Provision of NHS Mental Health Care Services
Health Committee Recommendations: Progress NHS Mental Health Services
Fourth Report: Provision of NHS Mental Health Services (HC 373) Published: 13 July 2000
Government Reply: Cm 4888 Published: October 2000
Government Response and Action
Recommendation A We agree with the Law Society that the appropriateness of any definition of mental disorder will depend on the purpose for which it is being used. We also agree that any criteria used for determining access to services should be far wider than those used to define the circumstances when compulsion may be permitted (para 25).
The Government's Green Paper Reform of the Mental Health Act 1983 made clear that we accepted the recommendation of the Expert Committee appointed to advise on the review of the Mental Health Act that there should be a broad definition of mental disorder in future mental health legislation. The purpose of this is to ensure that people who would benefit from the provisions of the new Act should not unwittingly be excluded. However we also accept that the process of assessment should be undertaken against much more narrowly defined criteria and that compulsory powers of care and treatment should only be used where thoroughly justifiable. Furthermore, as our recommendations make very clear, compulsory powers under proposed new legislation will only be used for any period longer than 28 days if they are approved by an independent tribunal. Access to mental health services more generally - including both primary and specialist care - is available to people with a wide range of mental disorders and will continue to be determined case by case on the basis of each individual's needs.
Recommendation B While we appreciate that stretched services need to set boundaries in order to be able to care for the patients on their case-load, we believe that, from the patient perspective, inflexible labelling is both unhelpful and often stigmatising. Given the fluctuating nature of mental illness, concepts such as "severe and enduring", while useful for targeting resources, must not be used inflexibly to restrict access. We recommend that when individuals are discharged from specialist services, such as those provided by community mental health teams, they should receive clear information on how they can easily re-access these services if their situation deteriorates (para 28).
It is vital that people with a mental health problem are able to obtain help quickly, according to their needs, and that decisions about treatment, care and onward referral are taken on the basis of a skilled needs assessment. Revised guidance on the Care Programme Approach, Effective Care Co-ordination in Mental Health Services: Modernising the Care Programme Approach, published last year, makes it clear that a patient should have information about who to contact in an emergency. NHS Direct will also, increasingly, provide a useful contact point for people with mental health problems who need to get back in touch with specialist services. The Department of Health fully agrees that individuals discharged from specialist services should receive clear information on re-accessing services. The Department will write to all Chief Executives of mental health services asking them to ensure that this happens in the light of the Committee's recommendation
Recommendation C Given the high incidence of co-morbidity of mental disorder and substance misuse, and the link between substance misuse, mental disorder and violence, we believe it is crucial that greater priority be given to this group of patients. We welcome the fact that the Department has been funding service development in this area, and intends to disseminate any lessons learned. We would also endorse the "practical steps" suggested by the Centre for Mental Health Services Development at King's College London, namely that the Department should: .Require joint working and coordination between mental health and substance misuse agencies, to address the complex social and clinical needs of this client group; .Require mental health services to take the lead for those people on enhanced CPA [Care Programme Approach] with a dual diagnosis; .Include working with people with a dual diagnosis as a requirement within the remit of assertive outreach services (para 33).
The Government agrees with the Committee's view that greater priority should be given to this client group: dual diagnosis has been given priority in the £4.5m programme for training in substance misuse recently approved by the Secretary of State in the current financial year. In Effective Care Co-ordination in Mental Health Services: Modernising the Care Programme Approach, we made it clear that people on the enhanced level of the Care Programme Approach are likely to have multiple care needs, including those related to substance misuse. The guidance makes clear that health and social services must identify a lead officer with authority to work across all agencies to deliver an integrated approach to the Care Programme Approach and Care Management on an individual basis. A care co-ordinator will have responsibility for co-ordinating care, keeping in touch with the service user, ensuring that the care plan is delivered and ensuring that the plan is reviewed as required. Those who find it difficult to engage with services clearly fall within the remit of assertive outreach services. The NHS Plan details further investment in assertive outreach - 220 teams will be in place by 2004, covering all 20,000 people in need of such services. The inclusion of people with a dual diagnosis in such services, and the need for mental health services to take the lead for those people with a dual diagnosis on enhanced Care Programme Approach, will be reinforced in guidance to health authorities and trusts.
