NSUN network for mental health is an independent, service-user-led charity that connects people with experience of mental health issues to give us a stronger voice in shaping policy and services.
Five Year Forward View for Mental Health: An independent report of the Mental Health Taskforce
On Monday 15th February 2016 the Mental Health Taskforce published Five Year Forward View for Mental Health: An independent report of the Mental Health Taskforce.
It includes a summary of where NHS mental health care is now and a range of recommendations for ways that existing problems might be solved and the quality of life for people with mental health needs of all ages might be improved.
The Mental Health Taskforce was formed in March 2015 and was initially intended to report in November of that year. It is the first time an independent body has drawn up the national mental health strategy, a role that previously sat within the Department of Health. Chaired by Paul Farmer chief executive of mental health charity Mind and vice chaired by Lambeth councillor, service user, survivor Consultant Jacqui Dyer, the Mental Health Taskforce was set up to “create a mental health Five Year Forward View for the NHS in England”; setting out where the treatment and care of people with mental health conditions should be by 2020. It has a model in the NHS Five Year Forward View published in October 2014 .
Evidence and views were collected from over 20,000 people, which the report describes as “an unprecedented level of feedback”. A summary of these views was made available prior to the publication of the report. The resulting priorities presented were prevention, access, integration, quality and a positive experience of care.
The document is made up of recommendations for actions to take us to a better situation for people with mental health conditions by 2020, with each of the chapters beginning with an ‘I statement’ “Every person with a mental health problem should be able to say:” and then going on to detail how people with mental health difficulties swish to be supported, what’s important to people and how they want others to behave toward them. This is derived from the development of the ‘No Assumptions’ approach to which NSUN contributed in 2014 and which tries to capture how services should feel to the people who use them.
The report is the first refresh of mental health goal setting since the passage of the Health and Social Care Bill into law in March 2012 which created the current NHS landscape and which separated the NHS from The Department of Health. It comes alongside the less publicised “Social work for better mental health” strategic statement and the ongoing Think Ahead mental health social work fast track scheme.
The headlines recommendations of the report are:
- an end to the practice of sending people out of their local area for acute inpatient care
- providing mental health care to 70,000 more children and young people
- supporting 30,000 more new and expectant mothers through maternal mental health services
- new funding to ensure all acute hospitals have mental health services in emergency departments for people of all ages
- increasing access to talking therapies to reach 25% of those who need this support
- a commitment to reducing suicides by 10%
- Increased focus on research
We have produced a table of the recommendations, attempting to look at what recommendations are about improving, expanding and increasing what exists and what are new. Read more here.
Over the last five years NSUN members have consistently said that ‘access to timely and appropriate resources and support’ is what is most important to them. So it is encouraging to see that our mantra of ‘we need the right support, at the right time, in the right place, from the right person’ adopted and adapted to “Getting the right care in the right place at the right time is vital”.
We used the Members’ Manifesto to structure comments throughout the consultation process and strongly urged a rights based approach and greater consideration to inequalities, race equalities, alternatives and service user/survivor led initiatives and research.
The report has been widely applauded as a major step in taking forward improvement in mental health care by many mental health charities. These responses have tended to focus upon the increased prominence that the Taskforce report appears to have given mental health in public debate and hail the increase in funding as a major step forward. They have, in the main, focused on who will win from the implementation of the headline recommendations if implemented, whilst ignoring those who are losing quality of life, security and financial support at present.
The range of recommendations for children and young people services and the implementation of the Future in Mind recommendations is very encouraging and have the potential to include some of the most innovative developments. However, there is little in terms of concrete recommendations for addressing inequality issues for older people or race equality.
Co-production is peppered throughout the report as a basic recommended approach, particularly in commissioning and individual care planning. The 4Pi National Involvement Standards are mentioned as a framework to apply to help ensure services are accessible and appropriate for people of all backgrounds, ages and experience, but sadly this appears to be the only service user/survivor led piece of work woven into the recommendations.
Much of the coverage of the report post launch praised the report for setting out just how much of mental health need is currently unmet in England and pointing out a number of unpalatable truths about where we currently are in meeting those needs.
