Select Committee on Health Minutes of Evidence

Memorandum by the Sainsbury Centre for Mental Health



  1.  The Sainsbury Centre is a national independent agency focusing on research and service evaluation, service development, training and policy development aimed at improving services for severely mentally ill adults.

  2.  The Centre has long maintained that the delivery of care to severely mentally ill people could be improved by better coordination of services across health and social services. It advocates:

    —  the agreement of joint local plans for mental health services;

    —  pooling of health and social care budgets;

    —  establishing a suitable joint accountability mechanism at strategic level;

    —  using a unitary care management model at operational level to plan and commission care for the individual; and

    —  shared and joint training for health and social care staff.

  This approach is compatible with the arrangements set out in the recent Government White Paper "The New NHS". It would almost certainly require primary legislation to enable budgets to be fully pooled.

  3.  The Sainsbury Centre has produced a range of reports on this issue which are appended. In addition, the Centre is currently producing a report on legal barriers to joint commissioning and budget pooling, which will be available early in the New Year. A copy will be provided to the Committee once it is available.

  4.  Staff at The Sainsbury Centre stand ready to provide further information or provide other help and information to the Committee. The contact point is Dr Andrew McCulloch, Senior Policy Adviser (telephone 0171 403 8790 and 0181 366 2599).


1.   Agency Responsibilities

  The Sainsbury Centre does not advocate any specific changes in agency responsibilities. All agencies concerned with the care of severely mentally ill people need to work together more closely if coordinated and effective packages of care are to be delivered.

2.   Organisational structures

  2.1.  Whilst much can be achieved by better joint working at operational level, some sort of formal joint mechanism is required between health and social services to enable joint plans to be agreed and to provide a clear accountability mechanism. A model was suggested in our papers "New Mental Health Authorities: Solution or Distraction" [Appendix 1] and "Statutory Joint Committees for Mental Health: Implementation Issues" [Appendix 2]. This was taken up by the previous administration in its Green Paper on mental health as Option 3 (joint mental health agency). A conference held in April 1997 endorsed this broad approach and raised many issues relevant to the Committee's inquiry. A report of that event is attached as Appendix 3. Finally, the Sainsbury Centre has recently set out, in conjunction with the NHS Confederation, a coherent policy statement on mental health services, which addresses issues of interest to the Committee, and this forms Appendix 4.

  2.2.  This issue needs to be revisited in the light of the recent White Paper on the NHS. However, the principle that a joint body or forum is required to carry out strategic planning remains valid. Some consideration is needed as to whether this best happens at locality or Health Authority/Social Services Authority level. On balance, the latter seems to remain the best way forward as service planning for severely mentally ill people requires a clear strategic focus. The Sainsbury Centre notes that social services input will be required at locality level as part of the plans set out in the recent NHS White Paper. This will be helpful, but is not enough in itself to ensure a joint approach.

3.   Incentives for joint working

  3.1.  The Sainsbury Centre believes that joint working should be a legal and administrative requirement at both strategic and operational level. Leaving the issue to incentives means that the best authorities will pursue joint working and be rewarded. The less good may remain where they are or even drop further behind. A clear direction is needed from the centre including:

    —  the signing off of local joint plans by regional offices; and

    —  a joint performance management system for mental health.

  3.2.  At operational level, a unitary system of care management (absorbing current care management and the best aspects of the Care Programme Approach) would again build joint working into the system. Financial incentives for effective joint working will flow from pooled budgets because these would provide opportunities for the more efficient deployment of the total health and social care resource. Pooled budgets are not an end in themselves but a way of deploying the total resource efficiently in the best interests of service users.

4.   Organisational and funding systems and processes for planning, commissioning and service delivery

  4.1  These will need major changes if the system is to function more effectively for severely mentally ill people. At present the structures work against coherent care and create perverse incentives for health and social care respectively. For example, health authorities can save resources if they can prevent bed blocking but this may require greater social support or the purchase of more residential care by social services. But there are currently no incentives for social care to respond in this way.

  4.2  The issues which need to be addressed are:

  Funding: Joint budgets are required to maximise efficiency and flexibility and to remove perverse incentives. Money needs to be able to follow the patient or client across bureaucratic care boundaries.

  Organisation: A forum is required to provide direction and accountability. This needs to be jointly owned by health and social services. It needs to generate a single plan for services which should be constructed following genuine consultation with all stakeholders such as users and professionals.

  Commissioning: Must be undertaken jointly on the basis of the agreed plan.

  Service delivery: Needs to be undertaken by genuinely joint community mental health teams, with staff answering to the same management line and working to the same model of care planning. This can be achieved by using the care management model across both health and social services and allowing both social workers and community mental health nurses (or other appropriate staff) to act as care managers. The best features of the Care Programme Approach can be retained but must be fully integrated within care management.

5.   Training and Professional boundaries

  The Sainsbury Centre has set out a clear agenda for developing joint and shared training between health and social care staff in its report "Pulling Together"[1]. In particular, joint and shared training opportunities need to be developed rapidly, and a benchmarking mechanism set up for such courses. Eventually, there may be common elements in both the basic and post-basic training of key mental health staff, but the separate identities of the existing professions should be retained. Greater joint and shared training is key to the other reforms which the Sainsbury Centre advocates.

6.   Relative cost-effectiveness of services and the movement of money between services

  6.1  At present efficiency is not being maximised because of the perverse incentives operating across health and social care. Fragmentation, duplication, gaps and differing priorities lead to scarce resources being wasted. For example, patients often "block" beds in hospital because social or residential care (which may be cheaper and most cost effective) is not available.

  If these perverse incentives can be removed there is an opportunity for greater efficiency.

  6.2  The current system for transfers of money (eg Section 28A) are based on out of date notions relating to the resettlement of patients from the old asylums. They do not necessarily meet current needs. The Sainsbury Centre's report on legal obstacles to budget pooling will address this point in some detail.

7.   Recruitment and retention of staff

  This is difficult in many areas, especially inner cities. Staff morale is low and burn out rapid. The joint policy paper The Sainsbury Centre published in conjunction with The NHS Confederation sets out an agenda for change (Appendix 4). Urgent action is needed in this area if some mental health services are not to break down.

8.   Barriers and incentives to encourage or discourage the use of particular services

  As already stated The Sainsbury Centre is in favour of the removal of perverse incentives and barriers to using services which are not based on cost effectiveness and individual need. A unitary system of care management across health and social care, using a single budget and working to a single strategic plan, will maximise efficiency and benefit for clients. This principle is likely to apply beyond mental health to other client groups requiring long term care.

The Sainsbury Centre for Mental Health. Pulling Together. The Sainsbury Centre for Mental Health: London. 1997

1   The Sainsbury Centre for Mental Health. Pulling Together. The Sainsbury Centre for Mental Health: London. 1997


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