Recommendation D The Centre also argued that the Department should extend the duty of partnership imposed on the NHS and local authorities by section 27 of the Health Act 1999 to include substance misuse and housing services. Section 27 requires NHS bodies and local authorities to "co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales". We would understand this to include local authority responsibilities for housing and substance misuse provision, as both have a clear input into the "health and welfare" of local residents. We recommend that the Department should issue guidance, clarifying this position (para 33).
The existing duties of partnership, imposed by the Health Act 1999 and by the Crime and Disorder Act 1998, already covers this client group. The duty of partnership covers all of the local authority's responsibilities as they contribute to the health and welfare of the local community - this includes housing. This partnership is reflected in the local Health Improvement Programme, which is developed with all key stakeholders and sets out how the health authority and local authority will deliver the national priorities of Saving Lives: Our Healthier Nation and other national targets, as well as local priorities for health. Each Health Improvement Programme is underpinned by a Joint Investment Plan for Mental Health outlining the range of action being taken across the health and local authority on mental health. Partnerships involving housing, substance misuse provision, education and other key local services will have been identified within this planning process to deliver key outputs for the local population. The Crime and Disorder Act 1998 requires partnership between local authorities, the Criminal Justice System and the NHS around Community Safety, and much work on substance misuse is located in that forum. Drug Action Teams, in particular, will have identified solutions using the whole range of partners at a local level. The proposed new National Treatment Agency for substance misuse will further strengthen cross-sectoral working at the local level. We will ensure that these existing duties are made clear when we issue guidance next year on the further development of Local Implementation Plans.
Recommendation E We would also draw to the Department's attention the difficulties being experienced by some patients with a dual diagnosis of learning disability and mental disorder. While this group of patients may not be as visible as those with the dual diagnosis of substance misuse and mental disorder, it is clear that services are far from adequate. We recommend that the Department should issue guidance highlighting the needs of this group of individuals and encouraging mental health and learning disability services to work much more closely and co-operatively together (para 34).
The Department has already taken steps to highlight the needs of this group of people. The Mental Health National Service Framework focuses on all adults of working age - including people with learning disability who have a mental illness. Signposts for Success - good practice guidance on commissioning and providing health services for people with learning disabilities - was published in 1998 and includes a section on mental health. The Department is also currently developing a national Learning Disability Strategy to be launched by the end of the year. This will set out a vision for learning disability shared across health, education, employment and social services. We are not looking for a radical departure from existing policy. We do, however, want to address a number of problems with services stemming from difficulties in implementation and inconsistent delivery - for example in the availability, coverage and quality of services on offer. The strategy will take account of the needs of people with learning disability who also have other conditions e.g. autism, mental health problems, challenging behaviour, sensory impairment. The Learning Disability Strategy health sub-group has been looking at issues such as the interface between specialist learning disability and generic services.
Recommendation F There have been undeniable failures in service since the policy of care in the community was first launched. But we feel that it is both misleading and unhelpful to state that the policy of care in the community has failed, as the Government has done on a number of occasions. We urge the Government to make clear in the language it uses (as indeed it has already done in the policies it has embraced), that care in the community is a positive policy and one which it supports (para 39).
The Government has never given any indication that it does not support the provision of effective community mental health services. But we would have been failing in our duty if we had not made clear our view that, in practice, a number of people were let down, sometimes with tragic results, by the piecemeal way in which the policy of community care was implemented and by the lack of suitable support services. With the benefit of hindsight we can say that the initial plans for introducing community care were over-optimistic and did not anticipate a range of problems which have contributed to failures in implementation. The key issue, however, is to learn the lessons from these past failures and to take steps to rectify them. We have done much in the last three years to demonstrate our commitment to providing a comprehensive and effective range of modern community and in-patient services, which are based upon evidence of effectiveness. The debate is no longer about institutionalisation versus community care but about how to assure provision of a range of services which services users and carers have told us they want and need. The NHS Plan will deliver these services, ensuring that all service users will have access to crisis resolution teams, all people who need the assertive outreach approach will be in receipt of such services and that additional investment will be provided in primary care and early intervention.
Recommendation G Work is clearly of real importance to the many people with mental health problems who want to regain power over their own lives. Help with training, education and finding work is crucial, as is the provision of information to employers to encourage them to support and retain people with mental health problems in employment. We believe that the employment service provided by South West London and St. George's NHS Trust provides an invaluable route back to "ordinary life" for people who have experienced mental health problems. We were pleased to hear that several other NHS trusts are developing similar schemes, and recommend that all trusts providing mental health services should consider how they can provide similar services to their users.
