In the early 2000s, mental health services in England underwent a further period of significant transformation. This was underpinned by the development of a 10-year national modernisation plan, the National Service Framework for Mental Health (subsequently referred to as the NSF-MH) and the mechanisms for implementing it.
The NSF-MH emerged as a result of public and political pressure to reform community mental health care. During the 1990s, media coverage of a series of high-profile adverse events involving people with mental illness contributed to a public perception that community care had failed. The incorporation of the European Convention on Human Rights into UK law provided further impetus for reform of mental health legislation.
A government white paper followed which outlined a process of transformation. The transformation process had three key aims – to provide:
- safe services – to protect the public and provide effective care for people with mental illness at the time they need it
- sound services – to ensure that patients and service users have access to the full range of services they need
- supportive services – to work with patients and service users, their families and carers to build healthier communities.
Although clinical and financial factors did not overtly drive the case for change, it was recognised that community services were insufficiently adaptive to meet the diverse needs of service users. On the one hand, community services were often unable to manage the complexity of some patients; on the other, young patients were being held back by limited expectations of what they could achieve. As such, ensuring services delivered both appropriate care and value for money played a core role. These factors were influential in the subsequent process of identifying service delivery models.
The NSF-MH aimed to improve quality and remove wide and unacceptable variations in service provision. It defined what mental health services should aim to achieve, how they should be developed and put into practice, and how they should be measured.
The intended benefits were inherent in the development process. A series of guiding values and principles as to how care should be delivered were agreed and used to shape decisions about future models of care. Each area of focus had clearly defined aims, such as increasing access to primary care and providing support close to home in a crisis. Many of these became minimum standards for the new models of care and mental health services.
Each of the quality standards outlined the intended benefits (which would be subject to performance assessment at a national level), alongside the models of care and guidance on good practice. Although there was little overt focus on cost effectiveness in relation to each standard, provider transformation plans anticipated reduced bed days as a result of crisis intervention and assertive outreach teams.
Process and management
An External Reference Group of health professionals, service users and carers, health and social service managers, partner agencies and other advocates was convened to develop the NSF-MH. The group distilled existing research and knowledge and considered a number of cross-cutting issues, such as race and gender.
The group also considered the mechanisms by which systematic change would be achieved. The resulting NSF-MH:
- set national standards and defined service models for promoting mental health and treating mental illness
- put in place programmes to underpin and support local delivery
- established milestones and a specific group of high-level performance indicators in order to measure progress within agreed timescales.
The focus for delivery was on local health and social care communities. Five national programmes were established to underpin implementation, covering: finance; workforce planning, education and training; research and development; clinical decision-making support systems; mental health information strategy.
The NSF-MH standards were elaborated and specified further in the NHS Plan, which included specific targets for numbers of new services (200 assertive outreach teams, 335 crisis resolution teams, 50 early intervention teams), numbers of people who would be supported by such services, and deadlines for implementation. The subsequent Mental Health Policy Implementation Guide set out specifications for each of the three services. These included staffing levels and roles according to population size, prevalence and admission rates, and length of contact as appropriate to the care model.
A national body was established to oversee implementation and develop future mental health policy. The National Institute for Mental Health in England (NIMHE) was supported by leadership at a local level through eight regional development centres. Each local authority had an NSF-MH local implementation team, with broad membership (including service users). They were required to draw up plans identifying which of the specified national and local milestones they would report against. Trusts were also required to have an NSF-MH implementation lead and team.
The NSF-MH required substantial increases in the workforce, particularly for the three mandated services. Some estimates were as large as 18,000 – an increase of nearly 80 per cent over the 10 years. Sub-groups were established on workforce planning and it was recognised that new models of care would require workforce diversification and new roles. NIMHE and the Royal College of Psychiatrists developed policy to support these changes. For example, New ways of working for everyone examined staffing roles, skill mix and the role of allied health professionals, while Creating capable teams provided best practice guidance to enable teams to assess staff numbers and skill requirements.
Deadlines were a key feature of implementation in relation to the three key models of community provision. The NHS Plan 2000 included a target implementation deadline of 2004.
The majority of funding for the NSF-MH/NHS Plan was from central government. Funds available were hypothecated or ‘earmarked’. They included £700 million over three years to implement the NSF, and £120 million distributed via a Mental Health Modernisation Fund.
