Evidence submitted by Christopher Reynolds
(Def 22)
This submission gives details of the NHS Deficit
on the funding of mental health budgets in Hertfordshire and the
potential impact of up to £12 million reduction in funding
on services.
1. Following a family suicide in 1985 I
have been actively involved in the mental health provision in
Hertfordshire as a trustee for Mind in Dacorum, on the North West
Herts Community Health Council, as the lay member on the board
of the Dacorum Primary Care Group, and on many other committees.
2. I am currently vice-chair of the Hertfordshire
Partnership Patient and Public Involvement Forum. In this role
I represent the Forum on the Board of the Hertfordshire Partnership
NHS Trust (which provides mental health and learning disabilities
services), the Joint Commissioning Partnership Board (which commissions
mental health and adult care in Hertfordshire and involves eight
PCTs and the Hertfordshire County Council), and the Hertfordshire
County Council Health Scrutiny Committee.
3. I was actively involved in the Investing
in Your Mental Health consultation, the findings of which
were agreed in December 2005. This looked at how better primary
care and community services could improve recovery rates and reduce
the number of long-term disability patients and the demand for
expensive in-patient beds.
4. In making a submission to this committee
I am concentrating on the relevance to mental health issues in
Hertfordshire and when I criticise local management decisions
I am aware that national decisions and policies may have ruled
out more rational local actions.
5. A significant problem relates to the
acute hospitals—and the rejection of a consultation in the
late 1990s to centralise on a new site due to public pressure
from those who lived close to the hospitals. Multiple site working
on less than ideal locations is at least part of the financial
"cancer" which has infected the acute hospital budgets,
and spread to the PCTs. The result has been a comparative squeeze
on the mental health budgets, with the end of year expenditure
being a smaller percentage of the actual spend compared with the
start of year budget.
6. When the eight Hertfordshire PCTs were
set up in 2001 the Joint Commissioning Partnership Board allowed
them to delegate responsibility for mental health. While things
have improved with the SHA led Investing in Your Mental Health
consultation, the delegation arrangements meant that the subject
was comparatively ignored at the primary care level. Some PCT
Boards seem to have initially considered it as little more than
a black hole in the financial spread sheet. It seems that the
comparatively low profile of the medical aspects of mental health
at the PCT board level have made it "easier" to put
pressure on its finances.
7. Since it was formed in 2001 the Hertfordshire
Partnership Trust has balanced its books in every year. It income
has increased during this period (but at a slower rate than some
other areas of health in Hertfordshire) and it has been increasingly
under pressure to subsidize the overspend elsewhere. For 2006-07
the SHA advised the PCTs to apply a 5% top slice to all trusts—with
no medical risk assessment being made to see if this could be
done without significantly disadvantaging patients. HPT assess
that this brings the total "efficiency" and other cuts
it has been asked to make to £12 million over two years.
For those working in the voluntary sector there is good evidence
that some of the efficiency savings made in 2005-06 have proved
to be real cuts in the level of service to patients.
8. Because the decision to make a 5% top
slice came only a couple of months after the major Investing
in Your Mental Health consultation had been approved it was
clear that there would need to be a consultation. This was rushed
through on a shortened timescale, received overwhelming opposition
and £3.2 million of the cuts have been referred to the Secretary
of State by the County Council Scrutiny Committee. The cuts are
now in a state of limbo—which is no good for patients or
staff.
9. If cuts have to be made it is important
that one is honest about them. To present them as if viewed through
rose-coloured spectacles misleads both the public and also the
Secretary of State as to the real risks to patients and carers.
The following examples come from the consultation (I could give
many more)—but I am sure they are commonly used to misrepresent
the effect of cuts across the NHS.
9.1 Mental health support is provided
by many agencies and not just the NHS. It was assumed that other
agencies would have the spare capacity to provide services to
replace those which were being cut. However the PCTs knew full
well that voluntary sector services were already inadequate in
many parts of the county—and their funding was being reduced.
Nowhere were there any mentions of the quality of any replacement
service of patient support.
9.2 The consultation ignored what would
happen to patients between the time the cuts were made (immediately)
and the time other agencies could fund (where from???) and establish
replacement support services. This would be a period of significantly
enhanced risks.
9.3 The consultation specifically asked for
risks associated with each cut. Over sixty organisations from
user and care groups, through to clinicians in primary and secondary
care provided written submissions indicating significant risks
- ranging from increased suicide rates to cuts which would prove
to be false economies. These were all ignored - in some cases
without the area of perceived risk even being identified.
9.4 1984 newspeak type arguments, often
robbing Peter to pay Paul, were used to justify cuts. For example
continuing care services were transferred to Hertfordshire Partnership
Trust—but under-funded. This represented a cut of circa
£1 million pa in core mental health funding and a saving
of £3 million pa by the PCTs. The fact that the PCTs had
previously overspent was used as an argument for further cuts
on core mental health services.
10. The problem with this consultation,
and I suspect many others, is that the consultation was carried
out by managers with little first-hand understanding of mental
health (see para 6) and who were under orders to make the cuts
regardless. I would like the committee to consider the following
recommendation, to ensure that cuts in medical services which
could adversely affect patients are seen to be approved by suitably
qualified expert committees, and not just by managers.
10.1 When any consultation involves
cutting services for financial reasons the consultation document,
and the final response document, should contain signed reports
by the clinical governance committee of all relevant trusts (and
the equivalent from any relevant support agencies) relating to
patient safety and welfare issues.
11. The national weighting of per capita
payments protects the more needy geographical areas of the UK.
The committee might consider proposing a mechanism to protect
the interests of the more vulnerable members of society, so that
money is not taken from mental health and learning difficulties
to bail out overspending acute hospitals.
I will be very happy to provide further evidence
if requested.
Chris Reynolds
6 June 2006
| 