Examples from the Taskforce report include:
- “In its recent review of crisis care, the Care Quality Commission found that only 14 per cent of adults surveyed felt they were provided with the right response when in crisis, and that only around half of community teams were able to offer an adequate 24/7 crisis service
- Only 14 per cent of adults experiencing a crisis feel they are provided with the right response and just over one third (36 per cent) feel respected by staff when they attend A&E
- Men of African and Caribbean heritage are up to 6.6 times more likely to be admitted as inpatients or detained under the Mental Health Act, indicating a systemic failure to provide effective crisis care for these groups
- People with severe and prolonged mental illness are at risk of dying on average 15 to 20 years earlier than other people
While it is excellent to finally have many of these issues set out as the basis for a five year strategy for the NHS in England around mental health, few have commented that this is only a strategy for the NHS. It is not a cross government mental health strategy; so does not discuss areas that are more politically uncomfortable such as the spending on social care; the continuing effects of the cutting of local authority spending on the fabric of the voluntary and community sector and little if any discussion about the ways in which social security reforms could be seen to have disproportionately affected those with long term mental health needs.
In a blow to those who were hopeful that Mental Health Taskforce would produce some innovative suggestions for the ways in which the lives of people who experience mental health difficulties might be made better, the report is very much based on rolling out a properly funded version of the things we already have, taking a ‘do properly what we already know works’ approach.
The report does recommend focusing innovation on three areas:
- New models of care to stimulate effective collaboration between providers to integrate services around the totality of people’s care needs and preferences;
- Expanding access to digital services to enable more people to receive effective treatment and provide greater choice of therapy; and,
- A system-wide focus on quality improvement to support staff and patients to improve care through effective use of data, with support from professional networks.
None of these approaches suggest a challenge to the status quo of NHS-provided mental health services; but a refinement or tweaking of the way things already work.
The Taskforce report recommendations are mostly about where we need to get to by 2020, rather than being about immediate fixes. As the report says: “In the context of a challenging Spending Review, we have identified the need to invest an additional £1 billion in 2020/21, which will generate significant savings. It builds on the £280 million investment each year already committed to drive improvements in children and young people’s mental health, and perinatal care.”
There’s little in the headline recommendations of The Mental Health Taskforce report that hasn’t been already trailed or announced. It is very much in line with the Life Chances vision set out by Prime Minister David Cameron in January 2015 and focuses strongly on prevention, which, while important, offers little for those who already have long term difficulties or needs.
What’s in the report for people with long term mental health difficulties?
While the Taskforce report does discuss the situation of those with “more severe mental health problems”; it makes far fewer headline-grabbing recommendations to solve the problems it presents. The lack of explicit recommendations for those of us with long term mental health needs will set alarm bells ringing for some.
As the Taskforce report says:
“Of those adults with more severe mental health problems 90 per cent are supported by community services. However, within these services there are very long waits for some of the key interventions recommended by NICE, such as psychological therapy, and many people never have access to these interventions. One-quarter of people using secondary mental health services do not know who is responsible for coordinating their care, and the same number have not agreed what care they would receive with a clinician. Almost one-fifth of people with care coordinated through the Care Programme Approach (for people with more severe or complex needs) have not had a formal meeting to review their care in the previous 12 months.”
The closest to a headline related to more severe mental health difficulty is the welcome recommendation that “by April 2016 50 per cent of people experiencing a first episode of psychosis have access to a NICE– approved care package within two weeks of referral, rising to at least 60 per cent by 2020/21;” a deadline of just two months from the publication of the report. Early Intervention in Psychosis services are an excellent intervention at a terrifying time.
The recommendations more related to a long term experience of mental health difficulty are less strongly tied to David Cameron’s Life Chances agenda of prevention; focus on young people, families and work; and heading off problems before they become more serious. They also have fewer deadlines and timetables attached to them. This puts them more firmly in the ‘it would be nice to have by 2020’ category than the recommendations that already have funding committed to them. For members and supporters of NSUN; these will be recommendations to keep tabs upon over the next 18 months or so, as they will be the ones that are more likely to be open to influence from outside political pressures.
