Mental health under pressure

Comments: 15
There can be little doubt that the mental health sector is under pressure, however understanding the nature of those pressures has been difficult.

The mental health sector comprises a number of inter-related services covering a range of different conditions which together create a system of care. This briefing paper aims to focus on mental health as a system of care, examining individual pressures within the wider context of provider and commissioner actions. Although services for children and adolescents, and older people are very much part of this system of care, this briefing paper focuses on services for adults between the ages of 16 and 65.

Mental health under pressure

No. of pages: 30

Our analysis is based on a review of the literature, national datasets, survey data and analyses from other bodies, and data collected as part of our quarterly monitoring report survey. In addition, we have conducted new analyses of NHS provider board papers, annual reports and strategic plans. It is well established that the availability of robust data and national information on mental health services is limited and this means that quality of services cannot be definitively assessed. We have drawn together information from a number of different sources each of which provides a particular insight into provision and quality in order to provide an overview of the state of mental health services and care in England.

In focusing on the pressures in mental health we have predominantly highlighted negative outcomes. This does not preclude that some pressures and actions have resulted in positive outcomes or that there are individual examples of good practice. Despite this there is little evidence that the pressures identified are only limited to specific areas of practice or individual providers, and many areas of pressure such as crisis care have been the subject of national focus and policy initiatives.

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#545119 Faye Wilson
AMPH and chair of BASW mental health reference group

We so welcome this article having worked closely with Community Care on this issue for three years the lack of beds,waiting hours for ambulances loss of AMPH roles poor out of hours EDT teams in some areas,also almost a denial of disability on the rising acuity of users needs who do require admission and a culture of group think when plans which are clearly untested and not thought through with a lack of critical thinking, it not being trendy to question them
My colleagues and I are the applicants when people need compulsory admission abd work effectivly in good integrated teamswho are often at considerable risk and yet we are rarely consulted about changes or listened too and have to fight to get around the table in any discussions both at national and local levels the arguments you have been raising are ones we have been shouting from the roof tops about only getting platitudes in return
Role of peer support is very welcome but not as a replacement for good professional care when people are most at risk
When will people listen we need to work more closely with Kings fund and have a joint voice
BASW MH ref group

#545120 Jeff Love

Although this report correctly highlights the pressure on mental health services and the cash shortfall that makes this worse, I am concerned that the focus on "professional" support and hospital beds is not necessarily helpful - there is a real risk (and it's becoming quite noticeable in media coverage) that people with mental health needs and their carers will see admission to a mental hospital bed as the gold standard for care, and will expect that to be the response to any severe mental health crisis, regardless of what other services may be available.
Once someone is admitted to a hospital bed, especially if they are then detained under section, they are likely to stay there and suffer continuing distress for much longer than they would do if they were supported either at home or in community settings - most mental hospitals are NOT places where recovery is seen as the priority and are not good places for someone to be if their mental distress is relatively short term in duration, because the levels of mental distress amoing patients in those hospitals is very high, often involving psychoses and personality disorders and the pressure of this on staff makes them less able to support those with less severe distress.
In my view the correct response would be to increase community based crisis services - both clinical and non-clinical- to avoid unnecessary admissions to hospital, to support rapid assessment and provide appropriate support.
There is a risk that the focus on "beds" in mental health care will end up replicating the current pressures on acute hospital care, where people end up in hospital beds for longer than necessary, or where admission is not necessary simply because, with limited resources available to meet need, there will not be enough community-based support to prevent admission and support earlier discharge.

#545121 terry bamford

The welcome initiatives on parity of esteem and priority for mental health care have yet to work through in practice. The grim picture described in the report of patients being placed far from home, 100%+ bed occupancy masked by patients on home leave, and collapsing community services is accurate. Plans too often make the cheerful assumption that self management will produce savings and reduced admissions without evidence as the briefing paper points out.
The consequences of cutting social care and community services are coming home even in the Prime Minister's consitutuency.
We need a focus on recovery with patients shaping their own treatment but not at the expense of good crisis support and acute services when needed.

#545123 Pearl Baker
Independent Mental Health Advocate and Advisory/Carer

I really do not have the time to read through all the data? and who said what to whom? 'expert by experience' and thirty years to 'boot' is enough for me to make my own comments, based on what it is actually like to be a Carer and an in individuals trying to get help for their mental health condition.

