Why access matters

AndyBellby Andy Bell

This week the Government and NHS England have set out in a ‘five year plan’ how they will put in place the first meaningful waiting time standards for mental health services in England. In the first instance they will be an 18-week wait for some psychological therapies and a two-week wait for Early Intervention in Psychosis (EIP) services. The plan also includes investment of £40 million this year and £80 million next in improving access to crisis services and filling in gaps in provision of EIP teams.

The plan follows an objective in the first NHS Mandate for the NHS to create access and waiting standards for mental health treatment to help to bring it into line with those for other kinds of health care. It sets out a vision, stretching into the next Parliament, for the creation of a much wider range of access standards for mental health services for both children and adults, building and improving on the initial two targets.

This is truly an important step on the road towards ‘parity’ for mental health care in the NHS. It raises many questions about how these standards will be achieved given the financial pressures mental health services are facing, whether they are the right places to start and indeed whether they will make a real difference to people’s experiences of mental health support.

What is clear from a growing body of research is that the level of unmet need for a wide range of mental health conditions among people of all ages is staggeringly high. Only a minority of people with the most common mental health conditions among children and adults receive any treatment at all despite the availability of effective interventions. Guidelines from the National Institute for Health and Care Excellence are routinely ignored and effective interventions are not offered – a situation that would be unthinkable in any other area of health care.

We also know that the longer people wait for support the more damage a mental health condition can do to their health, their family life, their schooling or work and their social connections. Long waits for psychological therapy, for example, don’t just cause distress among those left waiting and their families but they deter many from getting treatment at all. Untreated psychosis can have particularly damaging effects on a young person’s life that effective EIP services can prevent. And people wait in many parts of the mental health system, from being kept in police cells in an emergency and being unable to contact crisis team out of hours to being made to wait for months for psychological support or for a transfer from prison to hospital. These are all important and will all need to be addressed.

For the first time, we now have a commitment from the NHS to put in place proper access standards for mental health care. It is vital that this is regarded as the beginning of the journey and not the end. If implemented effectively, it should lead to a rebalancing of NHS spending, putting right decades of under-investment in mental health care by focusing commissioners’ minds on achieving better and faster access to effective treatment and support. In so doing, it will enable the NHS to use its limited resources more cost-effectively, to achieve more health gain and better outcomes by focusing on earlier intervention, more integrated support and timely responses when people ask for help.

To do this well, we will need robust performance measures and clear lines of accountability for achieving the standards. It is also crucial that waiting time standards are backed up with the same level of entitlement to cost-effective mental health treatment as we have to medicines and surgical procedures under the NHS Constitution. And of course it will be necessary to ensure access is not achieved at the expense of quality and good outcomes – of all mental health services supporting personal recovery.

This may look like a big hill to climb from where we are now, and it is. But that should not deter us from starting the journey. And it should make us determined to get the job done.

Extract from 2014 Sir Keir Starmer Centre for Mental Health Lecture, 16 September 2014

Five years ago, in 2009, the Bradley Report noted that “there are more people with mental health problems in prison than ever before”. With the prison population now standing at over 85,000, we can still say the same today.

keir_talkingThe evidence set out in the Bradley Report made the nature and the extent of the problem clear for all to see. His report made 82 recommendations under five headings: for early preventive measures; for all police custody suites to have access to liaison and diversion services to enable diversion to take place; for support in courts to give the same help to vulnerable defendants as is offered to vulnerable victims and witnesses; for adequate community alternatives to prison and better health provision for those in prison; and for greater continuity of care as people enter and leave prison.

The Bradley Report offered an end-to-end review setting out practical recommendations at every stage. None of it was rocket science. But that was five years ago. Where are we five years on? The Bradley Report’s recommendations were reviewed by Centre for Mental Health in June 2014. The headline news is good – there has been significant progress in key aspects of Lord Bradley’s vision.

But there are some areas where not enough progress has been made. There are no governance arrangements in place for providing Appropriate Adults in police stations. keir_sean_talkingAppropriate Adults will always be needed by vulnerable suspects as well as victims and witnesses; they need a statutory framework with funding on a proper footing. Recommendations to help vulnerable offenders to participate in court proceedings through intermediaries have not been taken up.

The Centre’s review called for an Operating Model for prison mental health care, similar to the one developed for liaison and diversion. It also identified a continuing concern about accommodation for people leaving prison and called for a new prevalence survey of mental health problems among offenders.

So there are still difficulties at all stages of the criminal justice system: the number of people in prison with mental health problems is no smaller than in 2009, with high levels of psychosis and personality disorder and a high suicide rate. We need a greater sense of urgency: a gear change in implementation and a shift in thinking to ensure victims, witnesses, defendants and offenders with mental health problems are properly supported throughout the criminal justice system.