A key objective of the Government is to enable all disabled people, including those with mental health problems, to make the most of their abilities at work and in the wider society and, as the largest public sector employer in the country, the NHS should also be making a significant contribution in delivering this agenda. The South West London and St George's Mental Health NHS Trust user employment project is an excellent example of such initiatives. The Equal Opportunities Unit of the NHS Executive recently funded an evaluation of certain aspects of the user employment project to facilitate the production of a "Good Practice Guide" to assist other trusts wishing to establish projects. So far, seven other trusts have established similar projects and efforts to establish at least a dozen more are in progress. In addition, the NHS Executive intends to publish guidance for NHS managers on the employment of people with mental health problems in the NHS in the near future. It is also important to ensure that an equally high priority is given to placing people with mental health problems in ordinary employment. Talent to Work and Pentreath Industries in Cornwall work in partnership with local training, health and related organisations to promote social inclusion by promoting work, greater independence and changing employers attitudes. Pentreath Industries and Talent to Work are excellent examples of successful job placement schemes with support. In addition, the Chancellor, in his budget statement, announced Job Retention Pilots to test the relative effectiveness of different employment and health strategies in reducing the number of people forced to give up work through prolonged illness or disability. Social services also have an important role to play in supporting people with disabilities in relation to employment. In late 1999 the Department of Health, in conjunction with the Department for Education and Employment and the Department for Social Security launched Welfare to Work Joint Investment Plans.
Recommendation H It is clear to us that a far more "joined-up" response is necessary from statutory agencies if users of mental health services are to be properly supported in the community. We do not believe it is acceptable or realistic to expect vulnerable individuals to deal with complex systems without support, especially where it is clear that these systems are ill equipped to deal with fluctuating illness. We would encourage the Department to give particular attention to the idea of a dedicated worker, who would be responsible for liaising between the various statutory agencies and ensuring that users of mental health services, living in the community, have access to the benefits and other services to which they are entitled. We recommend that the Disabled Person's Tax Credit should be extended to those working fewer than 16 hours per week and that the period for which benefit claims may be suspended, rather than closed, when individuals leave benefit to go into work, should be extended to a year. We also endorse the recommendations of our colleagues on the Social Security Committee, that the doctors undertaking assessments for disability benefits should receive better training on mental health issues with specialists available for dealing with more complex cases.
We already have in place a care co-ordination policy which requires health and local authorities to appoint a Lead Officer responsible for strategic oversight and development of the care co-ordination process across both agencies. Additionally each service user has a care co-ordinator responsible for co-ordinating care across agencies. A number of NHS Trusts and social services departments also employ workers specifically to ensure that users of mental health services have access to benefits and other services. We will be considering how to spread such good practice to help service users to find their way around the welfare system.
Disabled Person's Tax Credit
The Disabled Person's Tax Credit was introduced to help disabled people in work by providing support through the tax and benefit systems. Therefore, a distinction must be made as to what counts as work, with in-work support, and what is essentially income support - with some earnings disregard. The question then becomes whether 16 hours is the right point to make that distinction. The Government believes that, as 16 hours equals two full time days or three to four part time days a week, it provides a clear commitment to work. However, we will keep this issue under review as part of our continuing development of tax credits.
Claims to Incapacity Benefit separated by a period of 52 weeks or less are already linked together and count as one period for people who leave the benefit to go into paid work or employment training.
Assessments for Benefits
The Government's reply to the recent Social Security Select Committee Report on Medical Services recognises the particular difficulties which may arise when assessing claimants with mental health problems, and the need for sensitive handling of these claimants. The reply made it clear that Medical Services are committed to providing additional training over the coming year for all doctors. This will cover the question of appropriate behaviours and attitudes in dealing sensitively with people with disabilities in general, and guidance on the assessment of people with mental health problems in particular.
Recommendation I We welcome the fact that the DoH has spoken of "pulling all the necessary levers" to ensure that mental health services remain a priority. We remain unsure, however, who is in a position to "pull the levers" when action is required across Government Departments. We were encouraged to hear that the DoH and the Department of the Environment, Transport and the Regions have been working together on joint guidance, although the content of that guidance has not yet been made public. We also hope the newly appointed mental health "national director" will be in a position to highlight areas of work that require a cross-departmental approach. Nevertheless, we remain concerned that more formal arrangements, such as the existence of a dedicated mental health Cabinet sub-committee, are not in place to ensure the necessary co-operation between Departments (para 48).
