House of Commons - Health

Select Committee on Health Memoranda

5. ACTIVITY, PERFORMANCE AND EFFICIENCY (continued)

5.7.3 How many people were admitted to (a) NHS facilities and (b) independent hospitals under the 1983 Mental Health Act in 2004-05, by Trust and type of section? (Q84)

ANSWER

NUMBER OF PEOPLE SECTIONED BY TRUST AND THE TYPE OF SECTION

1. Table 84a presents information on the number of admissions to NHS facilities (Trusts, Care Trusts and Primary Care Trusts) where the patient was detained under the 1983 Mental Health Act at admission, and on the number of occasions a patient already in hospital as an informal patient was placed under detention. Table 84b shows similar information for independent hospitals, as defined by the Care Standards Act 2000, in each SHA area (these data were forwarded to the Department directly from the independent hospitals). There were a total of 25,100 formal admissions to NHS facilities in 2004-05 with a further 1,600 formal admissions to independent hospitals. Another 23,400 changes from informal to formal detentions were recorded (23,000 in the NHS and 400 in independent hospitals). There may be double counting of patients where a patient has been detained more than once in the year.

NUMBER OF PEOPLE SECTIONED IN PROPORTION TO SHA POPULATION

2. It is not possible to produce reliable figures on the numbers of people sectioned by SHA area of residence. The data provided on the aggregate return is provider-based and does not include geographic information on the area of residence. The Hospital Episode Statistics (HES) system does have some information on patients treated by area of residence, but the quality of data is poor on admissions of formally detained patients.

3. It is possible to look at the variation in the rate of psychiatric activity by Strategic Health Authority area of residence. Table 84c shows 2004-05 rate of consultant episodes varied from 2.99 to 5.85 per 1,000 population, with an average of 4.09 per 1,000 population. This does not imply similar variations in the rates for those sectioned.

NUMBER OF PEOPLE SECTIONED IN PROPORTION TO ADMISSIONS

4. In England, in 2004-05, there were 26,700 formal admissions to hospital (including high security hospitals and independent hospitals) under the Act and a further 23,400 changes from informal status to detention where patients were already in hospital. A patient subject to more than one period of detention under the Act during the year will be counted in these figures each time they are admitted to hospital under detention or have a change from informal status while in hospital. It is therefore not possible to determine the number of people sectioned. Around 14.2% of all admissions (estimated as 188,400) under psychiatric specialities in NHS hospitals in 2004-05 were formal admissions (26,700).

APPEALS

5. The Mental Health Review Tribunal is an independent judicial body that hears applications and references by and on behalf of patients detained under the Mental Health Act 1983 as amended by the Mental Health (Patients in the Community) Act 1995. This includes patients admitted for assessment and/or treatment, hospital orders, guardianship, after-care under supervision, and restricted patients who have come through the courts or transferred to hospital from prison. In some cases the nearest relative can also apply for the patient's detention to be reviewed. Most hearings are a result of applications by the patient or the patient's legal representative.

6. The act places a duty on Hospital Managers to refer a case to the tribunal at the end of specified periods where a patient has not had a hearing during that time. The Home Secretary in restricted cases is also obliged to refer cases to the Tribunal periodically and has a discretion to refer a patient's case at any time.

7. In the financial year 2005-06, there were 20,510 applications and references for appeals. During the same period 10,090 cases were aborted mostly because the patient was discharged by the hospital or the application was withdrawn before the hearing. There were 10,420 decided cases resulting in 1,570 discharges (absolute, conditional, deferred or delayed).

Table 84a

ADMISSIONS TO NHS FACILITIES UNDER THE MHA 1983 AND CHANGES FROM INFORMAL TO DETAINED STATUS WHILE IN HOSPITAL, ENGLAND: 2004-05(1)


			Numbers
	Admitted to hospital under Section	Subject to Section after admission(1)	Total detentions in hospital

