I asked our members who are involved with mental health services  to tell me about what was going on in their area, and what policy areas we should be concentrating on.  This is my reflection on what they told me.  I’m not an expert in this area, and the mistakes are mine.  Please contribute to the debate below.

NHS acute trusts are now almost all in deficit.  Less than half of the mental health trusts, however, are, because it’s much easier to deny services to people who are mentally ill.   Since 2010 the number of English NHS mental health beds has been cut by 25% (from 25,503 to 19,249), and the number of beds available per head is way below the EU average.

Many councils have been forced to pull out of the partnership agreements that were put in place to deliver integrated mental health services across health and social care and there are severe staff recruitment problems.

We need a comprehensive and evidence-based approach to mental health promotion.

Not everything is bad: there has been some progress in diagnosing people with dementia. Nationally 68% of those thought to be affected are diagnosed, which is a very considerable improvement.

Children’s services

Children’s mental health services remain lacking in resource and direction. There needs to be a clear  and more extensive model of service which really integrates with education and social services. Waiting lists are long and services only provided to a minority who could benefit. An 8 month waiting time for a child of 6 is not acceptable. A false economy.  Adult disorders mostly start in childhood.  We go round looking to diagnose physical illness before the symptoms show, but with mental illness we refuse to start treatment even when symptoms are apparent.

There has been an explosive rise in children’s self harm and the suicide rate is rising.

There is a severe and ongoing shortage of beds for children so they are admitted to adult wards, or transported hundreds of miles, which is particularly inappropriate.  There is no system for locating those that are available, which leads to huge waste of staff time.

Mental health professionals should work with paediatric teams in an integrated way all over the country, as is already done in the best centres.

Severe mental illness

Services for people with psychosis and similar long-term illness seem to be surviving a bit better than the others but they are severely affected by cutbacks in social care, and the lack of integrated services.  Some of the problems recounted to me were:

  • People discharged from secure facilities to sheltered housing complexes without sufficient day-to-day support. Typically no support available in the evening or at weekends.
  • Inadequate arrangements for acute episodes. People taken by the police or ambulance to A&E departments of hospitals where there are no psychiatric wards, and put in which is said to be a place of safety – a locked cupboard. People sent, at huge expense to private mental health institutions, often hundreds of miles away, because there are no beds available locally.
  • A two week wait for access to services for people with their first psychotic episode

More properly supported housing would help, as would 24 hour support, possibly by telephone. Recovery communities could to help people with severe and enduring mental illness to be well enough to lead the life they want to Shared records between acute services, community services, GPs and social care would help.

Common mental illness

  • There is plenty of advice for people with common physical problems about what they should do if they are worried, and when they should, or should not, go to A&E. Nothing for mental illness.
  • The Work programme does not work for most people with mental health problems.  A coercive approach which does not address their problems is counter-productive.  It drives up the suicide rate, not the employment rate.
  • alcohol services do not have time to get to the underlying issues which drive people to drink.

We need a comprehensive and coordinated approach to people with less severe forms of poor mental health.

Most people who claim benefits because they cannot work do so because of mental illness, either on its own or compounding other problems.  To get them back to work a more therapeutic and holistic service is required.  Couldn’t the NHS offer that?

When the NHS was established there were proposals to provide an occupational health service, but that didn’t happen.  So now only the largest and most enlightened employers have an occupational health service. If the NHS provided this service it would be more comprehensive and more effective (employees are often suspicious of such services provided by their employer) and would support small employers.

Increasing the availability of employment where people could engage in productive work in a supportive environment would help improve mental health , and reduce the huge burden of related incapacity benefits. The competitive, target-driven, insecure nature of modern-day employment has driven many vulnerable but capable people onto benefits.

Mental or physical?

People with severe mental illness live much shorter lives.  People with long-term physical illness often develop psychiatric complications.  Large numbers of people with what are now called medically unexplained symptoms get a poor deal without any effective treatment.

Addictions such as alcohol, cigarettes and food have their root in poor mental health, stress, psychological or personality difficulties. Much physical illness is caused or aggravated by these addictions or habits. Spending more on mental health will reduce the physical health funding need.

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16 Comments

  1. Olivergill says:

    What are the specific causes for people with severe mental illnes living shorter lives? The stated ‘ cupboard’ for securing pre or sectioned patients must surely be illegal and pure fantasy.