Through the New Deal and other joint ventures between the Department of Health, the Department of Social Security and the Department for Education and Employment, the Government is already looking beyond the confines of systems and is working in a more joined-up way to focus on what happens to individuals. The remit of the Home and Social Affairs Cabinet Committee enables it to discuss mental health issues, as and when necessary. The Cabinet Office keeps Cabinet Committee structures under review, and will take account of the need, identified by the Health Select Committee, to ensure cross-Departmental co-operation on mental health issues. The remit of the National Director for Mental Health, Professor Louis Appleby, is to work closely with health and social care professionals and senior officials across Government, to drive through the national programme for improving mental health services. To this effect, he has already met Keith Hellawell, the UK Anti-Drugs Co-ordinator, and senior officials from Department for Education and Employment, Department of Social Security and will soon meet the head of the Rough Sleepers Unit. Professor Louis Appleby will also provide clinical leadership and galvanise expertise in the mental health field.
Recommendation J We were impressed with the way NHS and social services staff have clearly responded to the challenge of working together to provide a more coherent service for the service user. Nevertheless, we remain unconvinced that it is sensible to retain two separate organisations, each with their own hierarchical structures, when the aim is to deliver a seamless service for the public. We believe that the evidence we heard gives additional weight to the recommendation we made in an earlier inquiry, that health and social services departments should be merged into single entities (para 51).
We are pleased that the Committee has recognised the great improvements in recent years in joint working between health and social care staff and organisations. The Government is determined to overcome the old divisions between health and social services in order to provide more coherent and seamless services. What is clear is that there will be a range of models for the provision of mental health services. There are a significant number of reorganisations planned around the country creating single, specialist mental health trusts and ministers will wish to see progress on integration locally of mental health and social care. The Government wishes to see widespread use of the new partnership freedoms set out in the Health Act 1999 as a means of delivering more integrated health and social care services. These new discretionary powers facilitate the pooling of funds, lead commissioning and integrated provision. The NHS Plan makes clear that, to ensure that mental health and social care provision can be integrated properly, statutory powers will be taken to permit the establishment of combined mental health and social care trusts.
Recommendation K We welcome and endorse the Secretary of State's clear statements on the need to make the NHS workforce more representative of the communities it serves. We were also impressed with some of the examples of good practice which were described to us. Nevertheless, we remain concerned that many patients from ethnic minority backgrounds clearly experience a far from adequate service, for a variety of reasons. Our concerns are heightened by the fact that these problems have been recognised for some years, but that change remains slow in coming. We note that discussions about institutional racism are current in many public services and believe that mental health services should not be excluded from these debates. Many of our recommendations below on issues such as user involvement and advocacy may be particularly relevant to ethnic minority patients. In addition, however, we would make the following specific recommendations. Firstly, the DoH's requirement that all NHS trust boards should undertake training on management of diversity should be expanded, so that all front-line NHS staff receive training on race awareness. Secondly, all educational bodies providing pre-qualification training to health professionals should be required to include training on cultural and racial issues as part of their core curriculum. Thirdly, all NHS trusts should designate a board member to take the lead on issues of race and culture within their trust and to ensure that active policies are in place to champion the needs of the ethnic minority groups in their area. Fourthly, the Department should ensure that trusts have access to a comprehensive network of interpreting services, if necessary providing grants to the voluntary sector to enable the necessary services to be developed. Fifthly, given that there is clear evidence that ethnic minority groups currently access services late, we recommend that priority is given to developing early intervention services, such as easy access to counselling. We believe that it is as important for trusts which do not include large minority ethnic populations in their catchment area to act on these recommendations as it is for those which do: the mobility of NHS staff means that staff trained in one part of the country may end up working in very different environments a few years later; and the vulnerability of minority populations to inappropriate services is arguably greater when they represent a tiny proportion of the local population (para 58).