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Community mental health survey 2014: Reflections on the results

seandugganby Sean Duggan

The Care Quality Commission’s national survey of people who use community mental health services is one of the key barometers of how well the NHS is responding to the needs of working age people with long-term mental health conditions.

This year’s survey for the first time offers important insights into how well the NHS is supporting people to in their personal recovery journeys as well as more traditional measures of satisfaction with the care and support they get. It shows wide variations in the extent to which people are getting the support they want and need to recover. And it shows a marked difference in the experiences of services between people whose care is coordinated under the Care Programme Approach (CPA) and those whose care is managed differently.

Recovery

Among the most significant determinants of how well mental health services support people to recover is the extent to which they build helpful and supportive relationships between staff and service users (Shepherd et al., 2014). The survey found that about three-quarters of service users felt listened to and treated with dignity and respect by professionals. But only about half of those on CPA, and a third of those who are not, said they were adequately involved in planning their own care and support.

Involving and supporting carers, family and friends of service users is also a key part of recovery oriented practice (Machin & Repper, 2014). Disappointingly, the survey found that only 55% of service users said people close to them had ‘definitely’ been involved as much as they would like. Peer support is also a key element of recovery-oriented care and the survey found that only half of those who felt they would benefit from peer support were offered it.

Employment

As well as encouraging hope for the future, recovery oriented services support people to build opportunities for a life outside their illness. Despite clear evidence about the role of employment in recovery for many people, help or advice with finding or keeping work received the poorest response of any question in the survey. Some 34% of people on CPA and 51% of those who were not said they received no help with employment but would have liked it.

Housing and finances

Advice and support in dealing with housing and personal finances are also vital to any recovery-oriented service and the results in these areas are also discouraging. Good quality welfare advice can make a significant difference to the health and quality of life of people using mental health services and should be regarded as integral to any modern mental health service (Parsonage, 2013).

Physical health

The survey also asked about support people had received for their physical health. People with schizophrenia can expect to die 15-20 years too soon, yet a quarter of people on CPA who had physical health needs and wanted support for them did not get it. This needs to change as a matter of urgency. Help with managing the physical side-effects of medication and support to stop smoking for people using mental health services must be regarded a priority by the whole of the NHS.

Commissioning

While the survey results paint a mixed picture of the degree to which community mental health services support people in their recovery journeys, they also provide a starting point for commissioners and providers that want to change. They identify some of the biggest priorities expressed by service users for better support. Not least among those will be the need to invest in effective employment support using the Individual Placement and Support approach. The postcode lottery in the availability of IPS needs to be addressed so that no one who wants to work is denied the best available support (Centre for Mental Health, 2013). Access to high quality welfare advice, and support with housing, should also become routine practice.

Funding

Community mental health services are under great financial pressure. After several consecutive years or real terms funding cuts, it is reported today that mental health spending is set to rise by 1.4% in cash terms this year (http://www.hsj.co.uk/5074846.article). While this might help to steady the situation, it will not provide the boost mental health services need if we are to achieve genuine parity between mental and physical health in the NHS.

In the meantime, however, many providers and commissioners of mental health services are seeking to reinvest in recovery-oriented practices, such as expanding the use of peer support or creating Recovery Colleges. This is a welcome change that should enhance people’s experiences of mental health care, building hope and creating opportunity for people who for too long have been denied a fair chance in life.

 

References

Centre for Mental Health (2013) Barriers to Employment

Machin, K. & Repper, J. (2013) Recovery: a carer’s perspective

Parsonage, M. (2013) Welfare advice for people who use mental health services

Shepherd, G. et al. (2014) Supporting recovery in mental health services: Quality and outcomes

Chief Medical Officer’s report sets clear agenda for reinvestment in better mental health

AndyBellby Andy Bell

Today’s report of the Chief Medical Officer, Dame Sally Davies, sends out a clear message that mental health can no longer be sidelined or ignored either by the NHS or by public health services.

Mental ill health affects almost a quarter of us at any one time and, as the Centre calculated in 2010, costs more than £100 billion a year. Three-quarters of children and adults with mental health problems get no treatment at all. Yet effective early intervention can dramatically improve people’s lives and prevent future distress.

The report, Public Mental Health Priorities: Investing in the evidence, makes a clear call for a greater focus on children’s mental health. Children with behavioural problems face a lifetime of ill health and disadvantage. This can be prevented or mitigated through evidence-based parenting programmes. Yet few parents get the help them need to manage their children’s behaviour when they seek it. Local authorities that invest in evidence-based parenting programmes can address one of the biggest public health problems their communities face and dramatically improve the health and wellbeing of some of their most vulnerable children.

