Great strides have been made to increase investment in mental health services and deliver on aspirations to improve quality and access, following a decade of campaigning from the mental health sector. Not only have services had a substantial cash injection in recent years, but the sector also has a fully costed programme for mental health delivery with The five year forward view for mental health. The NHS long term plan significantly builds on this, making it clear further progress on improving people’s mental health and wellbeing is a priority for the next decade. These are substantial and welcome steps forward by national policy makers.
In terms of quality and access, more people than ever are receiving treatment and care for mental health conditions and the majority of NHS mental health services are providing good care, with 71% of core services rated as good and 10% as outstanding by Care Quality Commission in 2019. The sector has also been a trailblazer for innovation and work to deliver new integrated models of service delivery in partnership with health and care partners across systems, and mental health leaders are thinking positively about how changes to commissioning and increased system working will help them be more efficient and strategic.
However, despite this progress and promise for the future, there are significant, specific challenges facing mental health provision and those trusts providing mental health services that need to be addressed. Many of these challenges are rooted in the fact that the mental health sector has suffered a historical, structural disadvantage compared to physical health provision.
The mental health sector challenge
The stigma surrounding mental illness and mental health sits at the heart of the sector’s disadvantage. Although welcome strides have been made, there is still a considerable level of stigma and a lack of equity of treatment that is reflected in how we view, support and deliver services. While aspirations are growing, supported by politicians and senior healthcare leaders, the healthcare system is still operating in the context of a ‘care deficit’ where we accept that not all those that need help and treatment will seek or be able to access support. It also means the provision of mental health services is not prioritised across the whole of the NHS.
How mental health services are commissioned and paid for also translates into the mental health sector’s historical and structural disadvantage. Unlike physical health care, the majority of mental health services are delivered through block contracts which are inflexible and do not reflect changes in demand once they have been agreed. New approaches to payment systems and contracting has the potential to support the much-needed expansion and enhancement of mental health services, however there remain significant hurdles to their successful implementation, primarily the level of data needed to develop blended payment contracts. The commissioning of mental health care and wider services supporting mental health service users, at a local and national level, is also severely fractured, impacting on the efficiency of service delivery and continuity of people’s care.
Despite this progress and promise for the future, there are significant, specific challenges facing mental health provision and those trusts providing mental health services that need to be addressed.
Senior Policy Advisor (Mental Health)
The transparency and governance of funding flows is a further key issue facing the sector. Despite the mental health investment standard, there continue to be concerns raised that funding for the mental health sector is not always making its way to the frontline services that need it most, with the standard being seen in some cases as a maximum limit based on affordability, rather than a minimum based on need.
Mental health trusts also need capital investment. NHS mental health providers get less capital funding than might be expected and only three mental health trusts were allocated funding in the waves of capital investment for trusts announced by the government in September 2019. The under prioritisation of investment in the mental health estate is having a real impact on patients and mental health trust leaders have expressed their concerns that lack of capital investment places their patients at increased risk. Greater capital investment in services would not only make a huge difference to patient and service users’ recovery, but also improve the morale of staff.
The impact of growing demand for inpatient care is a key issue trust leaders have told us are contributing to financial pressures for the sector this year in particular. Growing demand is leading to high use of out of area placements (particularly where there is no risk share agreement in place with clinical commissioning groups) and delayed transfers of care, often from inpatient to community settings or supported housing. Growing demand is also leading to a need for trusts to recruit more staff, and trusts are facing the increasing costs of staff recruitment and retention, including covering the costs of the agenda for change pay uplift.
The effects of cash reductions in local authority public health contracts, which has meant the decommissioning of some services such as substance misuse services for example, continues to be a key issue for combined mental health and community trusts. The frequency of re-tendering for services in the mental health and community sectors is a further key issue which means there is less financial security for providers over the longer term.
NHS Providers view - what’s needed
In order to address the issues outlined above and deliver on the ambitions for supporting people’s mental health and wellbeing over the next decade, there are a number of priorities and challenges that both mental health trusts and the national bodies will need to consider.
First of all, we need improved and transparent mechanisms that guarantee that mental health funding reaches the frontline services provided by trusts that need it most. Clear expectations also need to be set around delivering on national investment and initiatives for clinical commissioners and systems to deliver against, that are tightly monitored and enforced. More broadly, there needs to be greater understanding within systems of the mental health and wellbeing needs of local populations to ensure mental health service delivery is prioritised accordingly.
In the short term, we need to see mental health providers’ capital investment needs met so that urgent improvements can be made to estates. Encouraging less fragmented approaches to commissioning and reducing the frequency of retendering in the mental health and community sectors, alongside expanding and rolling out of mental health new care models - that are adequately funded and resourced - are all also crucial.
Over the longer term, we must make further progress on data collection and data quality to give a better understanding of mental health activity, access and outcomes that can then enable better commissioning.
To overcome the demand challenge facing mental health services more broadly, and derive full value out of investment committed to date to the sector, national policy must focus on increased support for both mental health and public health.
There are real opportunities to build on the impressive progress of recent years, but to fully deliver on the ambitions for supporting people’s mental health and wellbeing over the next decade we must remain clear-sighted and focused on tackling the challenges that remain for, and are often specific to, mental health provision and those trusts providing mental health services.
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