continue – our latest survey of NHS finance directors found that 40 per cent of respondents from mental health and community trusts plan to reduce the number of permanent clinical staff over the coming year. This suggests that many mental health providers are continuing to reduce their headcount, despite the risks this brings to quality of care.

These local plans have important implications for improvements at a national level. Work by NHS England to support implementation of access standards for early intervention services flagged insufficient staff and staff skill-mix as a key barrier to delivering the full package of care. Since the new standards were introduced in 2016, an FOI request by the Liberal Democrats to CCGs found that services commissioned by a quarter of the 170 CCGs that responded did not meet the relevant target.

It may be early days for the use of access standards in mental health, but alarm bells should be ringing if services commissioned by CCGs are not meeting the targets set, especially given the emphasis placed on this approach as a means of driving increased funding and improvements in care. And there is little evidence that things are going to get easier. The Mental Health Taskforce implementation plan outlines the workforce requirements to deliver each of the funded recommendations, which in some cases are considerable. Although funding has been allocated centrally for workforce development, ultimate responsibility for funding these staff will lie with commissioners and providers.

Funding good mental health care has always been perceived as an uphill struggle. There have been efforts to ensure funding is invested appropriately including getting CCGs to develop plans outlining how extra funds will be committed support improvements, development of national metrics to monitor progress, and increased reporting requirements on how funds have been allocated. But commissioners have already flagged concerns that the incorporation of targeted investment for mental health into baseline allocations for 2016/17 make it difficult to clearly identify the amount available for development of services making it vulnerable to pressures elsewhere in the system.

The NHS planning guidance for 2017–19 restates a requirement for CCGs to increase funding for mental health services in line with increases in their funding allocations and the national mental health director has pledged to take action in areas where funding has not reached the front line. This is very welcome but experience so far suggests that further directives will have little impact until significant progress is made in tackling the wider financial pressures in the NHS and implementing an alternative payment mechanism for mental health providers. Unless this happens implementation of the Mental Health Taskforce recommendations – and the ambition to achieve parity of esteem – will remain under threat.

Footnote

The data is presented as proportions to reflect changes in the number of trusts and from which data could be obtained. Data for 2012/13 to 2014/15 includes all trusts for which data was available, while data available for 2015/16 includes all mental health trusts and more than 95 per cent of acute trusts.

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Comments

#548391 George Ikkos
Hon. Archivist
Royal College of Psychiatrists

Thank you for this update.

I would like to highlight 2 issues:

1: Some psychiatrists are concerned that even when the money reaches the mental health trusts, it does not go to the right places. Specifically it goes to managment and administration, rather than clinical services. Even when it reaches clinicians, too much may be spent on administrative demands on clinicians rather than direct patient clinical care.

2: With respect to skills mix, some of us have expressed concerns that even when the staff are there in numbers, they may not have the skills to meet patient need. We have written about this in "The trouble with NHS psychiatry in England, Paul St John-Smith, Daniel McQueen, Albert Michael, George Ikkos, Chess Denman, Michael Maier, Robert Tobiansky, Hemachandran Pathmanandam, Teifion Davies, V. Sunil Babu, Omana Thachil, Furhan Iqbal, Ranga Rao, "DOI: 10.1192/pb.bp.108.023184 Published 28 May 2009 which may be accessed via the following link http://pb.rcpsych.org/content/33/6/219.abstract

When our paper was published no attempt was made to refute the key charge of lack of appropriate skills; rather it was argued that it was unrealistic to expect this.

All too often people with mental illness have been short-changed in our mental health services and the situation appears to be getting worse, both on the basis of your data and discussions on the ground.

#548392 George Ikkos
Hon. Archivist
Royal College of Psychiatrists

Correction: The second from last paragraph should read:

When our paper was published no attempt was made to refute the key charge of lack of appropriate skills; rather it was argued that it was unrealistic to expect this to be different.

#548394 Daniel McQueen
Consultant Psychiatrist
Tavistock and Portman NHS Trust & Cygnet Healthcare

Furthermore, even if there are enough people with the right training and skills in post, they still require a working environment that permits them to deploy their skills in the provision of care.

The current, increasing and apparently irresistible, demand for “documentation” and data, of low quality and relevance, enforced through unwieldy, data hungry, computerised medical records further erodes scarce and valuable clinician time for treating patients.

The drivers of this obsession with documentation are doubtless multiple but foremost among them must be the increasing mismatch between demand and resources due to concurrence of a growing and ageing population, more people with long-term conditions, and the politics of austerity.

