Memorandum
ADDITIONAL INVESTMENT
FOR ADULT
MENTAL HEALTH
SERVICES
44. The Comprehensive Spending Review carried
out in 1998 recognised that new resources were needed to modernise
mental health services and resulted in additional investment of
£700 million over the three years 1999-2002. Resources are
distributed to the NHS through the Mental Health Modernisation
Fund, and to Social Services through the Modernisation Fund element
of the Mental Health Grant. This is over and above the £3
billion already invested in health and social services for mental
health.
45. In 1999-2000, £128 million extra
has been invested in mental health services for working age adults.
Details are shown in the table below. An additional £20 million
has also been invested in mental health services for children
and adolescents, as shown at paragraph 81.
|
| Funding for 1999-2000 | £m
| Method of Distribution |
|
Health Service Funding
Adult Mental Health
Modernisation Fund
Of which:
| 40 | |
| In unified allocations—for 24 hour staffed accommodation, assertive outreach teams, out of hours access and anti-psychotic medication
| 19 | Unified allocations to Health Authorities
|
| A central fund—for additional secure places, Beacons and region-wide development activity
| 21 | Biddable funds for Health Authorities
|
| Strategic Assistance Fund for Mentally Disordered Offenders (final year—non-recurring)
| 15 | Distribution announced with unified allocations
|
| Mental Health Partnership Fund—to support innovative service strategies around broader mental health policy initiatives, with a particular emphasis on inter-agency partnerships
| 4 | Distribution announced with unified allocations
|
| Support for education and training for doctors and nurses from MADEL/NMET1
| 12 | Within levies
|
| Mental health promotion | 2
| £325k spent on rollout of CALM helpline in Merseyside and Cumbria; £365k to support the World Mental Health Day Campaign; Balance reserved for central initiatives
|
| Estimated expenditure on drug treatments2 |
17 | Unified allocations to Health Authorities
|
Local Authority Funding
Mental Health Grant (adult service)
| 38 | Allocation to Local Authorities
|
|
| Total | 128
| |
|
1 MADEL is the Medical And Dental Education Levy; NMET is
the Non Medical Education and Training levy.
2 It is expected that nationally around £17 million
from unified allocations will be spent on drug treatments in mental
health.
46. The Mental Health Modernisation Fund for NHS mental
health services for working age adults is targeted at early priorities
to deliver safer services—in 1999-2000 secure places, 24
hour staffed care and assertive outreach—in those areas
of the country with the greatest need.
47. In addition limited funds have been made more broadly
available to support moving towards 24 hour access to services,
and increased availability of the range of anti-psychotic drugs
and psychological therapies.
48. 35 mental health beacons, examples of the best the
NHS has to offer, were identified; two were among eight beacons
given Nye Bevan Awards and one of these won the prize for best
beacon overall. These services are funded to disseminate learning
to the rest of the mental health field.
49. In 1999-2000 the additional £38 million social
care Modernisation Fund for adults allocated through the Mental
Health Grant was aimed at improving training of front line social
care staff; development of needs-based planning; mental health
strategies and joint investment planning; and the appointment
of a senior manager for mental health in preparation for implementation
of the Mental Health National Service Framework.
50. For 2000-01 a further £15 million has been allocated
to health authorities, on the basis of need, towards the development
of at least 250 extra secure places. And £22 million has
been allocated within unified allocations to health authorities
to continue the development of assertive outreach services, 24
hour staffed care, atypical anti-psychotics, and 24 hour access
to services.
51. In 2000-01 local authorities have been allocated
an additional £13 million Mental Health Grant to invest in
mental health services, including Approved Social Workers; training
for front line social care staff; and rehabilitation and support
services, including respite care, to promote independence.
SECURE MENTAL
HEALTH SERVICES
High Security Services
52. The Government believes that partnerships and integrated
service development within the wider NHS and other statutory and
voluntary agencies are priorities for modern secure psychiatric
services, and will end the isolation of the high security service.