England	25,113	22,957	48,070
North East	1,170	862	2,032
County Durham and Darlington Priority Services	253	87	340
Gateshead Health	9	14	23
Newcastle Upon Tyne Hospitals	5	4	9
Newcastle, North Tyneside and Northumberland Mental Health	340	238	578
Northgate and Prudhoe	53	17	70
Northumbria Health Care	16	39	55
South Of Tyne and Wearside Mental Health	220	283	503
Tees and North East Yorkshire	274	180	454
North West	3,226	4,078	7,304
Five Borough Partnership	283	423	706
Bolton Salford and Trafford Mental Health	465	428	893
Calderstones	14	5	19
Central Manchester and Manchester Children's University Hospitals	0	0	0
Cheshire and Wirral Partnership	342	552	894
Lancashire Care	591	550	1,141
Manchester Mental Health and Social Care Trust	523	433	956
Mersey Care	254	535	789
Morecambe Bay PCT	135	221	356
North Cumbria Acute Hospitals	2	4	6
North Cumbria Mental Health and Learning Disabilities	99	113	212
North West Surrey Mental Health NHS Partnership Trust	76	203	279
Pennine Care	439	608	1,047
Salford PCT	0	0	0
Southport and Ormskirk Hospital	3	3	6
Yorkshire and Humber	1,925	2,051	3,976
Barnsley PCT	76	102	178
Bradford District Health and Social Care Trust	265	231	496
Craven Harrogate & Rural District PCT	49	35	84
Doncaster and South Humber Healthcare	237	400	637
Hambleton and Richmondshire PCT	32	37	69
arrogate Health Care	1	1	2
Humber Mental Health Teaching	195	166	361
Leeds Mental Health Teaching	332	311	643
Leeds Teaching Hospitals	0	31	31
Rotherham PCT	0	1	1
Selby and York PCT	103	71	174
Sheffield Care Trust	227	152	379
Sheffield Children's	1	0	1
South West Yorkshire Mental Health	406	510	916
York Health Services	1	3	4
East Midlands	1,903	1,567	3,470
Chesterfield PCT	24	5	29
Derbyshire Mental Health Services	340	456	796
High Peak and Dales PCT	7	6	13
Leicestershire Partnership	302	384	686
Lincolnshire Partnership	204	134	338
North Eastern Derbyshire PCT	9	10	19
Northampton General Hospital	1	5	6
Northamptonshire Healthcare	384	141	525
Nottinghamshire Healthcare	632	426	1,058
West Midlands	2,848	1,828	4,676
Birmingham and Solihull Mental Health	760	593	1,353
Birmingham Children's Hospital	20	5	25
Coventry Teaching PCT	208	149	357
Dudley Beacon and Castle PCT	95	66	161
Dudley South PCT	2	0	2
Heart Of England NHS Foundation Trust	0	4	4
Herefordshire PCT	59	85	144
North Staffordshire Combined Healthcare	226	188	414
North Warwickshire PCT	114	57	171
Sandwell Mental Health NHS Social Care Trust	164	75	239
Shrewsbury and Telford Hospitals	15	2	17
Shropshire County PCT	356	130	486
Solihull PCT	0	0	0
South Birmingham PCT	0	0	0
South Staffordshire Healthcare	214	202	416
South Warwickshire PCT	101	44	145
Walsall Teaching PCT	168	51	219
Walsall Hospitals	2	6	8
Wolverhampton City PCT	126	74	200
Worcestershire Mental Health Partnership	218	97	315
East of England	2,263	1,868	4,131
Bedfordshire and Luton Community	299	177	476
Cambridgeshire and Peterborough Mental Health Partnership	294	225	519
Colchester PCT	14	0	14
Hertfordshire Partnership	307	240	547
Norfolk and Waveney Mental Health Partnership	402	189	591
Norfolk and Norwich University Hospital	0	28	28
North Essex Mental Health Partnership	388	497	885
Norwich PCT	6	1	7
South Essex Partnership	268	216	484
Suffolk Mental Health Partnership	239	245	484
West Norfolk PCT	46	50	96
London	5,598	5,555	11,153
Barnet, Enfield and Haringey Mental Health	681	509	1,190
Barts and The London	5	23	28
Brent Teaching PCT	2	2	4
Camden and Islington Mental Health and Social Care Trust	548	146	694
Central and North West London Mental Health	656	1,111	1,767
East London and The City Mental Health	542	722	1,264
Enfield PCT	63	8	71
Hillingdon PCT	95	157	252
King's College Hospital	2	6	8
Kingston Hospital	0	18	18
North East London Mental Health	427	534	961
Oxleas	258	255	513
South London and Maudsley	1,143	996	2,139
South West London and St George's Mental Health	525	502	1,027
University College London Hospitals NHS Foundation Trust	0	4	4
West London Mental Health	651	558	1,209
Westminster PCT	0	4	4
South East	3,943	3,209	7,152
Berkshire Healthcare	459	203	662
Buckinghamshire Hospitals	1	7	8
Buckinghamshire Mental Health	172	123	295
East Hampshire PCT	59	31	90
East Kent NHS and Social Care Partnership Trust	251	379	630
East Sussex County	251	189	440
Fareham and Gosport PCT	1	1	2
Hampshire Partnership	478	366	844
Isle Of Wight Healthcare	128	31	159
Milton Keynes PCT	112	77	189
Oxford Radcliffe Hospital	3	5	8
Oxfordshire Learning Disability	4	2	6
Oxfordshire Mental Healthcare	365	195	560
Portsmouth City Teaching PCT	129	66	195
South Downs Health	255	151	406
Southampton University Hospitals	0	26	26
Surrey Hampshire Borders	120	236	356
Surrey Oaklands	182	222	404
West Kent NHS and Social Care Trust	525	604	1,129
West Sussex Health and Social Care	447	291	738
Winchester and Eastleigh Healthcare	1	4	5
South West	2,237	1,939	4,176
Avon and Wiltshire Mental Health Partnership	790	385	1,175
Bath and North East Somerset PCT	1	5	6
Cornwall Partnership	247	185	432
Devon Partnership	330	305	635
Dorset Health Care	212	456	668
Gloucestershire Partnership	244	146	390
North Bristol	0	9	9
North Dorset PCT	58	132	190
Plymouth Hospitals	11	19	30
Plymouth PCT	115	161	276
Royal Cornwall Hospitals	0	16	16
Salisbury Health Care	4	4	8
Somerset Partnership NHS and Social Care Trust	224	110	334
Swindon and Marlborough	1	6	7

Source: KP90.

Footnotes:

1. Includes all changes from informal status to detention under the Act, and detentions where the patient was initially brought to hospital under Section 136 (Place of Safety Order).

2 The high security psychiatric hospitals are now the responsibilities of NHS Trusts.

3 Following transition of data from the Department of Health to the NHS Information Centre for health & social care, including subsequent data refresh, there is an apparent discrepancy of 23 cases out of a total of 26,752. This represents 0.08% of the total cases.

Table 84b

ADMISSIONS TO INDEPENDENT HOSPITALS UNDER THE MHS 1983 AND CHANGES FROM INFORMAL TO DETAINED STATUS WHILE IN HOSPITAL, ENGLAND: 2004-05(1)


numbers	Admitted to hospital under Section	Subject to Section after admission(1)	Total detentions in hospital

Independent Hospitals by GOR and SHA area
England	1,616	400	2,016
North East	19	5	24
County Durham and Tees Valley SHA	18	4	22
Northumberland, Tyne and Wear SHA	1	1	2
North West	216	57	273
Cheshire and Merseyside SHA	13	1	14
Cumbria and Lancashire SHA	26	10	36
Greater Manchester SHA	177	46	223
Yorkshire & Humber	116	17	133
North and East Yorkshire and Northern Lincolnshire SHA	81	17	98
South Yorkshire SHA	1	0	1
West Yorkshire SHA	34	0	34
East Midlands	168	17	185
Leicestershire, Northamptonshire and Rutland SHA	105	17	122
Trent SHA	63	0	63
West Midlands	67	7	74
Birmingham and the Black Country SHA	21	1	22
Shropshire and Staffordshire SHA	43	4	47
West Midland South	3	2	5
East of England	84	16	100
Bedfordshire and Hertfordshire SHA	0	0	0
Essex SHA	22	14	36
Norfolk, Suffolk and Cambridge SHA	62	2	64
London	711	189	900
North Central London SHA	34	30	64
North East London SHA	286	66	352
North West London SHA	255	48	303
South East London SHA	104	35	139
South West London SHA	32	10	42
South East	199	80	279
Hampshire and Isle of Wight SHA	48	26	74
Kent and Medway SHA	6	6	12
Surrey and Sussex SHA	47	39	86
Thames Valley SHA	98	9	107
South West	36	12	48
Avon, Gloucestershire and Wiltshire SHA	26	12	38
Dorset and Somerset SHA	2	0	2
South West Peninsula SHA	8	0	8

Source: KP90.