The Government recognises that challenging institutional discrimination is a responsibility for those who lead and deliver mental health services, as in all other areas of public services. The proposed amendments to the Race Relations Act are both a principled and practical step forward by the Government to ensure that public bodies, including all NHS bodies, meet the needs of the whole community without discrimination. When the Secretary of State announced the Department of Health's action plan on race equality in January 2000, he acknowledged that "too often in the past people from black and minority ethnic communities have found that their needs were not adequately met within the mainstream of our services". The NHS Plan has set out the principles and measures for tackling such inequalities and disadvantage, emphasising that: .The NHS will shape its services around the need and preferences of individual patients, their families and their carers, including challenging racial discrimination .The NHS will respond to different needs of different populations Finding out the views of users and responding to their needs will be integral to modernising the NHS. The Mental Health Task Force, the work of the Modernisation Agency, and new performance management arrangements will set a clear framework for accelerating action to improve access and raise service standards for black and minority ethnic people. Progress is further supported by the Department's service wide programmes to tackle racial harassment in the NHS, to improve ethnic monitoring, to survey the experience of staff, to set targets for achieving a more representative leadership and diverse workforce, systematically to bring race expertise into policy development and to consult more widely with black and minority ethnic users and communities. We believe this extensive programme of work sets a clearly marked out development pathway for securing mental health services that provide responsive, fair, accessible, and appropriate services for black and minority ethnic users. At the same time we accept the need to take action on the Committee's specific recommendations as significant components of this overall drive for change. (See Cm 4888 for full response)
Recommendation L We believe that it is crucial that users and carers are involved in all aspects of service delivery. User involvement in setting the outcomes which services aim to achieve should be central in service planning. It is clear that such involvement can only be more than lip-service if the professionals involved are prepared to regard users and carers as equal partners, to involve them early on in the process when decisions are actually being made, and, sometimes, to hear uncomfortable views without feeling personally or professionally threatened. We appreciate that this will involve, for some, a new approach, and strongly recommend that both the pre- and post-qualification training of all health and social care professionals should include structured input from users as part of a national programme (para 62).
The Government accepts this recommendation. In the Foreword to the Interim Report of the National Service Framework Workforce Action Team published in September 2000, Ministers make it quite clear that in delivering mental health services the focus should be on the service user. The family or carers' needs should be taken into account as well. As part of the Workforce Action Team programme of work, each NHS and Social Care Inspectorate Regional Office is being asked to map all current education and training in support of the implementation of the National Service Framework for Mental Health. This will include information about the level of input to education and training by users and carers. By this means the local consortia and the Department can obtain a picture about the extent and level of user and carer involvement with a view to seeing what changes might need to take place in designing and delivering training and education. The Government has re-affirmed the central role of service users whereby the NHS Plan, which looks at the wider context rather than just mental health, sets out a clear vision that the health service should be designed around the needs of individual patients. For example, the Plan mentions the requirement to establish an independent local advisory forum to provide a sounding board for determining health priorities and policies as well as increasing lay membership of a variety of advisory and regulatory bodies.
Recommendation M We agree that, the more mental health services are able to "get the basics right", the easier it will be to challenge the fears surrounding mental ill health. We would encourage the inclusion of discussions of mental illness in the school curriculum. But we also call upon the Government to take a more proactive approach in challenging the perceived link between mental disorder and dangerousness. We recommend that the Government should fund a high profile public education campaign on similar lines to that supported recently by the Australian government which included extensive television, cinema and outdoor advertising to educate the public about the realities of mental illness. We also believe that the Government's own current emphasis on risk conveys a highly misleading message to the public. We return to the subject of risk later in this Report.
Mental Health in the School Curriculum
The Government recognises the importance of raising awareness of mental health issues in a range of settings, including schools. The Department for Education and Employment has introduced a recommended framework for personal social and health education, taking effect from September 2000. The personal social and health education curriculum is supported by various elements of the Government's Healthy Schools Programme.