The provisions in section 41 of the Health Act 1999 (see Annex
C) are designed to help address the current problems of isolation
by allowing the high security hospitals to join with other mental
health NHS Trusts. By ensuring better service integration there
will be greater sharing of expertise between clinicians. And there
will be easier movement of patients between high and medium security
facilities, and between these and local services.
53. In the meantime, the three Special Hospitals which
provide high security services will be subject to the "duty
of quality" in the same way as all NHS Trusts and Primary
Care Trusts.
54. The NHS Executive Regional Offices already have responsibility
for performance assessment of the three Special Hospitals, on
behalf of the Secretary of State, and will continue to carry out
this function for NHS Trusts providing high security services.
Performance assessment will be based on the NHS Performance Assessment
Framework. In addition, the Secretary of State will reserve the
right to direct Trusts that are approved to provide high security
services on matters of particular importance, eg child visiting
and security issues. The NHS Executive Regional Offices will monitor
compliance with the specific guidance on the provision of high
security care.
55. The Mental Health Act Commission will also continue
to have a role in monitoring standards of care of detained patients
in high security hospitals by visiting the hospitals and investigating
patients' complaints.
56. Following the publication of Judge Fallon's report
into the personality disorder unit at Ashworth Hospital, the three
high security hospitals have been working closely with the NHS
Executive Regional Offices to implement the recommendations of
the inquiry and improve service delivery and security at the hospitals.
New directions and guidance setting out minimum standards for
operational security were issued in 1999 which will ensure common
and consistent minimum standards and will be monitored by the
hospital authorities, the regional offices and through the new
specialised commissioning arrangements.
57. A review of security at all three Special Hospitals
has been carried out by Sir Richard Tilt, former Director General
of the Prison Service and his report will be published shortly.
Capital investment of £6 million is planned this year to
improve safety and security at all three Special Hospitals. Further
development of medium secure facilities will be considered in
the light of Richard Tilt's report and the National Beds Inquiry.
Low and medium Security Services
58. To ensure the continued development of appropriate
low and medium security mental health services, £14 million
was specifically made available from the Modernisation Fund for
Mental Health in 1999-2000 for new additional secure places, and
a further £15 million has been allocated for 2000-01. Changes
to the commissioning of high and medium security places (see Annex
C) will ensure that a full range of secure mental health services
are commissioned by regionally based commissioning groups which
will meet the needs of local populations and ensure continuity
of care between different levels of security.
PRISON HEALTH
CARE SERVICES
59. The survey of psychiatric morbidity in the prison
population of England and Wales carried out for the Department
of Health by the Office for National Statistics in 1997 found
that around 90 per cent of the prisoners in the sample reviewed
displayed evidence of at least one of the five disorders considered
in the survey. These were personality disorder, psychosis, neurosis,
alcohol misuse and drug dependence. More than one in five men
and two in five women reported having attempted suicide at some
time.
60. A report on The Future Organisation of Prison
Health Care undertaken by a joint Prison Service and NHS Executive
Working Group (March 1999) recommended that prisoners should have
access to the same quality and range of health care services as
the general public receives from the National Health Service.
61. In respect of mental health the joint Working Group
recommended:
— that the care of mentally ill prisoners should
develop in line with NHS mental health policy and the National
Service Framework, including new arrangements for referral and
admission to high and medium secure psychiatric services;
— that special attention should be paid to better
identification of prisoners' mental health needs at the reception
screening;
— that mechanisms should be put in place to ensure
the satisfactory functioning of the Care Programme Approach within
prisons and to developing mental health outreach work on prison
wings;
— that prisoners should receive the same level of
community care within prison as they would receive in the wider
community and policies should be put in place to ensure adequate
and effective communication between NHS mental health services
and prisons; and
— continuity of care for people moved from secure
accommodation or prison, or vice versa, into general mental health
services, should be a priority. Increased partnership working
between the NHS and Prison Service will enable prisoners with
mental health problems who require help from community mental
health services to gain access to such services whilst in prison.
