The NHS England mental health taskforce has published its report, a Five Year Forward View for Mental Health. The initial reaction has been positive – alongside some concern about the money and implementation.
What does the report say?
The report vividly sets out the problems with mental health services within the themes of prevention and stigma, access and choice, and quality and experience. There are commitments for service expansion, most notably for psychological therapies for common mental health problems, 24/7 crisis care, mental health care for children and young people and perinatal mental health services. There are also recommendations on regulation, research, workforce, payment systems and information.
It promises ‘new’ money of £1bn by 2020/21 – although details are scant. This is likely to be part of the overall health service allocation announced in the Spending Review, which is the bare minimum needed to keep the NHS afloat leaving little or no money for new service improvements. And it seems funding will not be ring-fenced - previously areas have planned for money to be spent on mental health only to reprioritise in-year responding to other pressures. While the money may be new for mental health, it is probably not new for the NHS, and does not guarantee on-the-ground funding for services. Many interventions in mental health have an ‘invest to save’ argument – but this doesn’t mean savings accrue to the NHS, let alone mental health services.
What are the tensions in the report?
The report certainly advocates improvement in mental health services. But even if all the commitments are met, there will still be a long way to go for everyone to access care they need. The graph below shows approximately how much of estimated need would be met through improvements set out in the report.
There is variation in the ambition of firm taskforce recommendations. Some are surprisingly punchy: recommending a review of the impact of the housing benefit cap on mental health, likely to sit uneasily with broader government.
Reading between the lines the taskforce may have wanted to go further in other areas. The commitment to increase the number of people accessing early intervention in psychosis services is small (from 50% in two months’ time, to only 60% by 2020/21), and a four hour wait for people in mental health crisis is absent (despite being a key recommendation from the Crisp commission last week. They set out a timeline for development of quality and access standards across mental health with no funding for implementation, and safe staffing levels are avoided completely.)
Prevention is another area of tension: the report recognises its importance with more funding for children and young people’s mental health care, and a national and local Prevention Concordat (agreements committing agencies to action). This seems at odds with cuts in public health, and starts from a low base: with local authorities spending only 1% of their public health budget on mental health.
The central versus local dynamic is interesting. The need for co-produced commissioning and local autonomy is majored on, but most of the recommendations are for national bodies, and rhetoric about national roll out of evidence-based standards does not chime well with local autonomy. There is also little firm support for commissioners and providers – NHS Improvement has only one recommendation against its name. You might expect as the body that supports providers it would play a major role.
Is it going to work?
Whether or not everything can be afforded, a commitment to any expansion of services in mental health is a major achievement in the current context. The mental health community and those working on the taskforce appear to have argued successfully for maintained focus and perhaps an increased share of NHS funding, for which it should be applauded.
However success in reality depends on what happens next. As the taskforce identifies, implementation is a challenging business. There are four risks that stand out for me:
- Mental health commitments are lost in the noise of a whole system financial crisis. Many of the improvements in mental health services rely on general practice (stressed out and unhappy), on local areas putting the promised money into mental health (impossible when acute trusts are failing financially, local authorities face further austerity and there are cuts to public health) and NHS and local government commissioners with ability and headspace to drive change (an ever shrinking resource). These are systemic issues – the answers are not within the mental health community’s gift.
- There isn’t the workforce to deliver the commitments. The report graphically outlines the gaps in capacity and the challenging environment facing people working in mental health, and recommends development of a workforce strategy. But to meet the taskforce commitments staff are needed now, not in several years. The NHS is also in the grip of a morale crisis – with industrial disputes, low staff engagement and staff experiencing mental health problems. People need to be engaged in change for it to be successful; the current context does not help this.
- The agenda proves too broad to manage effectively. Despite the unmet need that will remain, the taskforce commits the system to a great deal of work: service expansions, a new service to be regulated, massive strides forward in information and cross agency action on prevention. This needs both central and local resource, and undoubtedly some phasing. It is not clear what the key priorities that local and national leaders need to focus on are, or how they will be driven nationally.
- The system moves on leaving this strategy outdated. The hopes of the English NHS to transform and become financially sustainable are in the new models of care being trialled in the Vanguards programme. Vanguards are mentioned in the report, but the debate about new models of care does not resonate with the mental health community. This needs to change – the services, pathways, standards and information systems developed in mental health must fit seamlessly into new care models, or risk becoming obsolete before they are fully developed.
Local and national organisations now have an opportunity to translate good intentions into better mental health in England. It remains to be seen whether people and resources can be mobilised to make this happen. Much now hangs in the balance…
Felicity is Senior Policy Fellow at the Health Foundation. You can follow her on Twitter at https://twitter.com/@FelicityTHF