Footnotes:

1. Includes all changes from informal status to detention under the Act, and detentions where the patient was initially brought to hospital under Section 136 (Place of Safety Order).

2. Due to the transition of data from Department of Health to the Information Centre for health and social care and following data refresh there is a discrepancy of 23 cases out of a total of 26,752. This represents a 0.08% of the total number of cases.

Table 84c

ALL CONSULTANT EPISODES(1) OF PATIENTS WITH MENTAL ILLNESS BY STRATEGIC HEALTH AUTHORITY(2) OF RESIDENCE, 2004-05(3)


		Total	Rate per 1,000 population(4)
		205,803	4.09

Q20	Avon, Gloucestershire and Wiltshire Strategic HA	7,144	3.22
Q02	Bedfordshire and Hertfordshire Strategic HA	4,919	3.01
Q27	Birmingham and the Black Country Strategic HA	8,196	3.60
Q15	Cheshire and Merseyside Strategic HA	9,926	4.22
Q10	County Durham and Tees Valley Strategic HA	4,575	4.00
Q13	Cumbria and Lancashire Strategic HA	8,314	4.31
Q22	Dorset and Somerset Strategic HA	5,848	4.78
Q03	Essex Strategic HA	8,114	4.93
Q14	Greater Manchester Strategic HA	10,918	4.30
Q17	Hampshire and Isle of Wight Strategic HA	9,641	5.32
Q18	Kent and Medway Strategic HA	4,853	2.99
Q25	Leicestershire, Northamptonshire and Rutland Strategic HA	7,262	4.54
Q01	Norfolk, Suffolk and Cambridgeshire Strategic HA	8,752	3.88
Q11	North and East Yorkshire and Northern Lincolnshire Strategic HA	5,211	3.16
Q05	North Central London Strategic HA	7,240	5.85
Q06	North East London Strategic HA	8,213	5.31
Q04	North West London Strategic HA	7,071	3.83
Q09	Northumberland, Tyne & Wear Strategic HA	6,061	4.37
Q26	Shropshire and Staffordshire Strategic HA	5,566	3.71
Q07	South East London Strategic HA	8,623	5.68
Q08	South West London Strategic HA	6,306	4.74
Q21	South West Peninsula Strategic HA	7,146	4.40
Q23	South Yorkshire Strategic HA	5,317	4.17
Q19	Surrey and Sussex Strategic HA	10,147	3.91
Q16	Thames Valley Strategic HA	6,540	3.07
Q24	Trent Strategic HA	9,328	3.46
Q28	West Midlands South Strategic HA	5,587	3.57
Q12	West Yorkshire Strategic HA	8,985	4.26

Source: HES.

APPEALS

5.7.4 How many patients with (a) mental illness and (b) learning difficulties have been resident in each high secure hospital in each year since 1997? Are any data available for medium security hospitals and prisons? (Q85)

ANSWER

1. Table 85a and Table 85b show the total number of patients in the high security psychiatric hospitals at 31 December in each of the last nine years from 1997 to 2005, and the number of patients who were classified as having a learning disability (within the Mental Health Act 1983 categories of mental impairment or severe mental impairment) for the same period. The figures embrace mental illness, psychopathic disorder, mental impairment and severe mental impairment. The learning disabilities figures in the second part of the table are also included in the first part of the table and embrace the Mental Health Act 1983 classifications of mental impairment and severe mental impairment.

Table 85a

TOTAL NUMBER OF PATIENTS RESIDENT IN HIGH SECURE HOSPITALS


As at	Ashworth	Broadmoor	Rampton	Total

31.12.97	456	440	454	1,350
31.12.98	426	426	457	1,309
31.12.99	416	429	447	1,292
31.12.00	410	410	429	1,249
31.12.01	405	382	392	1,179
31.12.02	367	331	375	1,073
31.12.03	289	314	372	975
31.12.04	270	286	357	913
31.12.05	272	272	360	904

Source: High Security Hospitals.
Footnotes:
1. The figures embrace mental illness, psychopathic disorder, mental impairment and severe mental impairment.

Table 85b

TOTAL NUMBER OF PATIENTS WITH LEARNING DISABILITIES IN HIGH SECURE HOSPITALS


As at	Ashworth	Broadmoor	Rampton	Total

31.12.97	18	0	111	129
31.12.98	9	0	104	113
31.12.99	0	0	95	965
31.12.00	3	0	87	90
31.12.01	3	0	87	90
31.12.02	4	1	75	80
31.12.03	2	0	63	65
31.12.04	0	0	55	55
31.12.05	0	0	48	48

Source: High Security Hospitals.
Footnotes:
1. These figures are included in the first part of the table - embracing the Mental Health Act 1983 classifications of mental impairment and severe mental impairment.

2. The trend for a number of years has been for the high security psychiatric hospital patient population to reduce as secure psychiatric services more widely, particularly at a medium secure level, have been developed. This is in line with the Government policy that people should be treated in the least restrictive environment consistent with the need to protect themselves and the public, and as close to home as possible.

3. A high degree of priority has been given to moving inappropriately placed women patients out of the high security psychiatric hospitals. It is intended that a high security psychiatric women's service will only be provided at Rampton Hospital in the longer term. The women's service at Ashworth Hospital has already closed. There are currently 34 patients in the women's service at Broadmoor Hospital, with a target date of September 2007 for the closure of the service.

4. The ultimate impact of mental health prison in-reach teams on high security psychiatric hospital admissions remains uncertain. While these teams are preventing some psychiatric hospital admissions by improving the standard of community-type care available in prison, they are also improving the identification of prisoners who require transfer to psychiatric hospitals for treatment of mental health problems. Some of these individuals require a high security setting, although the effect on hospital facilities providing medium and other levels of security is more significant.

5. Broadmoor and Rampton Hospitals are involved in pilot projects for the assessment and treatment of people with dangerous and severe personality disorder (DSPD). Broadmoor Hospital is currently accommodating 23 patients in their DSPD Unit, while Rampton Hospital has 37 patients in their DSPD service. When both pilots are fully up and running Broadmoor and Rampton Hospitals will each provide 70 beds for DSPD patients.

6. There are also DSPD pilot projects in Whitemoor and Frankland Prisons. The impact on high security psychiatric hospital patient numbers in the longer term arising from the development of DSPD services will become clearer as the pilot projects are evaluated and decisions are taken about the type of settings in which this group of people should most appropriately be accommodated.