62. The Government has accepted the Working Group's recommendations
and agreed that a substantial programme of change should be taken
forward over the next three to five years on the basis of a formal
partnership between the Prison Service and the NHS. Two new joint
units have been created, located within the NHS Executive, to
lead and manage this process of change. The Prison Health Policy
Unit is working to ensure that the right policies are in place
to give a clear strategic direction and guidance, and the Prison
Health Care Task Force supports the delivery of change in the
field. Both units are now operational.
63. Work is underway to develop local partnerships between
each prison and their local NHS organisations. Prisons and Health
Authorities are being asked to assess the health needs of prisoners,
and to identify appropriate services to meet those needs and effective
ways of delivery. This work is being co-ordinated by the Prison
Healthcare Task Force, supported by Prison Service Area Managers
and the NHS Regional Offices, and early pilots are underway in
12 prisons in England and Wales. To support this process a health
needs assessment framework has been developed by the Department
of Public Health and Epidemiology, University of Birmingham. This
framework was issued recently and guidance setting out the programme
of work with actions and a clear time scale will be issued in
the next few weeks.
64. The new partnership arrangements that should improve
health care for prisoners with mental health problems and outcomes
include:
— better screening for mental health problems at
reception;
— the introduction of the Care Programme Approach
for those with mental health problems;
— reduced reliance on admission to the healthcare
centre and in some cases transfer to hospital as problems escalate
untreated;
— reduced self-harm and suicide;
— increased ability to participate in offender behaviour
programs; and
— reduced health related offending.
65. These improvements should also result in better use
of resources within the overall mental health envelope.
DANGEROUS PEOPLE
WITH SEVERE
PERSONALITY DISORDER
66. The Government is firmly committed both to ensuring
the safety of the public and to providing mental health services
that meet the needs of patients. The challenge to public safety
presented by a small minority of people with severe personality
disorder, who because of their disorder pose a risk of serious
offending, has been recognised by successive administrations.
67. Dealing with this problem brings together criminal
justice and health and social policy and raises complex and sensitive
legal and ethical questions. A consultation paper Managing
Dangerous People with Severe Personality Disorder: proposals for
policy development was published in July 1999. The consultation
paper set out two options for policy development which involve
both organisational and legislative changes.
Service development
68. The consultation document identifies the need to
develop new service approaches and acknowledges that it will take
time to establish the physical infrastructure required and to
ensure availability of sufficient appropriately skilled staff.
The Government recognises that, whatever option is chosen for
longer-term policy development, there is a need to develop capacity
within existing prison and health service structures to manage
dangerous people with severe personality disorder more effectively.
69. As a first step a number of pilot projects will be
set up to test the procedures that might be used to assess risk
and symptoms of personality disorder. An expert group was established
last year to identify what tools already exist and how a new assessment
system might work. The first of a number of pilot projects to
test the approach they proposed will be located at Whitemoor prison.
This will be part of a co-ordinated programme of pilot studies
that will be set up in the Prison Service and NHS.
70. The build-up of an evidence-based approach through
evaluation and follow-up will fit within a wider approach to research
in this area that will take in both criminal justice and health
service perspectives and concerns. The research programme will
also specifically focus on the factors that may cause or prevent
people from developing severe personality disorder—priorities
for research in this area will be co-ordinated across Government.
71. Work has also been commissioned to investigate ways
of improving services and multi-agency working arrangements for
people with severe personality disorder in the community.
BETTER CHILD
AND ADOLESCENT
MENTAL HEALTH
SERVICES
Child and Adolescent Mental Health Services
72. Since 1997, when the Government published its response
to the Health Select Committee's report on Child and Adolescent
Mental Health Services, the focus of the Department's work in
this field has been to address acknowledged deficiencies in the
range, quality and distribution of services. In particular this
has involved up-dating the information base and setting specific
development objectives underpinned by additional resources.
