Ahead of the general election on 8 June, we examine the big issues around health and care.
What's the issue?
Mental health has long been regarded as a poor relation of the NHS. Years of under-investment means that people with mental health problems often experience poorer access to services and lower quality of care than those with physical health conditions. For example, long waiting times are still common for psychological therapy; many people receive care in facilities outside of their home area because they cannot get the right care locally; and services for children and young people are widely regarded as inadequate.
In response to this, the Health and Social Care Act 2012 created a new legal responsibility for the NHS to deliver ‘parity of esteem’ between physical and mental health, which the coalition government subsequently committed to achieving by 2020. Parity of esteem means equal access to effective care and treatment; equal efforts to improve the quality of care; equal status within health care education and practice; equally high aspirations for service users; and equal status in the measurement of health outcomes (Royal College of Psychiatrists 2013).
What’s behind this?
The NHS has agreed an ambitious national strategy to improve mental health services in England, set out in The five year forward view for mental health. To fund the strategy, the government indicated that £1 billion would be made available each year by 2020/21 (from money already earmarked for the NHS), and in July 2016 NHS England published an implementation plan indicating how this money would be phased in and, notionally, how it would be spent. Mental health was also identified as one of four priorities in the recent delivery plan, Next steps on the NHS five year forward view, which describes how the NHS intends to improve care and ensure services are sustainable.
The commitments made in The five year forward view for mental health build on ongoing work designed to put mental health on a more equal footing with physical health. One component of this is the new waiting time standards introduced for psychological therapies and for early intervention services for people experiencing a first episode of psychosis. This is the first time that access targets, which have been used in some parts of the NHS for many years, have been set for mental health, providing an important driver for improving access to these services. The five year forward view for health recommended extending the scope of these standards to include a wider range of services over the next few years.
However, despite the increased profile of mental health at the national level, within local health systems much of this is overshadowed by concerns about funding. An analysis conducted by The King’s Fund found that in 2015/16, 40 per cent of mental health trusts in England received a real-terms decrease in their operating income. This is despite clear expectations from NHS England that clinical commissioning groups (CCGs) should increase mental health spending at least in proportion to overall growth in their budgets.
Evidence that some CCGs have not met funding requirements is particularly concerning as many of the commitments made in The five year forward view for mental health are dependent on money from CCG allocations, which are vulnerable to being squeezed when funding is needed to address pressures elsewhere in the system, especially in acute hospitals. Our research indicates that these funding pressures have led to financially driven service changes in mental health in many parts of the country.
Workforce shortages in some areas of mental health care will also need to be addressed if parity is to become a reality. High levels of vacancies in many mental health trusts have resulted in higher caseloads and make it harder for staff to give service users the time they need.
Another important measure of parity is whether mental health receives sufficient focus within wider efforts to improve health care. There is good evidence that addressing mental and physical health needs together is better for patients and can be more cost-effective. On this front too there are concerns – for example, around the inclusion of mental health within sustainability and transformation plans (STPs) or in work on new models of care. Although each STP is required to make reference to mental health, the degree of emphasis given to it varies, and there needs to be much greater focus on ensuring mental health care is integrated into other health and care services as part of these plans.
The King’s Fund view
The focus on parity of esteem is highly welcome, and there have been some specific achievements in recent years. All the main political parties are now committed to delivering parity, reflecting changes in public attitudes to mental illness. However, there remains a sizeable gap between rhetoric and reality, particularly in relation to funding. Parity will not be achieved if mental health budgets remain vulnerable at times of financial pressure. To deliver the improvements set out in The five year forward view for mental health, the next government will need to make sure that the money pledged reaches the front line. Otherwise parity will remain a distant goal.