Show us the money!
There’s been some debate as to whether the spending pledge is ‘new money’. When asked for a statement by Community Care magazine, an NHS England spokesperson said: “the mental health taskforce proposals need an extra £1 billion a year to be spent on new mental health services annually by 2020 and that’s precisely what we’re committing today. Only the most bizarre mangling of that fact would claim this isn’t ‘new’ money when it patently is new funding for mental health over and above what is being spent today.” However, the money will have to come from the existing NHS spending review settlement; meaning that it isn’t ‘new money’ in the sense of extra money from the Treasury directly to achieve the recommendations but an order to spend money on the things recommended. As Andy McNichol for Community Care says: “Untangling the claims is tricky as NHS England won’t provide a breakdown for what will be spent when.”
On the day before the launch of the Taskforce report, the BBC published the results of Freedom of Information requests that they said showed that funding for mental health trusts has fallen . The BBC report said: “Figures obtained through a Freedom of Information request showed the budgets for mental health trusts fell by 2% from 2013/14 to 2014/15. In the year to April 2016 the budget for mental health trusts was projected to rise just 0.3%. Of the 53 out of 59 mental health trusts in England which responded to the FOI request, 29 said their budget would be lower this year than last.”
Responding to the BBC, a department of health spokesman said: "These figures do not show the full picture for mental health spend - councils, third-sector organisations and NHS England all play a role in providing services, and all receive government funding. We have made more money available than ever before for mental health, increasing our investment every year since 2010 to a record £11.7bn last year."
As we explored elsewhere, local authorities are being hit hard by reduced budgets; which in turn affects the charity and voluntary sector. Many voluntary sector mental health organisations, including user led groups have suffered over the last six years, with an increasing number having to close due to lack of funds.
On 10th February, the National Council for Voluntary Organisations published a report Navigating Change: An Analysis of Financial Trends for Small and Medium-Sized Charities which showed that income to small and medium sized charities had fallen between 2008 and 2014, with the North West, North East and West Midlands hit hardest.
In the last 12 months over 20 of our member groups have disappeared and many more face potential closure in the months ahead.
A poor settlement for user activists and those with long term mental health needs?
It’s incredibly difficult to argue against a strategy that seeks to help people early and to prevent their lives worsening. The Taskforce report paints a picture of a creaking system with many structural and resource challenges; and chooses to focus strongly on the prevention of the worsening of problems in the future.
It will be difficult for those with more complicated needs who are already getting a poorer service to bring to the fore of public debate their needs without appearing to be dismissive of the needs of those with less severe conditions. It will also be similarly hard for those who have experienced mental health difficulties for decades to argue for better support without being accused of putting their needs before young people who may be prevented from having similar long term experiences.
While there are passing references to social determinants; the focus is strongly on work as the route out of poverty which in turn will improve mental health. Given all of the areas of policy that the Taskforce recommendations do not cover we will need to work as hard as ever to place the needs of people with long term conditions on the agenda.
It is now up to The Government and the various NHS bodies to respond to what is set out by the Taskforce. Taken as a whole, the report is probably the most comprehensive set of recommendations we’ve yet had as part of the development of a mental health strategy. There are some things within the report that will hearten many of us, and others that some may find more problematic.
As is ever the case; now the strategy is here the real meat of what happens will be contained in the frameworks to put it into place.
Revise the mental health act?
An untrumpeted area of interest for the Taskforce report is the conditions and usage of inpatient services.
The Taskforce recommends that Department of Health should work with a wide range of stakeholders to “to review whether the Mental Health Act (and relevant Code of Practice) in its current form should be revised in parts, to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will.”
The Taskforce report makes some strong recommendations that acute inpatient care needs to be looked at with greater scrutiny, focusing on the provision of the least restrictive care. It wants the practice of sending people out of area for mental health inpatient care to be ‘eliminated by no later than 2020/21. Further to that; it recommends that NHS England should better monitor uses of the Mental Health Act at a local and national level and that admissions should be reduced by 2020/21 by earlier intervention. The Taskforce wants Mental Health Act detentions to be reduced and for specific work to be undertaken to reduce “the current significant over-representation of BAME [Black and Minority Ethnic] and any other disadvantaged groups in acute care.”