7. Each of the high security psychiatric hospitals remains the responsibility of an NHS Trust—Ashworth: Mersey Care NHS Trust, Broadmoor: West London Mental Health NHS Trust, Rampton: Nottinghamshire Healthcare NHS Trust. The three Trusts are performance managed by the relevant Strategic Health Authorities.

8. The High Security Psychiatric Services National Oversight Group has responsibility for co-ordinating the planning and delivery of high security psychiatric services and for ensuring that the Secretary of State's specific duties under Section 4 of the National Health Service Act 1977 to provide high security psychiatric care are properly discharged.

9. Table 85a indicates a continuing downward trend in the total number of high security psychiatric hospital patients and in the number of patients with a classification of mental impairment/severe mental impairment at 31 December 2005. All figures exclude patients on trial leave of absence.

NUMBER OF PEOPLE WITH MENTAL HEALTH PROBLEMS IN MEDIUM SECURE PSYCHIATRIC UNITS

10. The position remains, as in previous years, that we are unable to supply data over the last four years for the number of people with mental health problems and with learning disabilities who have been in medium secure psychiatric units. We know, however, that there has historically been pressure on medium secure and other secure psychiatric beds. Therefore, steps have been taken to increase the number of secure psychiatric beds over the last few years.

11. The increase in bed numbers has significantly improved the prospects of patients requiring psychiatric care and treatment in secure conditions being placed in the most appropriate settings to meet their needs.

12. More generally, the development and modernisation of mental health services, which is one of the Government's core national priorities, has placed a focus on the local development of services to meet the needs of the local population. This has provided a more focused mechanism for identifying the needs of local populations and the development of integrated local services.

13. High and medium secure psychiatric services are commissioned by Primary Care Trusts but in a collaborative manner around "Cluster Group" arrangements. The Cluster Groups are charged with taking forward the development of appropriate secure psychiatric services.

14. A review of the forensic mental health system that will provide information to inform the future planning of secure psychiatric services is currently being arranged.

PREVALENCE OF MENTAL HEALTH PROBLEMS IN THE PRISON POPULATION

15. It is not possible to state with any precision how many prisoners have mental health problems at any one time. That is not a question of the application of objective criteria but is essentially a matter for the clinical judgement of the psychiatrists responsible for each person's care and treatment. However, a survey of mental ill health in the prison population undertaken in 1997 by the Office for National Statistics estimated that around 90% of prisoners had at least one of the five disorders (personality disorder, psychosis, neurosis, alcohol misuse, and drug dependence) considered in the survey. Co-morbidity levels are also high. [Psychiatric Morbidity among Prisoners in England and Wales ONS 1998].

16. The NHS Plan included firm commitments that, by 2004, 300 additional staff would be involved in providing mental health services to prisoners and 5,000 prisoners at any one time would be receiving more comprehensive mental health services in prison. All prisoners with severe mental illness would be in receipt of treatment, and no prisoner with serious mental illness would leave prison without a care plan and a care co-ordinator.

17. These commitments have been met through the prison mental health in-reach project, under which the NHS has funded the introduction into prisons of multi-disciplinary mental health in-reach teams. The project began at 18 establishments in England and the four in Wales in 2001-02, and was extended to another 26 during 2002-03 and a further 46 in 2003-04. Mental health in-reach teams are now operating at 102 establishments and since April 2006 all prisoners have access to them. The commitment in the NHS plan that 300 additional staff would be in post by the end of 2004 has been exceeded.

18. In December 2001, the then Prison Health Policy Unit and Task Force published, Changing the Outlook, a Strategy for Developing and Modernising Mental Health Services in Prisons. This set out the vision of where prison mental health services should be by 2006 and identified the steps that would have to be taken if it were to be realised. Every prison was expected to look critically, with its local NHS partner (Primary Care Trust) at its existing provision to establish whether it met the needs identified in the establishment's joint health needs assessment and conformed to the principles and standards set out in both the Department of Health's National Service Framework for Mental Health and Changing the Outlook.

19. The basic principle underpinning the Strategy is that mental health services for prisoners should, as far as possible, be provided in the same way as they would be in the wider community. Prisoners who, were they not in prison, would be treated in their own homes under the care of Community Mental Health Teams, should be treated on the wings, their prison home. Those needing more specialist care should be able to receive it in the prison health care centre, and there should be quick and effective mechanisms to transfer prisoners who need in-patient treatment for mental disorder to hospital.

20. Prisoners who are already receiving treatment for mental disorder in the community under, for example, the Care Programme Approach should continue to have access to that level of service while they are in prison and, if appropriate, on release. A more effective screening tool has been introduced at all establishments to identify those who have immediate and/or significant health needs, particularly mental health needs.

21. At the end of 2003, the National Institute for Mental Health in England (NIMHE) was commissioned to implement a national prison mental health programme to form part of a wider range of innovative NIMHE projects and work-streams. This work continues to be implemented by the Care Services Improvement Partnership (CSIP) of which the former NIMHE is a part. This "mainstreaming" of prison mental health is designed to ensure that front-line clinical staff and service users in prison are linked into a range of new developments, learning is shared and good practice disseminated. A nationally developed care pathway for prison mental health was published in January 2005 that provides detailed guidance to staff and service commissioners alike. By following the prisoner from arrest through custody and on to release, it underpins the concept of end to end offender management.

22. The number of prisoners transferred to hospital as restricted patients under sections 47 (sentenced) and 48 (unsentenced) of the Mental Health Act 1983 rose by 76% between 1991 and 1994 but thereafter remained relatively stable at an average of 745 each year until 1999. In 2005, the last year for which statistics have been published, 896 prisoners were transferred as restricted patients under those sections, a rise of 19% on the revised 2002 figure of 644.

23. Many prisoners, particularly those in the acute stage of a mental illness, are transferred to hospital within a reasonable timescale but problems of apparently excessive delay can still occur in some individual cases. Although considerable efforts have been made to reduce such delays, at any one time around 40 or so prisoners will have been waiting longer than three months for a hospital place following acceptance by the NHS. Tighter regular monitoring has already been introduced to identify any prisoners who have been waiting unacceptably long periods for transfer to hospital. A protocol issued in 2003 set out what must be done when a prisoner has been waiting for a hospital place for more than three months following acceptance by the NHS. As indicated by the rise in the number of transfers since 2003, both appear to have brought about an improvement.

