Despite the progress that has been made and the efforts of the sector, there remain significant, specific challenges facing mental health provision and NHS mental health trusts that need to be addressed to fully deliver the three shifts the government wants to make to health and care, and provide sustainable high-quality services, to the benefit of individuals and the wider system and society over the next decade.
This section focuses on exploring the quality and productivity challenges facing mental health services and their impact on patients.
Quality and safety challenges
Quality of care and patient safety across the NHS are at increasing risk due to the mismatch between demand for services and the overall funding, capital and workforce available. Just over a third of respondents (35%) to our autumn 2024 survey of trust leaders rated the current quality of healthcare provided by their local area highly, which is a drop from 41% last year and 48% in 2022, and over two in five (42%) were very worried or worried about their trust having the right numbers, quality and mix of staff to deliver high quality healthcare currently. We cannot continue to rely unreasonably on staff goodwill and resilience.
There are examples of good practice despite the challenging environment services are operating in, as highlighted in the Care Quality Commission (CQC)'s most recent national assessment of mental health inpatient services. For example, services supporting patients after discharge and multidisciplinary teams working together to understand the needs of the patients and use the least restrictive approach to providing care and treatment. However, CQC continues to find that too many people are not getting the level or quality of mental health care in environments that meet their needs and they have a right to expect, despite services' best efforts to mitigate the impact of staff shortages and other pressures on patients.
The regulator's latest assessment that people's experiences of using community mental health services continues to be poor – despite trusts' doing all they can to adapt and respond to rising, and often more, complex demand and a historic underfunding of these services – is also deeply concerning.
We have highlighted previously mental health trusts' significant experience of working in collaboration with service users, families and carers which is helping to deliver higher-quality, more person-centred and holistic care that better meets people's needs. However, there is clearly more that trusts need to consistently do in a number of key areas such as ensuring that people are properly involved in decisions about their care, that their care is robustly and regularly reviewed, and that they always feel treated with dignity and respect. Listening to service users, their families and carers and wider communities and embedding them into the design and delivery of services is vital to making improvements.
We have welcomed in the last couple of years a much-needed refocusing by the government and arm's-length bodies on core mental health services, particularly for individuals with severe and enduring mental health conditions, and recognition that wider national action is needed to tackle the underlying systemic issues impacting the quality and safety of services these individuals rely on. National action needs to be coordinated and focused on the fundamental, longstanding issues facing mental health services.
We know there are efforts underway to rationalise the recommendations coming into the system from the array of quality and safety reviews, inquiries and investigations that are undertaken, which we welcome and have been working to support. National-level vision and direction is needed to move beyond the specific reviews or reactions to individual cases and ensure national quality and safety recommendations have the intended, and necessary, impact.
Quality and safety reviews
Quality and safety in mental health services have come under significant renewed scrutiny at local and national levels in particular in recent years following a number of cases that have raised serious concerns. Trust leaders have been responding to learning from these cases at pace and reviewing their services, as well as their approach to oversight and assurance of safety, quality of care and management of risk.
NHS England, while recognising the significant work that has been undertaken to date, has most recently asked ICBs and mental health trusts to review their local action plans related to services available for patients who require intensive and assertive community treatment. A welcome, longer-term review of the whole system approach to supporting individuals with serious mental illness is planned and aiming to report by the end of 2026. In the shorter term, wider guidance on what good quality, safe care looks like will be developed. A judge-led public inquiry into the Valdo Calocane case has also been announced.
There has been welcome national improvement work taking place to bring about an overall cultural change within mental health services and improve the therapeutic environment of mental health settings. This includes a three-year inpatient quality transformation programme which is now in its delivery phase and includes the piloting of six 24/7 open access mental health centres that bring together community, crisis and inpatient care into one team. There is also national focus on improving access to, and the quality of, data on inpatient deaths and the final report from a national investigation commissioned by the previous government expected in May. The Lampard inquiry, which is likely to have implications for mental health services across the NHS, is also ongoing and will next hear evidence from senior trust leaders and staff later in April and May.
Meeting the needs of vulnerable and underserved groups
There are particular groups of individuals who experience the greatest inequalities in their access to, experience of and outcomes from health services. Focusing on better meeting their needs would support trusts' efforts to improve productivity and achieve best value for money.
People with a learning disability and autistic people have faced longstanding, structural inequities, with many not receiving the care and support they need and should expect from the health and care system. 41% of individuals who are in hospital could have their needs met in the community with appropriate support and half of those in hospital have been there for two years or more. Immediate action needs to be taken to ensure high-quality care and support is available for everyone, no matter where they live in the country or the complexity of their needs.
Similarly, action is needed to address the fact that black, Asian and ethnic minority communities experience significant inequalities in access, experience and outcomes from mental health services. Black people continue to be more likely to be detained under the Mental Health Act and receive more restrictive care in the community than other groups. NHS England set out in 2020 how it planned to support local health systems to better address race inequalities in mental healthcare and mental health trusts have since been working to implement particular elements such as the Patient and Carer Race Equality Framework (PCREF), which aims to eliminate racial disparities and improve communities’ trust and confidence in mental health services.