Inequalities and scrutiny
In relation to inequalities in mental health, The Taskforce recommends that any money given to CCGs to reduce inequalities should show up separately on the balance sheet and that NHS England should make it mandatory that CCGs “publicly report on how they are addressing unmet mental health need and mental health inequalities.” It states that there “has been no improvement in race inequalities relating to mental health care since the end of the 5-year Delivering Race Equality programme in 2010.”
It recommends that: “The Department of Health should appoint a new equalities champion with a specific remit to tackle health inequalities amongst people with mental health problems and carers across the health and social care system and through cross-government action.”
The Taskforce wants the Care Quality Commission to beef up its inspections of NHS funded mental health services, including looking at how these services involve people in care planning, how they work with communities and how they work with carers. It also wants all to make sure that the NHS learns from any suicides in NHS settings.
It also recommends that: “By April 2017, the Department of Health should establish an independent system for the assurance of the quality of investigations of all deaths in inpatient mental health services and to ensure a national approach to applying learning to service improvement.”
Interestingly, the document makes no reference to Healthwatch or to organisations like NHS Citizen, the bodies which we had been led to believe would be our best ways of influencing local level policy and conditions.
Experience of services
On the subject of medication, the Taskforce recommends that the Academy of Medical Royal Colleges by April 2017 develop standards for all professionals who can prescribe mental health medication to make sure that they can discuss the positive and negative effects of those medications with people, including discussing people’s personal preferences and where possible preventative physical support.
Care navigators are an interesting idea that the Taskforce slips into the recommendations: people available from diagnosis onward who will guide people through options for their care and provide relevant information and support. The Taskforce recommends that this role be fleshed out with “ voluntary and community sector organisations, experts-by-experience and carers to develop and evaluate the role of ‘navigators’ in enabling more people-centred care to be provided.”
According to the Taskforce: “People with existing mental health problems told us that services should be integrated - for example, physical health checks and smoking cessation programmes should be made available for everyone with a severe mental illness.”
Under this heading the Taskforce recommends better access to health checks and screening programmes; “as well as interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. It also recommends that all mental health inpatient facilities be smoke-free by 2018. This remains contentious for some service user activists and people with long term mental health difficulties.
It also recommends that NHS England should focus on producing a plan of work by 2017/18 to reduce the early deaths of people with severe mental illness. Some of this work they recommend should focus on training GPs and practice nurses while also suggesting outreach worker or carer training to help people with psychosis to access GP services.
The Taskforce also wants this work to be embedded across health services.
One area where the applause of large charities may be at odds with the lived experience of those with mental health difficulties is that of work. The taskforce report strongly ties the extended provision of psychological therapies to the goal of getting more people “back to work”. This has caused disquiet amongst campaigning groups.
The Taskforce report sets out the statistics for people with mental health difficulties in employment: “The employment rate for adults with mental health problems remains unacceptably low: 43 per cent of all people with mental health problems are in employment, compared to 74 per cent of the general population and 65 per cent of people with other health conditions. Of people with ‘mental and behavioural disorders’ supported by the Work Programme, only 9.5 per cent have been supported into employment, a lower proportion than for some proven programmes. There is a 65 per cent point gap between the employment rates of people being supported by specialist mental health services who have more severe health problems and the general population.” Of course, the number of people with conditions such as depression and anxiety in work are far higher than those with more severe diagnoses.
In a press release focusing on these measures, The Prime Minister’s Office unhelpfully tied together work and treatment, stating: “Almost 3 in every 5 people with mental health conditions are currently unable to work, despite evidence showing employment can be a crucial part of treatment.”
The same press release states that “£50 million will be spent to double the reach of programmes finding work for people with mental illness – known as Individual Placement and Support Programmes”; and “over £50 million is invested to more than double the number of employment advisors, so that they are linked into every talking therapy service in the country.” The Centre for Mental Health has carried out a sizable body of work on Individual Placement and Support. As they describe it: “IPS gets people into competitive employment first with training and support on the job.”