    1. Martin Rathfelder says:

      The common answer is that physical illness in people with severe mental illness is not treated, not taken seriously. The cupboard (well a small room with no windows) is in Manchester, but I’m told is no longer used, but it was used last year.

    2. Chris91172 says:

      Having worked A&E liaison in Manchester city centre the infamous “room b” was a “room” 5×5 foot with two fixed chairs that folded up when not in use with a two way door that could be secured only from the outside

    3. Chris91172 says:

      Causes are smoking, lack of motivation to exercise (medication or illness)

    4. Alison Harris says:

      Neglect of physical health care by services. Also iatrogenic effects from major tranquillisers. There is now a lot of CQUIN money attached to physical healthcare targets
      in mental health services (don’t know if that is a national thing or just in our Trust), so the situation is presumably improving.

    5. Alison Harris says:

      A massive gap that has not been mentioned is mental health and psychological therapies services for people with a diagnosis of so-called Personality Disorder. I would say that, on the ground, the severe lack of provision for this group, who are recurrently highly distressed, suicidal or self-harming is one of the biggest daily challenges for mental health practitioners both in Primary and Secondary Care. The result is that patients keep bouncing between services who are not commissioned to meet their needs and so keep getting passed on. Some psychiatrists take a dim view of them as they are perceived not to be ‘mentally ill’, hence they have few powerful advocates.
      In Salford, the advent of three senior practitioners for personality disorders, based in the Community Mental Health Teams and using an approach called structured clinical management has already led to demonstrable reductions in in-patient admissions and A&E attendances for some of their service users.

      There is also a group dubbed the Neglected Majority in a report by the Sainsbury Centre for mental health in 2005:

      http://www.nwppn.nhs.uk/attachments/article/53/SainsburyCentreforMH2005TheNeglectedMajorityPolicyPaper.pdf

      “The reality is that there is a group of people
      whose problems cannot be managed with
      confidence in primary care, but who are not
      appropriate for secondary care services. This
      group has the following characteristics:

      they have continuing mental health
      difficulties despite several treatment
      options from primary care, but do not
      have a severe and enduring mental
      health problem as described in the
      National Service Framework;

      their employment or accommodation
      is frequently at risk;

      their physical health, or other long term
      condition, is frequently worsened by
      their mental health problem.
      This group of people cannot be managed with
      confidence in primary care, and yet are
      inappropriate for specialist mental health
      services – they are the Neglected Majority.”

      The needs of this ‘intermediate care’ group have still not been met.

    6. I looked at the Sussex Partnership webste ( the local mental health trust where I live) . They say that for a person with schizophrenia or other severe mental illness life expectancy is 20 years lower than if they did not have that condition. There is very rarely any information given about long term harm resulting from continued use of any medication but the lower life expectancy is partly due to these medications. Do they know about long term effects of the continued use of antipsychotics? If not, have they tried to find out what harm can be done? Or are they just not bothering to tell patients? Or are they frightened to tell patients in case that encourages them into not taking vital medications? Therapy causes no long term harm, and aims to treat a condition rather than control symptoms. Why is more money not being invested into therapy?

  2. Bet Tickner says:

    Apologies for lateness, but I will restrict comments to isssues you’ve not mentioned:
    1. Tier 1 CAMHS

    Mental health support in schools and colleges and for looked-after children is a real issue.
    If Tier 1 off CAMHS is not working problems get worse and more
    children and adolescents come down the line in a worse state to
    Tiers 2, 3 and 4.

    With schools now buying their own provision, especially at
    secondary level, this is a really fragmented service.

    2. GP expertise in mental health

    Many GPs have not had training in mental health. Our local CCG
    arranged a series of classes but the people who came were
    “the usual suspects” – i.e. the GPs that already knew their
    stuff. So much of GPs time is taken up with this (we hear)
    that it should be mandatory to be trained in this area
    at least at a basic level.

    3. Provision for drop-in are forced to cut support for the voluntary
    sector. Reading Your Way ( in Reading) had to give up half its building
    and the provision of sport (via Sport In Mind) is really
    minimal.

    5. Mental health providers have to direct patients to
    sources of housing advice. This is getting harder to do
    as local authority budgets are squeezed. BHFT (our local trust) did poorly
    on this in the national survey – probably just because
    housing is so expensive in South-East.

  3. Child and adolescent health services are woeful currently due to a lack of direction nationally and underfunding and difficulty recruiting. This is just saving up problems for adult services (while making children with illness more ill and causing social and psychological problems for their families).