Improving the Information Base
73. A national survey of the development and emotional
wellbeing of children has been undertaken by the Office for National
Statistics and preliminary results were published in November
1999. Publication of the full survey is expected on 30 March this
year.
74. In addition, a number of national research projects
have been commissioned and are now underway. They are looking
mainly at inpatient psychiatric care for children and adolescents
but primary care, the use of legislation and links between social
services and child and adolescent mental health services are also
included.
75. Independent reviews have already contributed significantly
to knowledge of the current state of child and adolescent mental
health services.
76. In September 1999 the Audit Commission published
a report Children in Mind, focusing on specialist child
and adolescent mental health services in England and Wales.
77. In June 1999 the Mental Health Foundation published
Bright Futures, a report on promoting the mental health
of children and young people. The report covers the main factors
affecting children's mental health and makes recommendations to
central government and the provider agencies on how the mental
health of children and young people could be improved. Some of
the key themes are reflected in Standard One of the National Service
Framework (paragraph 10).
Service development
78. The National Priorities Guidance for Health and Social
Services 1999-2002 set the following objective:
To improve provision of appropriate, high quality care and
treatment for children and young people by building up locally-based
child and adolescent mental health services. This should be achieved
through improved staffing levels and training provision at all
tiers; improved liaison between primary care, specialist child
and adolescent mental health services, Social Services and other
agencies; and should lead users of the service to expect:
— a comprehensive assessment and, where indicated,
a plan for treatment without a prolonged wait;
— a range of advice, consultation and care within
primary care and Local Authority settings;
— a range of treatments within specialist settings
based on the best evidence of effectiveness; and
— in-patient care in a specialist setting, appropriate
to their age and clinical need.
79. The National Priorities Guidance for 2000-03 set
the following targets for child and adolescent mental health services.
Increase and improve services for children and adolescents,
including extra inpatient beds, 24 hour cover and outreach services,
and increase the early intervention and prevention programmes
for children.
ADDITIONAL INVESTMENT
FOR CHILD
AND ADOLESCENT
MENTAL HEALTH
SERVICES
80. The Government has allocated an additional £90
million over three years under the NHS Modernisation Fund and
the Child and Adolescent Mental Health Grant. The key aims are
to reduce the inequity in service provision by building up and/or
reconfiguring existing services to bring them to a level nearer
the best. This includes funding of £6 million, which is being
provided under the child and adolescent Innovation Mental Health
Grant, for the continuing support of 24 innovative inter-agency
projects originally funded in 1998. These projects are testing
different models of practice in areas where the mental health
needs of children have not always in the past received sufficient
attention, for example the mental health of looked after children,
of children excluded from school, and children in the youth justice
system. Findings from these projects will be widely disseminated
as the projects' evaluations become available in 2002. These evaluations
should influence provisions and practice in inter-agency work
for children at high risk of social exclusion.
81. In 1999-2000 a total of £20 million has been
allocated for child and adolescent mental health services development,
as shown in the table below.
|
| Funding for 1999-2000 | £m
| Method of Distribution |
|
Health Service Funding
Child and Adolescent Mental Health Modernisation Fund
| 10 | Biddable funds
|
Local Authority Funding
Mental Health Grant (child and adolescent service)
| 6 | Allocation to Local Authorities
|
| Innovation Mental Health Grant (child and adolescent service)
| 4 | Allocation to Local Authorities
|
|
| Total | 20 |
|
|
82. For 2000-01 this is supplemented by an additional
£10 million to the NHS including £5 million for Tier
1 (primary care and community) services. Announcements will be
made on how the further £5 million will be spent later this
year.
REFORM OF
THE 1983 MENTAL
HEALTH ACT
83. In July 1998 Frank Dobson announced the Government's
intention to carry out a "root and branch" review of
the Mental Health Act. An expert committee was appointed, under
the chairmanship of Professor Genevra Richardson to undertake
the first phase of the review. They were tasked to consider a
number of specific issues including how powers of compulsory care
and treatment might be extended to the community.
