What we think
Following years of underinvestment and lack of attention, mental health services are now firmly on the national agenda, and there has been a sea change in public attitudes. However, there is still a long way to go to achieve the ambition of parity of esteem between physical and mental health. A long-term commitment to investment and reform is needed to expand access and support vital improvements in the quality of care experienced by people using mental health services.
The commitments made in the NHS five year forward view for mental health and the NHS long-term plan have set the right direction for improving services. But these ambitions can only be delivered if sufficient numbers of suitably qualified and skilled staff are available; action is needed to address major workforce shortages by recruiting, training and retaining more staff, especially mental health nurses.
Alongside delivering the commitments in the NHS long-term plan, providers of mental health services need to focus on driving up the quality of care. As much emphasis needs to be placed on the culture of care – providing safe compassionate care grounded in the needs and values of people using services – as on increasing access to evidence-based interventions.
A more integrated approach to physical and mental health is needed to provide joined-up services to the significant numbers of people experiencing mental health problems alongside long-term physical health problems, and to address inequalities in life expectancy among people with serious mental illness. This includes embedding mental health expertise across all health and care services and addressing the physical health of people with mental health conditions.
The government first committed to achieving ‘parity of esteem’ between mental and physical health services in the Health and Social Care Act 2012, pledging to ensure that people experiencing mental health problems get the same access to safe and effective care as those with physical health conditions. Although progress has been made, there is still a long way to go, and people with mental health problems continue to face inequalities in quality and outcomes of care.
Historical underinvestment and cuts to funding have impacted on access to services and quality of care delivered by providers of mental health services. Increases in funding have often been attached to individual programmes, fragmenting services and leaving core services without the investment they need. Despite repeated commitments to increase funding, it has been difficult to track whether this money has reached frontline services.
The Forward View for Mental Health published in 2016 by NHS England, acknowledged significant failings in access to services and quality of care and outlined steps to begin to address this. Measures included improving access to crisis services and expanding provision of perinatal mental health care. Further commitments were made in the NHS long-term plan, including a ring-fenced investment fund, strengthening community mental health services and an expansion of support for children and young people.
Workforce shortages are likely to be the major limiting factor on these plans. In 2018/19 around one in eight nursing and medical posts in NHS mental health providers were vacant. This is negatively impacting on access to and quality of care, including long waiting times for children and young people’s services and the closure of inpatient beds due to staff shortages in some areas.
Quality of care in mental health services is highly variable. Improving Access to Psychological Therapies services consistently meet the required access and treatment standards. However, people’s experiences of community-based mental health services have deteriorated and there are ongoing issues with children and adults being sent to inpatient units out of their local area due to insufficient bed capacity. The Care Quality Commission and the Independent Review of the Mental Health Act have both highlighted quality of inpatient care as a key issue. This is particularly concerning as many people in inpatient units are detained under the Mental Health Act and subject to treatment against their will.
Recent and ongoing reviews have highlighted that in some areas of care, services are failing to treat people with compassion and dignity. Examples include the use of restraint and seclusion within inpatient services. The culture of care is fundamental to quality but has received insufficient attention in recent years.
Physical and mental health are closely connected: there are high rates of mental health conditions among people with long-term physical health problems; life expectancy is lower among people with severe mental illness, largely attributable to poor physical health; there is limited support for the psychological aspects of physical illness; and ‘medically unexplained symptoms’ (physical symptoms for which no clear biological cause can be identified) are poorly managed. These issues mean that care is less effective than it could be, perpetuating inequalities in health outcomes and increasing the cost of services.