The LA have no money left in the 'pot' for anybody., cutting services, even David Cameron has come under 'fire' for writing to his LA complaining about the 'cuts'.

GPs are told you have to discharge severely mentally ill patients in the community if they have not been in hospital for a while, despite the fact they are living in 'supported unregulated accommodation'.

Carers are left with no Carers assessments for months, and sometimes not at all.

No 'emergency crisis assessments' are carried out.

'Patients centred' care and treatment is a 'myth, even if this was offered, many 'severely mentally ill' would need help to put forward their views.

My latest client a young mother with a son who suffers from Autism/Mental Health problem, has just been transferred from child services to Adult Health and Social Care. The day centres they were referred to consisted of young 18 years old to 84 years old in the same day centre, they left disgusted, absolutely nothing to do.

The Personal Budget has not been paid since September although agreed.

There is absolutely nothing 'out here' for anyone.

#545125 Suzi Robin
Consultant psychiatrist

Welcome article, just to add , Surrey down CCG is taking 1/4th funding from older adult mental health services in name of similar untested new service
Feeling a sense of learned helplessness

#545127 Mrs |J Freer

My son had a major psychotic episode in France and was admitted to a hospital where he was sedated. He was discharged quickly and we returned to UK. Since returning to UK his treatment has been scandalous. His psychiatrist told us that he would not be hospitalised but would be treated in the community. My son does not think he is ill, which is all part of his condition, so does not take the medication he has been prescribed. The psychiatrist told us that he would either get better, or would do something which would result in him being sectioned under the Mental Health Act and he would then get treatment! (If he attacked one of his family - that would be fine.) We have always been a close and law-abiding family, but now my son has been arrested and does very bizarre things, but not enough for Psychiatrists to agree to section him. The psychiatrist appears to be hiding behind the Act and his profession. He has refused to speak to my family about my son's condition, even though my son signed a form at the outset that agreed to us being kept in the loop. The psychiatrist now says that he has told him verbally that he does not want us to be informed, even though obviously he is not fit to make such decisions. The doctor and the local team are not really helping my son and we feel powerless to help. He is running up debt on credit cards and is likely to lose his flat as he is not earning to pay the mortgage and no-one is helping him to claim benefit, even though he has asked for help to complete the forms. Shortage of funds - maybe - but there is absolutely no real care in the community available it seems to us. This concept is a total myth.

#545128 Prasanna de Silva
Consultant Psychiatrist
Mental Health Solutions

1. We need to concentrate on community care via collaborations with housing providers to set up a network of safe flats supported by home treatment staff, with Skype consultation for diagnosis and treatment guidance. This would be for patients in crisis but known to services, and can be part of a virtual ward or a step down facility.
2. As psychiatrists, we need to be compliant with patient's human and equality rights when providing psychiatric care in and out of hospital. Legal challenges on human rights and equality legislation should be granted legal aid to promote compliance.
3. Patients and carers should be provided with a joined up care plan, including a treatment plan, risk management plan and a recovery / resilience plan. This should be the main document reviewed at CPA / MDT / ward meetings, and should be carried by the patient along with a list of current medications, points of contact and hypersensitivities.
4. We should have a single PROM across all mental health services: my choice would be '2 minutes of your time' devised by Northumbria Healthcare trust. this should be consistently offered at CPA meetings and following discharge from psychiatric wards, with all teams given 3 monthly feedback on results (which is how Northumbria operates this).