    There is care available for those with less severe common mental health problems such as anxiety and depression through the IAPT programme but often the waiting lists are huge and it is not unusual in my area to wait 9 months for treatment.

    Severe mental illness is often well treated in the acute phase but resources dictate fairly sketchy follow up with little in the way of evidence base of how to conduct community-based treatment/support.

    This leaves whole swathes of people in the middle with moderate disease as a diagnostic label but with significantly life affecting symptoms for whom there are almost no appropriate NHS provided services.

    Studies consistently show that 40-50% of work-related illness is due to mental health symptoms. Provision of APPROPRIATE occupational health support (as opposed to the government’s fit for work scheme aimed at reducing sickness absence for employers) would be likely to reduce this disease burden perhaps together with moves towards educating employers about the beneficial health effects of good management and the reduced secondary costs of illness on them and the state.

  4. alan dean says:

    I think you have covered the issues well.Some are very long term like the very poor services available to children and young people.The squeeze on services for prevention and support is compounded by service reductions in this area by both health and social care and as you say they are easier to cut than other areas as the impact is felt elsewhere.eg homelessness
    Alan dean

  5. bhfisher says:

    Do we have a coherent set of solutions, apart from better funding for existing services? Do the existing services need to change? I am still not clear what parity of esteem actually means in terms of service delivery.

    “model of service which really integrates with education and social services.” – What would that look like?

    “a comprehensive and evidence-based approach to mental health promotion.” There is one: http://ethicsfoundation.org/2015/09/04/mental-health-promotion-saves-lives/

    I think there have been many training initiatives in MH for GPs. I’m not sure how successful they have been.

    Can we continue this discussion with more of a focus on solutions?

    Brian

  6. Roger Berry says:

    The loss of beds is not always a bad thing as the real need is to build up community resources and provide support to users in their own homes.
    Here in Worcestershire the local Trust has persued such a policy with some success

    1. I agree that community services are vital and can prevent a person from needing inpatient care. Ideally nobody would need inpatient care as it is never great but there will always be a need for it at times. I regularly try to support friends who are ‘waiting’ for a bed. They are far too ill to be in the community but there are no beds available. I also regularly see friends who are discharged from hospital too early and all the help they have been given is wasted. 30% of inpatient beds have been lost and that is far too much. They cannot always be replaced by community care, this is a huge safety risk. At a time when many people are stressed about money, paying bills, welfare cuts, poor housing etc there is a greater need for inpatient beds as well as community services. When people talk about replacing inpatient beds with community services they are so often just wanting a cheaper option. BOTH are needed!

  7. Terri Eynon says:

    Solutions tried in Leicestershire’s primary care service have included linking IAPT practitioners to GP practices and providing each practice with a named Mental Health Facilitator (averaging a half day a week for a 6k list).
    The IAPT service has generally managed to keep decently short waiting times – though not always the 4 weeks we would like to see. The MHFs are popular with GPs as they take responsibility for physical wellbeing in people with severe and enduring mental illness. They are also there to plug the gaps. They will see people who GPs are struggling with but who just don’t fit the IAPT format. For example, they will screen for bipolar and advise on the management of personality disorders in the community.

    The MHFs were also popular with some psychiatrists as they provided a safety net for people who were ‘recovered’ and needed someone to just check in with once a year (minimum) and be there to advise on suitable community resources.
    There have been problems of course. Some GPs have been more than willing to exception report people with mental health problems from the Quality and Outcomes Framework – despite having an MHF ready and willing to chase up their patients and even do blood tests at home if necessary. The Mental Health Trust went through a phase of offloading their long term patients without offloading any of the Trust’s resources in to primary care.

    The solution we all wanted – a community mental health service that was joined up with the rest of the primary care health community – never happened.

    As far as GP Training goes, I share the concerns raised above. GP registrars do spend time in psychiatry – but are largely dealing with acute psychosis.
    From a GP point of view, we need little training in acute psychosis just as we need little training in the management of an acute abdomen. Our job is to go ‘Whoah! Something really bad going on in here’ and refer ASAP.

    The training GPs really need – in the ongoing psychosocial management of people with persistent anxiety and depression, personality disorders and mostly-recovered psychosis happens – if at all – in primary care. I did (with psychiatrist colleagues and under licence from Chris Williams) teach the Five Areas Model of CBT to GPs and other primary care professionals. We had some funding from the IAPT roll out. It aimed to give them some tools to manage anxiety and depression in chronic disease and medically unexplained symptoms. The primary care practitioners were great in the sessions. No GPs came to the follow up meetings that would have built their real-life skills.