In their report The Taskforce welcomes “the introduction of a Joint Unit for Work and Health, which is already piloting new approaches and recently secured significant new investment for an innovation fund.” Ian Duncan Smith, Secretary of State for Work and Pensions has stated: “We will set out more on our approach in the Work and Health White Paper.”
In November 2015, a joint analysis between Mind and The Independent newspaper found that benefits sanctions imposed upon people with mental health difficulties had risen from 2,507 in the year 2011-12 to 19,259 in 2014-15; “a 668 per cent rise.”
At the time of writing, the Government is reported to be under pressure from MPs to postpone or cancel an intended cut to the value of Employment Support Allowance, equal to around £30 per week for people with disabilities involved in work related activity.
In January, the Royal College of Psychiatrists warned in an article that “unjust and ineffective” use of “threats and sanctions” against people who cannot work due to their poor mental health.”
Given the wider lack of trust in the motives of the DWP in the reform of social security benefits amongst those who are currently claiming this area will probably draw the most fire from smaller campaigning groups.
Crisis teams and hospital liaisons
The Taskforce is looking for improvement in the ways in which services deal with mental health crisis; as it is looking to reduce admissions overall by 2020/21. As the report says: “the Care Quality Commission found that only 14 per cent of adults surveyed felt they were provided with the right response when in crisis, and that only around half of community teams were able to offer an adequate 24/7 crisis service. Only a minority of hospital Accident & Emergency (A&E) departments has 24/7 cover from a liaison mental health service, even though the peak hours for mental health crisis presentations to A&E are between 11pm and 7am.”
The Taskforce recommends the extension of Crisis Resolution and Home Treatment Teams (CRHTTs). It also sets a target that no acute hospital should be without an all-age mental health liaison service in Accident and Emergency and inpatient wards by 2020/21
Prime Minister Cameron previously announced the available funds for this as being £247 million to invest in liaison mental health services in emergency departments and over £400 million to enable 24/7 treatment in communities as a safe and effective alternative to hospital over the next five years.
The Taskforce recommends the development of access and quality standards for the full range of mental health conditions and recommends investment to increase access to psychological therapies for people with psychosis, bipolar disorder and personality disorder, although NHS England has had less to say about how that might be achieved.
CCGs and Health and wellbeing Boards: not working so well?
A subtext of the taskforce’s report is that the systems for commissioning mental health services are not quite where they need to be to achieve significant changes. In the draft version of the report leaked to newspapers prior to publication it appears that this criticism may have been more explicit. There is a sense in which the Taskforce feels that CCGs and local authorities just aren’t where they need to be in terms of data and thinking to fully match up to the role they now have in commissioning.
According to the Taskforce report: “Analysis commissioned by NHS England found that the national cost of dedicated mental health support and services across government departments in England totals £34 billion each year, excluding dementia and substance use. £19 billion of this is made up of government spend, though there is little or no national data available for how up to 67 per cent of mental health funding is used at a local level.”
It recommends that there should be greater transparency in data “to promote choice, efficiency, access and quality in mental health care, ensuring that all NHS-commissioned mental health data are transparent (including where data quality is poor) to drive improvements in services.” It also wants all CCGs to report on their investment and spend on mental health by condition and per person from 2017/18 onwards.
By 2020/21, The Taskforce recommends that “Health and Wellbeing Boards should have plans in place to promote good mental health, prevent problems arising and improve mental health services, based on detailed local data for risk factors, protective factors and levels of unmet need. These should specifically identify which groups are affected by inequalities related to poor mental health and be co-produced with local communities to generate innovative approaches to care and improving quality.”
The Taskforce also recommends NHS England and NHS Improvement should develop “evidence based approaches to co-production in commissioning” by 2018 and mentions the 4Pi National Involvement Standards (produced by people who use services and carers) as a framework to “help ensure services or interventions are accessible and appropriate for people of all backgrounds, ages and experience.”