Mental health targets: making the best of the opportunity

Targets. Mental health has had them, lost many of them, and England and Wales are now planning on more. The spending review announcement of £600m for mental health seems to be linked to at least one new target, if not more.

We’ve recently published analysis considering how to choose, design, and targets.

It has made me think about targets and mental health. Are we setting the targets we should, or just those that are do-able? Have we really thought through their design and consequences? Before I go further, I should explain that I worked on developing mental health targets while working at the Department of Health. It’s a pressured and difficult business, and one in which I definitely made mistakes. There are constraints that need to be worked around - I’m interested in how new targets can make the best use of funding and focus for mental health.  

Our report uses mental health as a case study for understanding whether targets should be set – and found it a promising area: historically overlooked (arguably because of a lack of targets), underfunded, and issues with quality.

Five tests for targets: should they be applied to mental health services?

A pressing problem?

Yes: mental health outcomes and accessibility of services are recognised as issues by the public, the media, government and the NHS.

Amenable to action?

Yes: there is an evidence base pointing towards effective interventions and service design, and examples of excellent services.

Resources available?

Maybe: there is some national money earmarked for mental health, and a clear business case for prioritising scarce resources to invest. However, services have suffered disproportionately in austerity, and ongoing financial pressure makes changing how money is spent locally difficult. In addition, the human resources – people and skills are in short supply in some areas.

Performance measurable?

Yes, with development: Waiting times for services are measurable (the data needs smartening up) – better measures of outcomes are needed to balance against target-driven pressure on waiting times.

Impact on wider system?

Yes, with good design: There is an opportunity cost of improving mental health services. Increasing focus on mental health may mean other untargeted areas (eg community services) suffer.

Potentially then, targets could be part of the solution to improving mental health services  – not least through balancing the effect of high profile access targets in physical health. To be effective they need to be designed and supported well.

How do current mental health targets measure up?

Many people with mental health problems currently receive no support or treatment. This complicates policy design: meaning the challenge is not just to make current services better – but to create high quality support to all those that need it.

The current targets are positive for those with common mental health problems. IAPT should now have a ‘triple lock’ applied to it: services meeting a percentage of prevalence, waiting times standards, and service quality maintained through an outcomes target. Some way to go until this is achieved everywhere, but the framework balances quality, access and need.

Targets remain very limited for people with severe and enduring mental health problems. The only standard is waiting times for early intervention in psychosis services with quality defined through access to ‘NICE recommended interventions’. The services have an excellent evidence base and are certainly important. However the type of intervention, let alone the quality, is difficult to measure, and they serve relatively few people.

So targets currently make general secondary care services (for instance support given by community mental health teams), services for children and young people, and preventative services vulnerable to de-prioritisation. Whether national initiatives in other areas mitigates this risk remains to be seen.

Where next?

In designing new targets, NHS England and others will be walking a tightrope of aspiration versus financial reality. If they are to design targets that help, not hinder quality in mental health they will need to:

• Think hard about priority. Non targeted areas are vulnerable to cuts with the service under financial pressure. One approach might be to put in an overarching target across mental health in the manner of the 18 weeks waiting times target in physical health. This may even up the framework between mental and physical health. However, it does little to set out and focus on the priorities in mental health: both where should be protected and where should be improved. To do this, additional targets need to be on the real priorities, remembering that if everything is a priority nothing is. The logical conclusion of an honest prioritisation exercise may be fewer targets in other areas of health care, or a greater focus on service quality over waiting times in new targets.
• Make real progress on data. Data is already a policy priority, but more progress is needed both to measure achievements and understand and mitigate against unintended consequences of action.  Transparent information is needed on all aspects of quality in mental health services (whoever is providing them) – particularly coverage, waiting times and benefit gained from services.
• Supporting change. Targets are more likely to be successful when they are part of a comprehensive effort to support change – this needs to be put in place including resources, practical support and leadership.

Finally, collaboration will be key in designing new targets – involving people with mental health problems and staff working with them to design pragmatic solutions for a resource strapped system. If done well this can ignite people’s passion to make services better – something worth more than a target on a piece of paper can ever be.  

Felicity is Senior Policy Fellow at the Health Foundation. You can follow her on Twitter at www.twitter.com/@FelicityTHF