Raising Public Awareness
National Service Framework standard one requires health and social services to develop coherent strategies to promote mental health for all, working with individuals and communities, and to combat discrimination against individuals and groups with mental health problems, and promote their social inclusion. In support of this the Department is in the process of developing a major anti-discrimination campaign, on similar lines to that undertaken in Australia. The contract to do this will be awarded before Christmas, and will challenge public stereotypes of mentally ill people as violent or unpredictable. Given local authorities' new responsibility for promoting the social, environmental and economic well being of the local community, local authorities will be active partners in delivering strategies to reduce discrimination. The Department of Health funds the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. This inquiry provides national data on homicide and suicide by people in contact with mental health services. It's findings dispel the public misconceptions that the great majority of mentally ill people are violent. We will continue to work in partnership with mental health service users and other agencies with the aim of educating the general public about mental health issues to reduce stigma and discrimination. The Government does not, however, accept the view of the Committee that its public comments on the issue of risk have been misleading to the public. There is a delicate balance to be struck here. On the one hand there is no doubt but that the huge majority of people with mental health problems represent no threat whatever to the public, and this response has already outlined some of the action being taken by the Government to raise public awareness of this. On the other hand, it is undeniable that there exists a small group of people with a form of mental disorder - including, but not restricted to, some people with a severe personality disorder - whose actions demonstrate that they may pose high risk to the safety of other people. To recognise and meet both the treatment needs of this small group, and the public's need for protection, does not run counter to the general thrust of the need to reduce stigma and discrimination against people with all forms of mental disorder: indeed, it is only if the public perceives that it is being adequately protected from those who present a threat that efforts to reduce stigma and discrimination against the great majority are likely to succeed. only if the public perceives that it is being adequately protected from those who present a threat that efforts to reduce stigma and discrimination against the great majority are likely to succeed.
Recommendation N We were impressed with the arrangements described by the DoH for the implementation of the National Service Framework at local level and in particular with the requirement to produce detailed gap analyses so that there is clear information on where services need to be improved. We urge the Department to ensure that this information is made publicly available, at both local and national level. We would also emphasise the need for regular monitoring of progress within the Framework. If a need for more specific guidance on prioritisation emerges from that monitoring, then such guidance should be provided at national level (para 69).
A comprehensive mapping of health and social care mental health services is currently being carried out to create a robust baseline position for purposes of planning, benchmarking, performance monitoring and performance management of the implementation of the mental health national service framework. The exercise covers the full range of mental health services for adults of working age up to 65, across agencies in statutory, voluntary and private sectors and covering the whole spectrum of care from severe mental illness to services for people with mild and moderate mental health problems. Information will be collected on the types of services available, their functions and what they are called; the sectors and the providers; the target groups; the population served; and the numbers of staff employed categorised by disciplines. Local Implementation Teams have been established within the regions. Currently, these teams are co-ordinating the collection and collation of the mapping data provided by health authorities, local authorities and Trusts. This data will be available for local, regional and national monitoring with a view to mapping service provision and, in due course, to measuring progress. Routine maintenance of local databases will provide an opportunity to track shifts in patterns of services in response to identified needs and gaps in service provision. In the first phase of National Service Framework implementation monitoring, Local Implementation Teams produced Local Implementation Plans which show how each locality plans to implement the National Service Framework. In the second phase, a self-assessment framework is being completed by Local Implementation Teams. This, together with mapping data, will provide sets of locally completed and shared health and social care information that can be used by all concerned for regular monitoring of progress in National Service Framework implementation. Data from the mapping and the Regional monitoring will be available in electronic format and made available on request.
Recommendation O While the Modernisation Fund money is clearly welcome, we believe that it is the overall level of funding going to mental health services via Health Authority allocations that will be more significant in ensuring that the National Service Framework becomes a reality and not merely an aspiration. We urge the Secretary of State to ensure that mental health services do indeed get their "fair slice of the cake". We also recommend that the Department should monitor the very disparate levels of spending on mental health services between Health Authorities, and where necessary draw Authorities' attention to spending which falls well below the national average (para 71).
The Government agrees that mental health services should receive a 'fair slice of the cake'. Discussions are currently taking place for allocating new investment for 2001/02 for all non-centrally funded initiatives in mental health that will achieve both 'fair shares' and leverage to promote change. Significant investment has been provided for the development of mental health services, as we mentioned in the introduction. The Department of Health is undertaking a detailed benchmarking exercise and will closely monitor the consistent development of additional mental health services across the country throughout the period of the NHS Plan. In addition to this funding, allocations are also made to local authorities to ensure implementation of the National Service Framework. The Mental Health Grant provides 70% core funding with local authorities being required to invest at least 30% of the total. Additional monies are also allocated at 100% to all local authorities for them to extend their services to meet the criteria set out in the National Service Framework. Local authorities also spend some of the resources provided through the revenue support grant on mental health services. The Department holds data on mental health spend per head by health authority (crude population and weighted population), which allows us to identify those health authorities who are spending below the national average. However, there is no clear relationship between the level of mental health spend and the quality of service. In some areas with comparatively low levels of spend, excellent services are provided. Where there is a clear relationship between poor quality of service and low levels of spend, the Department of Health and Regional Offices will take the appropriate action.