The report also has a major focus on work. Too many people with mental health problems are given inadequate help to get or keep work. Yet employment can be an integral part of recovery for many people. Better help for people to retain employment and to get timely access to psychological therapy when they become unwell is crucial.

Many of the building blocks of better health and work support are already in place. A growing proportion of mental health services provide an Individual Placement and Support service that gets the best results in supported employment – but it is still not offered everywhere. The Access to Work scheme offers financial support for reasonable adjustments at work – yet just 3% of funding is used to support people with mental health problems. And more employers are waking up to the importance of supporting the mental health of their staff – but many more are yet to recognise and act on this.

The report recognises the importance of linking mental and physical health. Some 4.6 million people in England today have a long-term physical condition and a mental health condition. Improving support to people with physical and mental health needs is vital both to improve their health and to cut the £10 billion extra cost to the NHS. Developing effective collaborative care arrangements that offer people with long-term conditions effective and engaging mental health support could improve quality of life considerably and may help to reduce premature mortality.

Last week’s Barker Commission report for The King’s Fund advocated ‘equal support for equal need’. Today’s report identifies that this is still far from being a reality for people with mental health problems. Access to evidence-based treatment remains patchy. Waiting times are variable. The Chief Medical Officer’s report reinforces the case for parity of funding for mental health support as part of the answer to this longstanding inequality.

Today’s report once again demonstrates once again that there is a compelling case for reinvesting in effective mental health support for people of all ages. The task now is to convince more than 200 clinical commissioning groups, 150 local authorities and a range of other key agencies, from schools to employment services, to make mental health the priority it clearly should become.

Current evidence on depression – the view from Centre for Mental Health

seandugganby Sean Duggan

Around nine out of 10 people who commit suicide suffer from a mental health problem with depression being the most common co-existing difficulty affecting 60% of those who tragically take their own lives. Nearly one-fifth of adults in the UK experience anxiety or depression. Often these problems remain unrecognised and untreated – sometimes for many years. This is despite that fact that there are effective interventions that have been proven to make a difference to those suffering with depressive illnesses.

The World Health Organisation has estimated that by 2030 more people will be affected by depression than by any other health problem. These findings reinforce the importance of treating depressive disorders as a health priority and of making available proven, cost-effective and accessible interventions to reduce their burden. Other evidence reinforces the critical importance of intervening early to improve the life chances of those facing or already suffering from mental illness.  Early intervention not only improves the prospects and life chances of those with poor mental health, it reduces the burden on families as well as broader costs to the public purse.

Yet the UK spends less than 4% of its national budget on mental healthcare with evidence pointing to a health system increasingly geared towards short term solutions (Lintern, 2012).

So what should we do?

We need to be more alert to the early signs of poor mental health.  It is particularly important to identify poor mental health early and give children a good start in life in terms of their emotional wellbeing.  Increasingly science is pointing to the damaging effects both of maternal depression and anxiety before and after the birth of a baby. This damage not only affects a mother’s wellbeing; poor maternal mental health also undermines the mental health of children.  Only a small number of mothers suffering from poor peri natal mental health get identified; even fewer get the help that can make a difference.  Simple screens used by midwives, health visitors and GPs could help identify risks and support better access to care.  The Centre is currently working with partners to improve the availability of better quality peri natal care, to assess its cost effectiveness and to support improved GP practice.

We also need to identify childhood and youth mental health problems as early as possible.  The government acknowledges that half of people with lifetime mental health difficulties first experience symptoms by the age of 14 and one in ten children aged between 5 and 16 will have a diagnosable mental health problem.  Most parents actively seek help for their children and yet only a quarter get the help they need. This is in spite of excellent evidence that effective interventions can both make a difference to children’s life chances and to the future burden on the public purse. Far too frequently, children’s needs are picked up by chance.   Teachers don’t know the symptoms of mental health problems in children (often these present as behavioural problems) and, if they do, they remain unsure where to refer them.   We need more systematic ways of picking up when children’s wellbeing moves outside healthy ranges and we need better and more accessible support with mental health and emotional wellbeing available in schools to help teachers, parents, children and young people to get prompt help when they encounter families or children distress. Furthermore, young people have often expressed significant concerns that help is not available in convenient and non-stigmatising settings, that it often feels irrelevant to their needs and that they often face a lengthy wait to access the help that they need. Young people should have a major role in shaping what prevents and helps them recover from mental health difficulties and this needs to be taken into account in the design of local support.

Early identification for adults also requires whole-system sensitivity both to the signs of poor mental health and about what to do when early signs are spotted. This includes the need to build awareness and capacity in employers, faith leaders, police custody, courts and custodial settings, voluntary and statutory sector support services and many others providers working with groups at higher risk of developing poor mental health.