24. However, there remains some lack of clarity around the arrangements for transferring prisoners with mental health problems to hospital. The Prison Service, Prison Health, the National Institute for Mental Health in England (NIMHE), and the commissioners and providers of NHS hospital services are now working collaboratively on a two year project that began in April 2005. Its principal objective is to establish a national waiting time standard for transfers between custodial settings and hospitals that is equivalent to the waiting time for referrals between mainstream NHS providers and hospital and which is maintained for all prisoners requiring transfer. In January 2006, it produced procedures for the transfer of prisoners under Sections 47 and 48 of the Mental Health Act 1983. This aimed to reduce unacceptable delays in the transfer of prisoners by providing clarification and a clear description of the transfer process.

5.7.5 Is there any evidence of increasing emphasis on "talking therapies" in NHS mental health treatment? (Q86)

ANSWER

1. There is robust clinical evidence of the effectiveness of talking treatments for various mental health problems such as depression, anxiety and schizophrenia which have been carefully considered by the National Institute for Health and Clinical Excellence during the development of clinical guidelines for such conditions.

2. More talking therapies are being provided over the NHS in recent years (as evidenced by the increasing investment in psychological therapies from £125 million in 2001-02 to £142 million in 2004-05 (The 2005-06 National Survey of Investment in Mental Health Services, Mental Health Strategies, http://www.dh.gov.uk/assetRoot/04/13/50/11/04135011.pdf) and the significant increases in the number of clinical psychologists and qualified psychotherapists employed in the NHS (NHS Staff 1995-2005, The Information Centre for health and social care, http://www.ic.nhs.uk/pubs/nhsstaff)). Our evidence shows, however, that services are not keeping pace with increasing demand from service users and that provision is not evenly spread across the country. To a large extent, psychological therapies can be seen as a victim of their own success.

3. The Office for National Statistics' Psychiatric Morbidity Survey 2000 found that 24% of people assessed as having a neurotic disorder were receiving treatment of some kind for a mental or emotional problem. Of those receiving treatment, only 9% were having talking therapies and a further 4% were receiving both medication and talking treatments (Surveys of Psychiatric Morbidity among Adults in Great Britain, Office for National Statistics, http://www.dh.gov.uk/assetRoot/04/06/81/88/04068188.pdf).

4. The NHS Patient Survey 2005 also reported that while 40% of the respondents received talking therapies in the previous year, one in three (33%) of those who had not had talking therapy said that they would have liked it (Survey of Mental Health Service Users 2005, Healthcare Commission, http://www.healthcarecommission.org.uk/_db/_documents/04019829.pdf). In the previous year's Patient Survey, 59% of service users said they would have liked talking therapy (Survey of Mental Health Service Users 2005, Healthcare Commission, http://www.healthcarecommission.org.uk/_db/_documents/04008183.pdf). The Department's consultation on patient choice also showed that the single most common request from people with mental health problems is for quick access to effective talking treatments (Building on the Best Mental Health Taskforce Report, December 2003, http://www.dh.gov.uk/assetRoot/04/07/86/54/04078654.PDF). There is also anecdotal evidence from primary care professionals that waiting times for talking therapies are too long (GP frustration over depression therapies, 10 September 2005, Pulse-i, http://www.pulse-i.co.uk/articles/fulldetails.asp?aid=7759).

5. Approximately 2.75 million people visit GP surgeries each year with mental health problems that could be treated effectively with psychological interventions. Only a minority of these people (8%) receive any form of talking therapy. So, despite the big increases in psychologists in recent years, the key challenge remains in making further stepped increases in the psychological therapy workforce and targeting and improving access for people that would benefit from this service.

6. There is evidence to suggest that the demand for psychological therapies has increased in recent years as more services have become available. For example, the Building on the Best Consultation exercise identified improved accress to talking therapies as the top priority for mental health service users in extending the scope and range of choices available to them—a point reinforced in the more recent SCMH study.

7. The Department's improving Access to Psychological Therapies Programme will make the case for investing in this additional psychological therapy workforce. As well as seeking to confirm clinical effectiveness, and to capture health and social benefits to service users, the programme will collect evidence to demonstrate the overall financial benefit to the economy that will be derived from investing in psychological therapy services by reduing the number of people with mental health problems on Incapacity (and other) Benefits and reducing sickness rates in the workplace (as part of the Treasury's cross-cutting review of Mental Health and Employment announced in Budget 2005).

8. The IAPT programme will define:

the numbers of new staff required to deliver comprehensive, evidence based psychological interventions;

training requirements and opportunities for retraining of existing staff;

the provision of Computerised self-help; and,

reform of care pathways based on the NICE recommendation for the provision of a "stepped care" model by which patients receive treatment according to the severity of their condition and their initial treatment response.

BACKGROUND

9. There has been a significant political and societal interest in the need for improved access to psychological interventions for individuals accessing health care (Turpin, G, Hope, R, Duffy, R, Fossey, M and Seward, J (2006) "Improving Access to Psychological Therapies: Implications for the Mental Health Workforce" (due for publication shortly). There has also been a recent move to demonstrate the effectiveness of introducing a stepped care approach to the delivery of psychological therapies (Department of Health (2006) "Our Health, Our Care, Our Say: A new direction for community services". White paper. Department of Health, London) and to examine the cost of service provision and the economic impact. Professor Lord Layard and his team at the London School of Economics have been commissioned by the DH to undertake this evaluation, initial findings expected early in 2007. In order to test different modalities of psychological therapy provision robustly, the Government have invested £3.7 million in two demonstration sites and, supported by Care Services Improvement Partnership and work in its eight regional centres, a national improving access to psychological therapies network has been developed.

10. Recent high profile reports have also highlighted the cost benefits (Layard et al, 2006 Centre for Economic Performance (2006). "The Depression Report: A New Deal for Depression and Anxiety Disorders". London School of Economics) and the clinical effectiveness (Gillespie, K Duffy, M, Hackmann, A and Clark, DM (2002) Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb, "Behaviour Research and Therapy 40", 345-357) of appropriately delivered evidence-based psychological interventions. The National Institute for Health and Clinical Excellence (NICE) has developed guidelines that strongly endorse the use of psychological interventions for the treatment of a range of mental health disorders (eg Depression: National Institute for Health and Clinical Excellence (2004) Depression: Management of Depression in primary and secondary care. NICE, London.).

