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
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
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
Figure 4
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.
- Read the 2015 report referenced, Mental health under pressure
- See how the NHS is performing in our latest quarterly monitoring report
Comments
Beds continue to be closed, for financial and administrative reasons. I find no clear evidence of patients preferring community care, often as I have known it stated. I don't doubt there are people who are in such a position that remaining at home is a reasonable option. I have never been consulted about the decision.
Patients are no more than inconvenient and expensive bed occupants. Excessive beds have already been closed and they will close more, because it suits their plans, Beds are administrative entities, not the source of genuine asylum. That concept no longer exists. Guilt is effectively engendered in those who would prefer the continuous support afforded by admission. Do they actually want to get institutionalised?
The Conservative Government decided to 'target' those on Welfare, and many Mentally Ill (Schizophrenics) were forced to look for work, and LOST All other forms of Welfare Benefits,now living on less than £6500 per year.
Many Schizophrenics live with their families, and subject to Section 117 of the 1983 MHA, this group are targeted the most, despite their 'high needs' they are taken off Section 117, and receive no input from any other Professionals, other than regular medication.
The above group are 'targeted' by ATOS Independent Assessors for 'fit for work' and PIP, resulting in Discrimination, loss of Welfare Benefits, resulting in Carers using their OWN Pension to Support/Care/provide a home.
There is more homeless on the streets than ever before. Carers are getting older and will die, who then will Care for those who have become 'INVISIBLE'
THE NHS THE GOVERNMENTS’ ONGOING DUPLICITY.
I refer to your reported comments on the Government’s recent statements on the NHS , however you appear to have overlooked the reality flowing from the removal of the NHS from democratic control by the Health and Social Care Act 2012.
As a result of the above Act, there is now nothing that Jeremy Hunt, NHS England or the Department of Health can do to force the 175+ independent NHS Foundation Trusts to spend the tax payers money given to them in any particular way – they now can only request but can do nothing if that request is ignored.
That is why virtually none of the one billion pounds of taxpayer’s money that the Government states it has provided for mental health services was actually spent on those services.
The findings of the investigation carried out by the King’s Fund’s (an organisation whose views the Government routinely quotes to when they are in favour of the Government’s treatment of the NHS) are a warning that the funding required to improve mental health care is not reaching the frontline services where it is most needed, and, in the opinion of the Kings Fund this reality will have a direct impact on access to treatment and the quality of patient care.
Helen Gilburt, a Fellow in Policy at The King’s Fund who did the analysis, said:
‘The fact that the planned increases in funding for mental health have not materialised in trust finances in so many areas is worrying, as there is a real-ly urgent need for investment.
‘Patients should expect access to timely and effective treatment, yet across the country there is widespread evidence of poor-quality care, and patients are increasingly reporting a poor experience of mental health services. Many of the pressures in mental health are being seen in areas of care where patients are most vulnerable.
The reality is that as the Government now cannot force any of the now “free from democratic control” 175+Nhs foundation Trusts to spend any of the tyax payers money given to them in any particular way and all the evidence is that the so called “extra” money to which Theresa May and Jeremy Hunt refer, was not spent on mental health services at all and there is nothing that the
Government can do to change the situation without repealing the Health and Social Care Act.
Kevin S. Riley Solicitor.
There was a time when they could get away with it but now, being far more accountable, many are showing that they are not up to standard. The real problem then becomes that they can remain in post and are well rewarded for their incompetency, indeed some are even promoted.
All that is then left is to continue with the smoke screen of greater budgets, which is wearing so very very thin.
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.
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.
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