This mismatch is both denied and aggravated by the Orwellian political rhetoric of “excellence”, “continuous improvement” and “efficiency savings” and an inspections framework that calls clinical providers to account for outcomes while they have no control over resources or demand.

Inevitably this leads to "… an emphasis on procedure, the usual resort of bureaucrats far from the field of action, whose aim is to control outcomes for which they are responsible but which they cannot directly influence." [Oyebode, APT, 2005]

#548414 Amar Shah & Tri...
Associate Medical Director for QI (Amar) & Associate Clinical Director for Patient Safety (Tricia)
ELFT (Amar) & South West AHSN (Tricia)

Einstein is quoted as saying 'We can not solve our problems with the same level of thinking that created them'. With this in mind, although additional money, parity of esteem and increasing attention to mental health services is very welcome, our view is that this alone will not deliver the improvements that we, our service users and the population demand.

We would instead urge those in leadership roles to shift their mental models to assume abundance, focus relentlessly on delivering the highest value with the resource we already have, leveraging the greatest assets we have available - our people (both staff and service users) and their boundless optimism and creativity.

At East London NHS FT we have started taking this path, and are finding that there is huge opportunity for improvement within our existing system, if only we find the right way to release it. As an example, the article suggests that we will struggle to meet our access targets without more funding. At ELFT, we have found that we can significantly improve access to all our community services without extra resource, simply by thinking differently and involving all in creative problem-solving, using quality improvement as the mechanism to engage deeply, test and learn how to solve these complex problems.

Committed leadership with a clear vision for higher quality can provide the environment in which front line teams can innovate, flourish and transform the cost and quality of care. The provision of an intense but universal training programme in improvement methods with a robust support structure, transparent data systems and attention to involving service users/carers/customers in the process can enable diverse organisations to make gains across the system that add up to a healthier, more engaged workforce, better quality outcomes and experience for our population and more efficient organisations.

#548488 Karen

I am interested in the assertion that "Mental health trusts provide about 80 per cent of all mental health care" This article gives a partial view based on a treatment and cure approach. I would suggest the reality is that MH trusts receive 80% funding to provide mental illness treatment and care for a specific group of people. The work done by others - GPs, charities, churches, schools etc etc to provide Mental Health wellbeing and care is where our society should be putting its efforts to make a bigger impact.

#548490 john kapp
Director
SECTCo

I agree with Helen, as this is my experience in Brighton and Hove. Our allocation of the better Care Fund is £20mpa both last financial year, and this one, yet to the best of my knowledge, none of this has been drawn down to treat the vulnerable people it was intended for, despite my protestations, published on section 9 of www.reginaldkapp.org. Our CCG is now in special measures. Please contact me on johnkapp@btinternet.com

#548491 Karen Skinner
Masters Student Global Labour & Social Change
Ruskin College Oxford

I agree with the comments above about the endless need and time requirements for data collection which has no tangible benefit for the end user. My son has paranoid schizophrenia aged 25 years and is in desperate need of more face to face contact time with his CPN and a positive message of hope in his life. sadly he only sees her once a month for his risperidone injection. That is hardly providing a full and enriched care package if his only contact is for this purpose. Its time we framed mental health in a more positive light, thats what helps patients. The funders need to be more determined to seek resources that reflect higher quality services, not just an injection. Its almost an insult for young people who have lost so much life potential and need good bio-psycho-social care packages tailored to personal needs.

#548501 Helen Gilburt
Fellow, Health Policy
The King's Fund

Really helpful comments. Funding for mental health Trusts is by no means the sum of mental health but with many of the taskforce recommendations requiring increased staffing and greater capacity to improve the quality of care, getting funding to these frontline services is a key issue.

This however does not detract from the fact that there is wide variation in access and quality between mental health services and much that can and should be done to improve quality. The work of trusts such as ELFT demonstrate that quality is not a simple question of more money, but the effective and efficient use of funding and how a concerted focus on quality improvement can support this.

The decrease in funding may also reflect support for other services that support people with mental health problems, but there is no way to track this funding, and little indication on the ground of a real growth in voluntary and community sector support, in fact we hear much the opposite.

Data collection is only a pointless process if data is not used to improve provision, or provides insufficient insight to support improvement. There is a strong argument that better data on if and how money is spent would be greatly beneficial, but importantly that this was to the benefit of service users, carers and communities. However, the challenges of measuring what is meaningful and which could inform service delivery and quality improvement at a national scale can be experienced as burdensome with little demonstrative positive value.

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