84. Professor Richardson submitted her report in July
1999. This took account of comments her committee had received
in response to the report they had circulated in April consulting
on their outline proposals.
85. The Government published proposals for a modern legislative
framework for mental health in a Green Paper Reform of the
Mental Health Act 1983 on 16 November 1999. These proposals
are out to consultation until 31 March 2000. The Green Paper is
broadly based on the framework suggested by the Committee, although
not all of their proposals are accepted.
86. The focus is on managing risk and providing better
health outcomes for patients in a way that strikes the right balance
between public safety and the rights of individuals. The key changes
proposed in the Green Paper include:
— Extension of compulsory powers to the community—When
implemented these proposals will for the first time extend powers
for compulsory care and treatment for those with severe mental
health problems beyond a hospital setting so that compulsory treatment
may take place in the community. In future, formal care and treatment
will be provided in the least restrictive environment that is
consistent with the need to ensure the health and safety of the
individual patient and the safety of other people.
— Independent decision-making—The Green Paper
proposes the establishment of a new tribunal to take decisions
on any proposals for compulsory care and treatment lasting longer
than 28 days. It will replace the current dual process of the
Mental Health Review Tribunal and managers' reviews.
— Clearer procedures—The current Mental Health
Act provides several routes into compulsory care and treatment.
The proposals in the Green Paper set out a single set of procedures
based on formal assessment before a compulsory care and treatment
order is applied. Separate procedures already apply for people
referred by the courts or from prison. This separation will remain
but will also be simplified.
— Principles—New legislation will be based
on a clear set of principles that will be included within the
new Act. The principles will cover: the preference, wherever appropriate,
for the use of informal care; the need to involve patients as
far as is possible in making decisions about their care; the need
to ensure the safety both of the individual and of other people;
and the need to ensure that compulsory care should be imposed
in the least restrictive environment that is consistent with safety.
87. The proposals for the reform of the Mental Health
Act are designed to provide a robust framework for compulsory
intervention, which keeps pace with modern patterns of care and
safeguards both the rights of patients and the safety of others.
88. The Government has allowed over four months for consultation
on the proposals in the Green Paper. The very detailed report
from the Expert Committee has also been made widely available.
Comments on the Government's proposals will be fully taken into
account in developing proposals for new mental health legislation
for England and Wales to put before Parliament.
LEGISLATION FOR
THE MANAGEMENT
OF DANGEROUS
PEOPLE WITH
SEVERE PERSONALITY
DISORDER
89. As mentioned earlier (paragraphs 66 to 71) the consultation
paper Managing Dangerous People with Severe Personality Disorder:
proposals for policy development sets out options for policy
development which involve both legislative and organisational
changes.
90. Option A maintains the current statutory framework
and service structures but would amend criminal justice and mental
health legislation. This would allow for greater use of discretionary
life sentences and would remove the "treatability criterion"
from the Mental Health Act for civil detainees. Services would
be provided in specialist facilities in both prisons (for offenders)
and secure mental health services (for civil detainees), but these
facilities could be drawn together by ring-fencing funding and
setting up a central agency for commission services for this group
in both prison and the health service.
91. Option B provides for new powers in civil and criminal
proceedings to provide for indeterminate detention of dangerous
people with severe personality disorder (including powers for
supervision and recall following detention). Those subject to
these new powers would have to be held in a new service that was
separately managed from mainstream prison and health services
provision.
92. The consultation period ended on 31 December 1999.
These responses will be considered alongside responses to the
Green Paper on reform of the Mental Health Act 1983.
CONCLUSIONS
93. This represents an ambitious agenda, developing modern
mental health services which are culturally appropriate and which
reflect the needs and wishes of service users and their carers.
94. The National Service Framework sets out national
standards and service models for local implementation with national
support. The milestones will ensure early delivery, but developments
must be soundly based to ensure sustainable change.
March 2000
| 