#545129 Ricky Banarsee
Director WeLReN
Imperial College

The report is a timely reminder of the issues which are at the heart of mental health services delivery. It reflects the underlying dynamics of financial imperatives, quality and outcomes. With ever decreasing resources (in real term) and increasing health inequality, the scenario highlighted by Helen will surely get progressively worse.
Although it has a focus on community care, the report is a bit thin on the role of primary care and its impact of mental health delivery. Faced with mounting cost pressures, mental health services are turning to a skill-mix approach for quick-fixed solutions. In many areas, social workers are taking the role of psychiatrists to monitor and review of mental health cases. The bottom line of this approach will inevitably lead to increased pressures on primary care services. GPs are squeezed in the middle. They complain that in areas they feel less confident are also areas where they feel less supported. The CQC recently found that patients satisfaction with GPs re mental health issues were at 60%.
A future mental health services could be primary care led, with specialist interventions and expertise easily accessible in primary care settings. This will involve professionals on both sides of primary and secondary care working together in a more collaborative way, alongside patients and family and carers. However the very language of “both sides” may be unhelpful. What could be welcomed is to see is a merging of primary and secondary care services so that the distinction (and many of the problems that arise from people being moved from one ‘box’ to the other) becomes much less evident.
I would agree with her views on service reconfiguration. Although whole system integration is a preferred model, there were many reservations from both health and local government about the likelihood of it being achieved. Despite their support for whole system integration, health and local government respondents revealed contrasting opinions on the ideal structure of integrated arrangements.
Is there a better strategy? Part of the problem may lie with the information local commissioners work with. Their over- reliance on JSNA to provide health intelligence for policy and strategy is a weak approach. These are not often untested, inaccurate and unreliable. There is a lack of rigour and standards in the way information is collated. More often JSNA lack depth and a real description of needs - there is no qualitative data to support the desk-top based JSNA giving a on the needs of the community. We should be aiming at developing a standardised methodology.

#545131 Rob Smith
Chief Executive
Kids In Communication

The Big Lottery is in the process of allocating 100m to 10 areas across the UK. The Headstart fund is focused on 10-16yrs ( was 10-14yrs) to support mental illness and build resilience. It was noticeable at a recent workshop that an image of Nicky Morgan - education was shown - and a new focus was displayed - employability . Has the Gov now hijacked this much needed fund? Also, in Wolverhampton there is now concern that the original balance between delivery within Schools and Community delivery has been now focused entirely to a schools based approach based around the Sumo and Penn programmes. As a CE of a community project dealing with young people I have concerns that the agenda is being driven by education rather than health. Parents agree , Does anyone else share these concerns ?. The board in Wolverhampton is lead by Wolvethampton Council and funds are at risk of being used to fund existing in house projects. Very concerned that young people in Wolverhampton will lose out as a result.

#545136 Mark Trewin
Senior manager mental health
Bradford council

This report is a missed opportunity. I cannot believe you have defeated social care off to a short section were you concentrate on housing and unhappy staff! Social care is mental health in most instances and especially following discharge. The AMHP is a key role. You talk about detentions did itissomething only doctors do. The key to transforming care is to increase the role of social care and the social inclusion recovery model.

#545141 Amit Shah
Co-founder and CEO

One of the themes that we hear about time and time again is the access to a mental health expert at short notice, particularly for those living in remote areas or too distressed to leave their homes.

Twealr helps to alleviate this by offering an online solution that enables users to reach out to experts in a timely manner. Plus it also offers a free Q&A service enabling users to reach out to and connect with other users struggling with mental health issues on an anonymous basis as well as post questions to experts.

Hopefully it is one step forward in solving the mental health crisis within the UK.

#545143 Netta Hollings
Programme Manager - Mental Health
Health and Social Care Information Centre

These are my own views and not the views of HSCIC.

It is very depressing that this paper starts with "An absence of robust data makes it difficult to provide a definitive assessment of the state of mental health services." Especially without quantifying what is allegedly lacking. I would contend that there is not a lack of robust data - there may be a lack of information produced from the data, the data may available in many different places but there is not a lack of data. To say this belittles the efforts of clinicians and informaticians in provider organisations who continuously strive to collect and submit large amounts of good quality data. If the correct information is not being produced, that does not mean that there is no data. It would be useful if the author could enter into a dialogue about what they would consider to be useful data. Then we could add it to either our list of requested analysis or our list of requested additional data to collect.