5.8 Performance Ratings

5.8.1 Could the Department comment on trends in (a) NHS star ratings and (b) social services star ratings performance? How many NHS organisations and councils saw a drop in their rating in each year for which data are available? Can the Department comment on any common factors between organisations with a ratings drop? (Q87)

ANSWER

1. Star Ratings and the number of NHS trusts whose rating has risen/fallen on the previous year are set out in the Table 87a to Table 87d. Because of changes to organisational configuration and the assessment process, data between years is not directly comparable.

2. Star ratings and the number of councils whose rating has risen/fallen on the previous year are shown in Table 87e.

Table 87a

ACUTE AND SPECIALIST TRUSTS(1) (2)


Star rating	2000-01	2001-02	2002-03	2003-04	2004-05

***	35	52	63	76	73
**	103	88	68	58	53
*	23	36	31	29	38
Zero	12	10	14	10	9
Number risen on previous year	—	46	51	50	34
Number fallen on previous year	—	40	35	41	42

Source:

2000-01 to 2002-03 risen/fallen value is the Department of Health.

2003-04 to 2004-05 risen/fallen value is the Healthcare Commission.

Footnotes:

1. Due to mergers of NHS organisations it is not always possible to compare an organisation's star rating to the previous year.

2. For 2000-01, only acute trusts were performance rated.

Table 87b

AMBULANCE TRUSTS(1) (2)


Star rating	2000-01	2001-02	2002-03	2003-04	2004-05

***	—	12	10	10	13
**	—	16	7	11	6
*	—	4	9	6	9
Zero	—	0	5	4	3
Number risen on previous year	—	—	2	9	8
Number fallen on previous year	—	—	14	7	7

Source:

2000-01 to 2002-03 risen/fallen value is the Department of Health.

2003-04 to 2004-05 risen/fallen value is the Healthcare Commission.

Footnotes:

1. Due to mergers of NHS organisations it is not always possible to compare an organisation's star rating to the previous year.

2. For 2000-01, only acute trusts were performance rated.

Table 87c

MENTAL HEALTH TRUSTS(1) (2)


Star rating	2000-01	2001-02	2002-03	2003-04	2004-05

***	—	4	13	15	21
**	—	67	42	38	45
*	—	13	26	23	12
Zero	—	2	3	7	5
Number risen on previous year	—	—	12	21	30
Number fallen on previous year	—	—	16	25	15

Source:

2000-01 to 2002-03 risen/fallen value is the Department of Health.

2003-04 to 2004-05 risen/fallen value is the Healthcare Commission.

Footnotes:

1. Due to mergers of NHS organisations it is not always possible to compare an organisation's star rating to the previous year.

2. For 2000-01, only acute trusts were performance rated.

Table 87d

PRIMARY CARE TRUSTS(1) (2)


Star rating	2000-01	2001-02	2002-03	2003-04	2004-05

***	—	—	45	45	58
**	—	—	139	181	158
*	—	—	98	63	80
Zero	—	—	22	14	7
Number risen on previous year	—	—	—	104	82
Number fallen on previous year	—	—	—	69	77

Source:

2000-01 to 2002-03 risen/fallen value is the Department of Health.

2003-04 to 2004-05 risen/fallen value is the Healthcare Commission.

Footnotes:

1. Due to mergers of NHS organisations it is not always possible to compare an organisation's star rating to the previous year.

2. For 2000-01, only acute trusts were performance rated.

Table 87e

COUNCILS


Star rating	2000-01	2001-02	2002-03	2003-04	2004-05

***	—	11	16	20	26
**	—	52	74	82	86
*	—	75	52	40	33
Zero	—	12	8	8	5
Number risen on previous year	—	—	41	27	37
Number fallen on previous year	—	—	6	11	18

Source:

2000-01 to 2002-03 risen/fallen value is the Department of Health.

2003-04 to 2004-05 risen/fallen value is the Healthcare Commission.

Footnotes:

3. A high-level analysis of the areas where performance has been poor for 2004-05 is in Table 87f.

4. The table shows areas of poor performance for Trusts with a zero star rating. The figures reflect the number of zero star Trusts where more than one Trust has scored "Significantly Underachieved" pn a particular Key Target, or "Low" on a particular Balance Scorecare indicator. The figures in brackets shows the total number of zero star Trusts by type.

5. A rules based approach was used to determine the overall rating, where penalty points are given for failure against Key Targets and the Balanced Scorecare indicators. The rating was then awarded according to the total amount of penalty points received, with particular weighting towards achieving Key Targets. Zero star trusts are therefore likely to have failed one or more key targets.

6. A high-level breakdown of all ratings is available in "NHS performance ratings 2004/2005" available on the Healthcare Commission's website.

Table 87f

TRUSTS


	Acute & Specialist Trusts (9 zero stars)	Mental Health Trusts (5 zero stars)	Primary Care Trusts (7 zero stars)	Ambulance Trusts (3 zero stars)

Key Targets
Elective patients waiting longer than the standard	6		2
Financial Management	8	3	7
Outpatients waiting longer than the standard	3
Total time in A&E: four hours of less	3		2
Category B Calls meeting 14/19 minute target				2
Crisis resolution team implementation		2
Balanced Scorecare
Clinical focus		3
Patient focus	3	4
Capacity and capacity focus	3
Improving health			2
Service provision			4

7. A high-level analysis of the areas where performance has been poor for 204-05 is in Table 87g.

8. The table shows areas of poor performance for Councils with a zero star rating. The figures reflect the number of zero star Councils where more than one Council has scored "no" or "poor" on a particular Judgement. The number in brackets shows the total number of zero star Councils.

9. A high-level breakdown of all ratings is available in "Performance Ratings for Social Services in England, December 2005" available on the Commission for Social Care Inspection's website.

Table 87g

COUNCILS


	2004-05

Judgements	Councils (5 zero stars)
Children's social care services—Serving People Well?	4
Children's social care services—Service Provision	3

HEALTHCARE

10. The publication of "NHS Performance Ratings" takes forward the Government's commitment to provide both patients and the general public with comprehensive, easily understandable information on the performance of their local health services, and is seen as an important step towards delivering a more open and accountable NHS.

11. The performance ratings system provides a high-level overview of NHS organisations' performance across a wide range of measures. The rating awarded is based on the trust's performance against a number of key targets and a wider set of "balanced scorecard" performance indicators.