Trust leaders are clear that support for children and young people must be a priority to meet needs now and prevent a mental health epidemic in future years. Nearly all respondents (90%) to our 2024 survey said that the health and wellbeing of children is not considered enough in national policy, and only 33% were satisfied that local plans adequately prioritise these services.
Stigma and structural disadvantage
Many of the challenges facing the mental health sector are rooted in the fact the sector has suffered a historical, structural disadvantage compared to physical health provision. One of the key reasons for the sector’s disadvantage is the broader societal and historical impact of the stigma surrounding mental illness. While welcome strides have been made to challenge this stigma and raise awareness of the need to improve care, the healthcare system is still operating in the context of a ‘care deficit’ where it is deemed acceptable that a significantly larger proportion of those that need mental health care and treatment will not be able to access timely support compared to those with physical health conditions, and the provision of mental health services is not prioritised across the whole of the NHS. A broader set of mental health waiting time and access standards comparable to those we have had for decades for physical health services have not yet been fully introduced despite having been consulted on and agreed to years ago – in part due to a lack of resources to deliver them in practice.
The national focus on productivity, and approach to measuring and improving it, having been up until very recently largely focused on acute services is another example, and symptomatic, of the sector’s disadvantage. The fragmented commissioning and delivery of mental health services, the use of block contracts to pay for them, and the longstanding neglect and underinvestment in the mental health estate, are further such examples as highlighted in the next section of this briefing.
Productivity challenges
Mental health trusts have been working in a variety of ways to improve productivity within their services, such as by increasing work with system partners and through provider collaboratives, making use of benchmarking data to inform clinical and operational decision making, and improving business intelligence support. Some trusts are also taking innovative approaches to delivering patient initiated follow ups, piloting different staffing models, and using social value tools with system partners to inform investment decisions.
Providers of mental health, learning disability and autism services have been trailblazers in working together with wider partners, both formally and informally, to improve the delivery of specialised services through provider collaboratives. Working in this way at scale enables trusts to act collectively with local partners on a range of issues including clinical transformation and resource management. Savings achieved through efficiencies, economies of scale and cutting the use of expensive, inappropriate out of area placements can be reinvested in providing the right support for people closer to home.
Trust leaders are committed to doing all that they can to achieve the best value for money for taxpayers. They have stressed the importance of viewing productivity through a much wider lens of improvement and the concept of 'delivering value' – focusing on striving to improve outcomes for patients, which will simultaneously help the NHS to be more productive – as opposed to solely measuring the total number of 'inputs' (for example, NHS funding and number of staff) and the total number of 'outputs' (such as the amount of activity delivered).
Accurately measuring the productivity and value of mental health services is a challenge. This is partly due to evolving models of care, where progress is not always linear and delivery can require more resources (often upfront or in the short term). Evolving models also increasingly involve wider system partners, which adds additional challenges to accurately capturing and measuring data that evidences the productivity and value of new services. Often value and productivity savings are delivered in a different part of the system, not in the organisation itself. Variation in existing models of care and coverage too makes accurately measuring the productivity and value of mental health services a challenge.
It is important to note that the bulk of investment in the mental health sector in recent years has also been directed towards establishing new services, rather than remedying pre-existing underinvestment in core mental health services. These core services are fundamental to meeting local mental health care needs, and particularly supporting individuals with the greatest level of need, at the right time, in the right place. There has also been a lack of funding for wider public services, which has an impact on the productivity of mental health services as it undermines efforts by councils to improve the health and wellbeing of their communities and places additional demand on the NHS.
Estates-related issues also impact trusts' ability to improve productivity. Mental health trusts have disproportionately gone without adequate investment in the modernisation and development of their estates. Key findings from work by the National Audit Office earlier this year highlight the impact, as does our May 2024 survey of trust leaders where 57% of respondents stated that estate-related issues were severely or significantly impacting their ability to deliver improved productivity levels. Structural factors, such as the historic use of block contracts in mental health services, have had a significant impact in a variety of ways, ranging from culture and motivation to the quality of data and mental health trusts' analytical capacity. These, along with challenges with annual planning cycles hindering trusts' ability to make strategic long-term investments, have too been highlighted by trust leaders as barriers to greater productivity.
It is welcome that recent steps have been taken nationally to improve the benchmarking available for mental health activity and cost bases, which have historically been limited and made it challenging to accurately measure productivity levels.
When looking to effectively measure, and improve, the productivity of mental health services, trust leaders have stressed the importance of focusing on patient access, experience and outcomes. Looking at the right allocative and process-focused metrics, better capturing the impact of system working and also taking inequalities into consideration is important. Trust leaders have been clear that a common language about productivity and value is needed as much as the right metrics.