It is not acceptable that people with mental health problems can expect to die 10 to 20 years earlier than those without a diagnosis (http://www.psych.ox.ac.uk/research/forensic-psychiatry). It is essential that we begin to take seriously the distressing and damaging impact that mental illness has on lives, on communities on families and on the public purse. Investment in mental health support must be increased at least to match investment in physical health and also to adequately reflect this increasing economic burden.  Most importantly it should aim to reduce the significant distress and health inequalities faced by those facing or living with poor mental health. However, increased investment needs to go hand in hand with a more creatively designed and responsive system of support which provides non stigmatising help, builds capacity in communities and in workplaces, provides easy access to help where and when people need it and which draws together what we know works and what those with lived experience know promotes their progress and recovery.

Sean Duggan is chief executive at the Centre for Mental Health

Mental health care for all stages of life must be improved for all to thrive

AndyBellby Andy Bell

This week, a new book by Lord Layard and Professor David Clark sets out a call for a transformation in the way we think about mental health and the priority mental health care is given.

Thrive: the power of evidence-based psychological therapies, argues that mental ill health causes far greater suffering than has ever been realised by policymakers and that through investment in cost-effective interventions much of that distress can be prevented or treated successfully.

Layard and Clark build a persuasive case for extending and improving mental health support at all stages of life, starting from pregnancy and early years and throughout life. They show that responding better to our mental health needs is not only just and humane but also good economics.

Much of the focus of Thrive is on the value of investing more in psychological therapies. Layard and Clark identify a wide range of therapies that have been shown to be highly cost-effective in improving people’s health: including but not only cognitive behavioural therapy. But they also look at a much wider range of interventions, for example those that will enhance resilience such as social and emotional learning in schools, parenting programmes and mindfulness.

Thrive offers a vision for the future and a case for change that no one can or should ignore. And it reminds us of our place in history; how the decisions we make today affect our future and the lives of future generations. The book concludes that:

“Future generations will be amazed at how blind we were. They will also be amazed that we were so cruel. When we ourselves look back at earlier generations, we are shocked by how they treated slaves, or women and children in the mines, or people with physical disabilities.”

We are thus at a crucial point in time. The last two decades have seen some very important developments in mental health policy and practice: the National Framework for Mental Health; the Improving Access to Psychological Therapies programme; the development of prison mental health services and of liaison and diversion; and the growing movement to put personal recovery at the heart of mental health care.

But we also face huge challenges. Three quarters of adults and children with mental health problems go without treatment. Three quarters of CCGs last year cut or froze their spending on children’s mental health services. And too many people with mental health problems are left without the help they need to pursue their personal goals.

Thrive should be required reading for any aspiring member of Parliament, for any CCG or health and wellbeing board member, and for any future government. It offers both a message of hope and a warning we should all heed and take action to support.

The Bradley report five years on – finishing the vital job

Lord_Bradley_bwby Rt Hon Lord Bradley

In the five years since I published my independent review of the support offered to people with mental health problems and people with learning difficulties in the criminal justice system, we have seen significant progress towards achieving the vision set out in that report with the clear and unambiguous support of both governments.

In looking back at what has changed over the last five years, it has been encouraging to see the development of more liaison and diversion teams, both for adults and for children and young people, offering early intervention in police stations and courts across the country. While there is a lot more to be done in making sure liaison and diversion is available everywhere, the commitment of the Department of Health, Ministry of Justice and NHS England to the successful completion of this job has been key to the continued progress we are making.

We are also now seeing the emergence of new and creative ways of supporting people with mental health problems and those with learning difficulties across the criminal justice system. Initiatives like street triage, which offers a more humane crisis response, and youth justice liaison and diversion, which provides support to children and young people when they come into contact with the police. We still have a lot to learn from these as we build the evidence of what makes the biggest difference to people’s lives and the most cost-effective use of public money.

I have been impressed ever since I began work in this area with the dedication, creativity and resilience of the people who work in it. Many have personal experience of being in the criminal justice system themselves and now try to help others going through it. Many work in voluntary and community organisations, offering credible alternatives to traditional services, while others are based in the NHS and local government, finding new ways of improving care and support despite the difficult financial climate.

Bradley_report_five_years_onThis report looks at what has been achieved so far, at what has changed in the context we work in, and at what still needs to be done. I hope that it demonstrates the value of finishing the vital job we have begun of implementing liaison and diversion nationwide as well as making further progress in less well developed actions.

Finally, I hope that in another five years’ time we are able to look back on continued progress and to say with confidence that as a society we respond more effectively and more humanely to the needs of people with mental health problems and people with learning difficulties who are at risk of offending or who come into contact with the criminal justice system.