12. Since 2002-03, the Healthcare Commission has had responsibility for production of performance ratings. Prior to 2002-03, the Department of Health published performance ratings.

13. The indicators for rating performance were based on priorities and guidance set by the Department of Health. These indicators may change from year to year. They also reflect, for some priorities, the incremental changes made to targets to achieve year-on-year improvements to the service patients will receive.

14. Where organisations under perform, resource is available locally to support modernisation and improvement. In addition, DH's Recovery and Support Unit work closely with SHAs to improve performance through supporting implementation and management.

15. From 2005-06, the Healthcare Commission will take forward a new approach to annually assessing each NHS organisation's performance. The new annual health check will provide a richer and more comprehensive picture of the performance of the NHS. It will also establish a baseline of performance from which organisations can improve.

SOCIAL CARE

16. The publication of "Performance Ratings for Social Services in England" is in response to the 1998 social services white paper "Modernising Social Services", in which the Government committed to put in place effective systems to monitor and manage performance.

17. The performance ratings system provides a high-level overview of Social Services organisations' performance across adult and children's services. The rating awarded is based on the council's performance against information from a number of sources including performance data, evaluation through inspection/reviews and monitoring by the Commission for Social Care Inspection Business Relationship Managers.

18. Prior to 2003-04, the Social Services Inspectorate published performance ratings. Since 2003-04, the independent regulator the Commission for Social Care Inspection has had responsibility for production of performance ratings.

19. External support, such as Performance Action Teams, assist council staff in developing their capacity and systems to deliver improved social services. This support is provided to councils obtaining zero stars to improve their capacity and systems, and to one star trusts to prevent them slipping to zero stars. Also, attention is now being directed to councils whose performance judgements have remained static ("coasting") over a period of three years.

20. The information for 2004-05 shown in table 5 includes the ratings for Children's social care. From 2005-06, the Children's Services ratings will be separate and Commission for Social Care Inspection will only publish Adult Social Care Ratings.

5.9 Management Costs

5.9.1 What were management costs by type of NHS organisation and as a share of total NHS expenditure in each year since 1997-98? (Q88)

ANSWER

1. The information requested is given in Table 88.

Table 88

MANAGEMENT COSTS 1997-98 to 2004-05 (ENGLAND)


£ millions	1997-98	1998-99	1999-2000	2000-01	2001-02	2002-03	2003-04	2004-05
	Actual	Actual	Actual	Actual	Actual	Actual	Actual	Actual

HA/SHA	432	414	497	536	463	97	115	133
PCT	—	—	—	24	224	723	847	986
NHS trust	1,296	1,290	1,287	1,307	1,306	1,311	1,425	1,457
GP Fundholding(1)	—	—	—	—	—	—	—	—
Total	1,728	1,704	1,784	1,867	1,993	2,131	2,387	2,576
Total NHS Expenditure(2) (3)	34,664	36,608	40,201	43,932	49,021	54,042	63,001	69,706
Management costs as % of NHS Spend	5.0%	4.7%	4.4%	4.3%	4.1%	3.9%	3.8%	3.7%

Source:

Audited health authority annual accounts 1997-98 to 1998-99.

Audited (strategic) health authority summarisation forms 1999-2000 to 2004-05.

Audited NHS Trust summarisation schedules 1997-98 to 2004-05.

Audited primary care trust summarisation schedules 2000-01 to 2004-05.

Footnotes:

1. Figures not available.

2. The large rise in expenditure between 2002-03 and 2003-04 is due to a change in accounting basis from stage 1 resource based budgeting in 2002-03 to stage 2 resource based budgeting in 2003-04. This involved a transfer of non cash items into the DEL. On a stage 2 basis, the value for the total expenditure in 2002-03 is £56,503 million.

3. Total Net NHS Expenditure (England), 2004-05 is estimated outturn expenditure.

4. Percentages and totals may not be precise owing to the rounding of figures to £m.

5. The Department of Health does not collect data from NHS Foundation Trusts therefore the table does not include management costs of NHS Foundation Trusts.

6. Management cost information is collected in audited returns, which provides external scrutiny on the figures. The Department does not have concerns over the quality of the data.

5.9.2 Could the Department detail expenditure on management consultants as part of turnaround teams, nationally and by organisation? Could the Department comment on the availability of more general data concerning NHS expenditure on external consultants? (Q89)

ANSWER

1. The information requested on turnaround teams is given in Table 89.

2. Organisations within the turnaround cohort were asked to outline the estimated costs of turnaround support at a local level ie turnaround director/advisor support. Some organisations have included ancillary/indirect costs to turnaround eg external legal, communications, training and benchmarking support.

3. More generally, the Department does not collect information from the NHS on this type of expenditure. Primary Care Trusts and NHS Trusts operate within the framework of Department of Health policy; they are held to account for this by SHAs, not directly by the Department. NHS organisations account separately for their financial performance, publishing their own set of annual financial accounts.

Table 89

ESTIMATED COST OF TURNAROUND SUPPORT FOR COHORT ORGANISATIONS

£ millions


Organisation	Category	External Turnaround Support Fees (January 2006- March 2007)