Half of the modernisation fund was distributed as part of unified allocations, mainly for services. Some was held centrally for Department of Health initiatives; the rest was allocated via a mental health grant comprising (variations of) a core grant to support existing services, a target fund to improve provision and, for specific initiatives, a partnership fund. The latter was for revenue expenditure only; it was not to be used to finance any capital needs or as a substitute source of finance for social care already being provided.
The Department of Health held funds for centrally funded initiatives, including the provision of secure beds, and for the establishment of regional mental health development programmes and NHS Beacons to encourage innovation in mental health. Local authorities were required to contribute 30 per cent to the core grant and partnership fund; they were expected to invest 15 per cent-30 per cent of the core grant (years 1 and 2) in additional training.
During the main period of implementation (1999/2000 to 2005/06), expenditure on adult mental health services increased in real terms by 47 per cent – an annual rise of 6.7 per cent – with around a third going on development of community-based teams (particularly those set out in the NSF-MH). It is important to note that there was substantial investment in the NHS at this time and the funding allocated was in line with these rates of investment.
It is undeniable that huge transformation was delivered across community services and in a relatively limited period of time.
The focus on workforce and skill mix resulted in large increases in the number of clinical psychologists and support workers, and moderate increases in the number of psychiatrists and mental health nurses.
However, full implementation was never reached and there was limited data on how many patients were being looked after by the new specialist teams (see Challenges below). A request under the Freedom of Information Act revealed that 14,882 people were being looked after by the assertive outreach teams (at 31 December 2004). This fell short of the target of 20,000 ‘adults with severe mental illness and complex problems’ thought to be in need.
The expected benefits of community care, combined with evidence for some of the service models, led most providers to reduce their inpatient bed provision. Some closed beds in anticipation of the reductions in need; others closed them in parallel with community service development or afterwards, as a result of over-capacity. However, the new models of care often failed to deliver the anticipated reductions and, in some cases, cuts in bed capacity were overly optimistic.
Some care models were found to be poorly adapted to the settings in which they were implemented. Assertive outreach proved particularly difficult to implement in rural settings.
The plan missed a crucial opportunity to create continuous evaluation of how the NSF-MH standards were being implemented. Key questions remained about how far the transformation delivered improved outcomes for mental health services and users.
Although top-down implementation was very effective, not all providers, commissioners and staff understood or agreed with the rationale for the specifications where supporting evidence was more limited. Over time, services implemented under the NSF-MH were reconfigured and dismantled. Current policy is restating the need to implement at least two of these models.
The sheer numbers of staff required within the timeframe and diversification of roles was ambitious. It was estimated that to implement the NSF-MH in full by 2010/11, aggregate staff numbers needed to increase by 38 per cent relative to the numbers employed in mental health care in 2005/06. Particular pressures arose in relation to those services that were more clearly mandated, where an estimated increase of 80 per cent was required over the 10 years. Staff for assertive outreach teams were often drawn from rehabilitation services, decimating existing provision, and gaps in early intervention staffing were particularly large.
Retrospective studies suggest that funding and workforce requirements were underestimated. Estimates suggest that total annual spend on adult mental health services needed to increase by 8.8 per cent a year in real terms for full implementation. The 2002 Wanless report estimated that spending needed to increase by 9.6 per cent a year. Between 1999 and 2002, estimates put the total investment needed at around £623.25 million – falling short of the promised £700 million. In practice, budgetary constraints hampered implementation locally.
Transparency and accountability
Funding for the NSF-MH was often part of unified allocations. The Department of Health did not require trusts to record spending in a standard way, and sometimes extra funding was not specifically identified within these allocations. The lack of transparency, alongside financial pressures and insufficient priority afforded to mental health, left spending to local organisations to argue over. Experts judged that some local health authorities ‘disinvested’ from mental health during this period.
Wider systemic considerations
Assertive outreach was underpinned by a case management approach providing for every aspect of an individual’s needs. However, this was not always within the power of the service, and a lack of access to appropriate supported housing has been noted as an important limiting factor.
The focus on implementing particular models of care within the NHS Plan led to concerted attention on new functional teams, but resulted in a lack of investment and consideration of existing community mental health services. Staff from community mental health teams furnished the new teams, resulting in a loss of skills and expertise.