#545144 John Kapp

The Better Care Fund was agree by Parliament 2 years ago, and is £3.8 bn pa this year to give better care, such as NICE recommeded Mindfulness Based Cognitive Therapy (MBCT) 8 week courses to depressed patients. This gives about £20 mpa to every average CCG, but few if any are spending it on better care. Health and Wellbeing Boards should call their CCGs to account on this, and the Childrens Menta Health Transformation Fund £1.25 bn over 5 years. See section 9 of for more details, or call me on 01273 417997,

#545150 Sue Ilsley
Peer Trainer

I really have to take Kings Fund to task over their ideas of 'expert help'. No one would doubt that if someone had ideas of suicide or harming others that they need to be in a place of safety. Service users will tell you that no-one gets well on a ward, you are chucked in amongst troubled souls and they are little more than holding pens. Some staff are really good people others are not even as proficient in people skills as prison officers. Psychiatrists do not wear badges and invariably believe it is beneath themselves to introduce themselves. The World Mental Health Organisation made dignity their theme this year so that just about says it all. Recovery focus practise is about allowing people to help themselves and make it possible to for them help themselves. More beds is not the answer but a rethink around what mental health and mental illness is and isn't would go a long way to improving a system that has become an industry with little focus on end user outcomes. Plenty of money for enquiries, commissions and reports but little actual meaningful help to those struggling with mental illness. The recent 'More harm than Good' conference at Roehampton university is enlightening about the medical model, the nonsense of the DSM and the failure of drugs to cure what are basically responses to life and the resilience to navigate life but we persist in the idea that medication will sort it all out. You do not need a trained expert to hand out pills just someone good at record keeping, what else is available on wards is highly debatable. The system doesn't need money it requires a change of attitude, understanding, empathy and compassion. I once worked with a Director of quality assurance and service user involvement, her view was..'you could sack 50% of staff, work with 25% and 25% are actually caring professionals who really want to make a difference in other peoples lives.
Check out the following:
Dr James Davies: The Origins of the DSM

Robert Whitaker: Our Psychiatric Drug Epidemic

Robert Whitaker: ADHD, Changing the Child Instead of the Environment

Prof Peter Gøtzsche: Why Few Patients Benefit and Many are Harmed

Prof John Abraham: The Misadventures of Pharmaceutical Regulation

CEP 2015 conference panel discussion: Prescriptions for Change

From my own point of view I woud tell anyone finding themselves in the system to head for the hills because it is designed to ensure you are disempowered and perceieved as other. As another Peer trainer glibly informed me ; professional care = CARE cover arse retain employment. I guess The Kings Fund has to justify its being and rattle on about professional care and professional expertise and money, whereas I just see it as a change of thinking. My local commissioner loves to spend money on all sorts of ecternal consultancies but she can't decide to throw a bit of money at personal health budgets because why should people with mental health problems choose to purchase something that might make all the difference in the world to them. Never mind what Darzi said back in 2007 lets just keep going round and round in circles and keep the industry going.

#545650 Wendy

The focus of the article was the move away from traditional community mental health teams and community specialties towards a so called individualised care package with what has now become access to generic pathways of care.
The reality of this wide changing re-organised system is that it managed to do what I suspect it would not have done if it was as open about the real aims. There came a mass redundancy exercise, downgrading exercise, and early retirement exercise that reduced mental health staffing at an alarming rate. It was a way to hide the true purpose of the new system and align it to basic care levels that fit in a privatised health system. Reducing mental health care assessments to fit a care pathways model is an american system that I suspect doesn't provide anything more than you might get for paying a basic rate of private insurance.
Despite many appeals, research data provided and hard work from existing staff that this model would not work in our country with our different system of provision this was outrightly ignored.
The point about the medical model and big Pharma aside the role of my profession as a psychologist was before the re-orgnisation very under-resourced and thinly spread but since the redesign and re-organisationis nothing short of a scandal. Whilst trusts like to point out the inclusion of psychological services to service users who highly value this approach they have drastically cut fully qualified psychologists by 2/3rds since the redesign. Succesive governments keep talking about IAPT provision but IAPT workers are not fully qualified and whilst competency in delivering therapy can be improved upon, they are currently only trained to deliver very basic therapy skills.
The alternative model could be delivered if there were a big shift away from psychiatry, diagnostic labelling, care pathways based on them and a move towards psyhological assessment and formulations that informed more therapeutic provision. Joined up social care with therapy to address individual stress and a recovery model understanding could alleviate the need to keep dispensing expensive medication that can actually create more mental health issues than they are supposed to treat.
The real barriers to real change is that too many vested financial interests lie in the pharmacuetical approach to mental health issues. Give us just a tiny fraction of that money and just think of the difference that could make.
In the mean time I will try and help just a tiny fraction of people that I can in this diabolical system of care.

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