George Eliot Hospital NHS Trust	1	0.1
Shrewsbury and Telford Hospital NHS Trust	1	0.6
South Warwickshire NHS Trust	1	0.0
North Cumbria PCT	1	0.6
The Royal West Sussex NHS Trust	1	0.8
Surrey and Sussex Healthcare NHS Trust	1	1.5
University Hospital of North Staffordshire NHS Trust	1	0.4
Mayday Hospital NHS Trust	1	0.4
Barnet & Chase Farm Hospitals NHS Trust	1	0.4
Mid Yorkshire Hospitals NHS Trust	1	1.2
Selby and York PCT	1	0.6
Dacorum PCT	1	0.2
Royal Cornwall Hospitals NHS Trust	1	0.4
Hammersmith Hospitals NHS Trust	1	0.9
Brighton & Sussex Univ Hospitals NHS Trust	1	0.8
North Cumbria NHS Trust (combined with North Cumbria PCT)	1	—
Sheffield PCTs	1	0.6
Weston Area Health NHS Trust	1	0.2
United Lincs Hospitals NHS Trust	1	0.7
Hillingdon PCT	1	0.8
Cheshire West PCT (5H3)	1	1.0
Kennet and North Wiltshire PCT	1	0.2
West Wiltshire PCT (5DH)	1	0.2
Royal Wolverhampton Hospital NHS Trust	2	0.2
Sandwell and West Birmingham Hospitals NHS Trust	2	0.2
North Stoke PCT (5ME)	2	0.0
Cambridge City PCT	2	0.3
North Middlesex Univ Hospital NHS Trust	2	0.3
Queen Mary's Sidcup NHS Trust	2	0.3
Queen Elizabeth Hospital Kings Lynn NHS Trust	2	0.3
Oxford Radcliffe Hospital NHS Trust	2	0.1
St George's Healthcare NHS Trust	2	0.3
West Hertfordshire Hospitals NHS Trust	2	0.5
Royal Free NHS Trust	2	0.0
Scarborough, Whitby and Ryedale PCT	2	0.4
Yorkshire Wolds and Coast PCT	2	0.3
West Middlesex University NHS Trust	2	0.5
Guildford and Waverley PCT	2	0.3
The Mid Cheshire Hospitals NHS Trust	2	0.0
Kensington and Chelsea PCT	2	0.3
East and North Hertfordshire NHS Trust	2	0.5
East Elmbridge and Mid Surrey PCT	2	0.5
East Cheshire NHS Trust	2	0.0
Hounslow PCT (5HY)	2	0.5
North West London Hospitals NHS Trust	2	0.1
Southport and Ormskirk Hospital NHS Trust	2	0.1
Maidstone and Tunbridge Wells NHS Trust	2	0.2
Southampton University Hospitals NHS Trust	2	0.3
Bexley PCT	2	0.2
Colchester PCT	2	0.1
Maidstone Weald PCT	2	0.1
High Peak and Dales PCT	2	0.3
Kingston PCT	2	0.6
East Hampshire PCT	2	0.0
South Cambridgeshire PCT (combined with Cambridge City PCT)	2	—
Blackwater Valley and Hart PCT	2	0.1
SW Kent PCT (combined with Maidstone Weald PCT)	2	—
Fareham and Gosport PCT (combined with East Hampshire PCT)	2	—
Cotswold and Vale PCT	2	0.3
North Somerset PCT	2	0.2
Good Hope Hospital NHS Trust	3	0.0
North Tees and Hartlepool NHS Trust	3	0.0
Ashford and St Peters NHS Trust	3	0.3
Bedford Hospitals NHS Trust	3	0.0
Sedgefield PCT	3	0.0
Essex Rivers NHS Trust	3	0.1
South Tees Hospitals NHS Trust	3	0.0
Bedfordshire Heartlands PCT	3	0.0
Princess Alex Harlow NHS Trust	3	0.1
West Suffolk Hospitals NHS Trust	3	0.3
Queen Elizabeth Hospital NHS Trust	3	0.0
The Lewisham Hospital NHS Trust	3	0.0
Morecambe Bay NHS Trust	3	0.0
Isle of Wight NHS Trust (combined with Isle of Wight PCT)	3	—
RUH Bath NHS Trust	3	0.0
Suffolk Coastal PCT	3	0.0
North Devon Healthcare NHS Trust	3	0.2
Chelmsford PCT	3	0.0
Witham, Braintree & Halstead Care PCT	3	0.0
Broadlands PCT (5JL)	3	0.0
North Norfolk PCT	3	0.0
Southern Norfolk PCT (5GI)	3	0.0
Suffolk West PCT	3	0.3
Waveney PCT	3	0.0
Lewisham PCT	3	0.0
Wandsworth PCT (5LG)	3	0.0
Morecambe Bay PCT	3	0.0
Ipswich PCT (combined with Suffolk Coastal PCT)	3	—
Isle of Wight PCT	3	0.1
N Hants PCT	3	0.1
New Forest PCT (5A1)	3	0.0
South Wiltshire PCT (5DJ)	3	0.0
Bromley Hospitals NHS Trust	4	0.0
Bromley PCT	4	0.0
North Hampshire Hospitals NHS Trust	4	0.0
Tendring PCT	4	0.0
Barnsley PCT	4	0.0
TOTAL		22.1

Footnotes:

1. For category 1 and 2 organisations (as at May 2006), the estimated expenditure for external support on turnaround between January 2006-March 2006 was £4,769k. The projected costs for turnaround for the financial year 2006-07 is estimated to be £15,830k. These costs include DH contributions of £93k towards the cost of the first three months of turnaround support for the category 1 organisations.

2. For category 3 and 4 organisations (as at June 2006), the estimated expenditure for external support on turnaround between January 2006-March 2006 was £173k. The projected costs for turnaround for the financial year 2006-07 is estimated to be £1,306k.

5.10 Financial Balance

5.10.1 What has the NHS financial balance been in each year since 1997-98? (Q90)

ANSWER

1. The information requested is given in Table 90.

2. For all years, except 2005-06 the figures are from the audited summarisation schedules and are therefore definitive. The 2005-06 figures are from the Month 12 Financial Monitoring Returns with the exception of the foundation trust figures, which are from Monitor. These figures must therefore be treated as provisional until they are signed off by the NAO/Chief Executive.

Table 90

NHS SURPLUS/(DEFICIT) 1997-98 TO 2005-06


				£ millions
Financial year	HAs/PCTs	NHS Trusts	Foundation Trusts	Total NHS position

1997-98	(18)	(104)		(121)
1998-99	17	(36)		(18)
1999-2000	(52)	(77)		(129)
2000-01	56	56		112
2001-02(1)	111	(40)		71
2002-03	189	(94)		96
2003-04	210	(138)		73
2004-05	100	(322)	(37)	(258)
2005-06(2)	48	(560)	(24)	(536)

Source:

1997-98 to 2004-05 Audited Summarisation Schedules.

2005-06 Month 12 Financial Monitoring Returns.

Footnotes:

1. The total for NHS trusts in 2001-02 does not sum to the total of the individual organisations due to a central adjustment relating to a prior period adjustment being made in the underlying accounts following a change in the interpretation of FRS11.

2. Provisional.

5.10.2 What have deficits and surpluses been in each (a) NHS Trust (b) Primary Care Trust and (c) Strategic Health Authority been in each year since 1997-98 for which data are available, in £s and as a percentage of turnover? (Q91)

ANSWER

1. The information requested is given in Table 91a to Table 91d.

2. Figures for 2005-06 are subject to audit and remain provisional.



© Parliamentary copyright 2007	Prepared 21 November 2006