    The trouble with trainees and early years GPs is that they continue to learn from the hidden curriculum. They learn that a phone-call to the crisis team is likely to be a frustrating experience. They learn that it is easier to give a sick-note than challenge an abusive employment situation. They learn – if they are sensible – not to be too good at mental health because it is the sympathetic doctor whose clinics always run late.

    The current funding of primary care gives little incentive to GPs to provide a quality service in mental health. I take some pride in being part of a profession that (quite often) tries to do the right thing even when it is not in our financial best interests.

  8. Really interesting comment by Steve IIiffe here giving an assessment of mental health care as it stands today. I think there is a place for the term ‘mental health problems’ at times, although I recognise individual problems need very different attention. But one place where the umbrella trem is relevant is when we talk about underfunding, because all mental health problems attract just that. Another occasion when it is appropriate for that term to be used is when we talk about stigma and discrimination. Because all mental health problems are accompanied by this. I have often felt that the fact that the public will rarely campaign for better psych services is becuase of the discrimination and stigma. I have asked people in my area why they haven’t protested about bed closures in the psych wards. One answer is that they didn’t know about bed closures and another common one is that they didn’t like to, they felt uncomfortable.
    In the SHA one thing we can do that I believe would be a really massive help towards improved mental health is open up that conversation. Show the public its OK to talk about mental health, show patients that they don’t need to be ashamed of their illness and start offering some facts about mental health to the public every way possible. There are too many myths out there already. We could also campaign for government to form a strategy with concrete ideas and targets for reducing stigma and discrimination.
    But please, we do need to accept that inpatient beds are needed as well as better community services. It is not OK for a person needing inpatient care to be put on a ‘waiting list’ for a bed. They will be even more ill when they get that bed and need longer in hospital as a result.

  9. Steve Iliffe says:

    Perhaps the all-inclusive term “mental health problems” causes more confusion than clarity, especially when we are encouraged to think about solutions. It is a category fallacy, lumping together very different things. Resisting the urge to integrate and considering problems in their individuality may help more.

    For example, there are dangerous gaps in acute services for people with learning disability, and in forensic psychiatry, where there may be no bed available on a given day in the whole of England, in either public or private sectors; this is unsafe and needs urgent investment, now.

    CAMHS are hard-pressed and under-resourced despite the clear relationship between symptom onset in young people and persistent disorders in adulthood; this is a historical habit within the NHS, of paying only lip-service to a problem.

    Responses to people with personality disorder (about one in five of GP attenders) are messy, variable and dependent on the enthusiasms and skills of particularly interested professionals; the response to this problem within general practice has been weak.

    Meanwhile mental health services are stretching their resources, increasing capacity in the short-term by having fewer contacts with patients – in effect ‘under-dosing’. The latest HSCIC report shows a 41% reduction in day centre contacts, 6% reduction in crisis resolution and home treatment team contacts, 16% fewer general psychiatry contacts, 37% fewer IAPT contacts and 21% fewer contacts by assertive outreach teams.

    Some of the apparent rising demand for mental health services of any type seems to be simply due to the ageing of the population. The incidence and prevalence of dementia syndrome is increasing (although not as much as those seeking funding for services have claimed), physical disability is strongly associated with depression in later life, and the ‘baby boomers’ who took to substance misuse are not necessarily mellowing – the opposite in some ways, as their substance habit interacts with the disabilities and illnesses of older age. In later life mental ill-health is intrinsically connected to physical illness, making compartmentalisation of care harder. There is some good news here – the NHS may not have got ageing and mental health quite right yet, but it is getting there.

    Whilst there is a clear problem of under-funding it may not be enough to put it right because the poor relation status of mental health services long pre-dates austerity economics. Terri Eynon’s comment applies to many places, despite the best efforts of many people: “The solution we all wanted – a community mental health service that was joined up with the rest of the primary care health community – never happened”.

    Adopting the recovery model was seen by some as a way of putting right the historical failings of the NHS when dealing with mental ill-health, by shifting the emphasis away from a biologically-driven medical model of treatment and care. Such a shift raises questions about the balance between specialists, and generalists, and between doctors, nurses and psychologists, in the workforce. The SHA might usefully debate the future configuration of services for people with the range of mental illnesses, so that a future phase of investment can be well informed.

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