Conclusions
1.Achieving parity of esteem between mental and physical health is a laudable ambition but pressure on the NHS budget will make it very difficult to achieve. The Department and NHS England have taken an important first step towards parity of esteem by putting in place, for the first time, standards for the time people should wait for mental health treatment and the care they should be able to access. So far, they have introduced standards for three specific areas of mental health provision. How the improvements in services will be paid for is less clear. The Department has announced an additional £1 billion for mental health services over the next five years, but this money is not ring-fenced. There is a risk that commissioners and providers, already under financial pressure, will have no choice other than to deprioritise other mental or physical health services if they are to meet the new standards. Witnesses gave evidence that spending on mental health services leads to a net financial gain, once better outcomes for patients, lower costs to the health system and wider economic benefits are taken into account. However, information available to commissioners about the full costs and benefits of spending on mental health services is not good enough to support well-informed decisions about how best to use the limited available funding. NHS England also confirmed that it aimed to extend waiting time standards, firstly to eating disorder services and then to a broader range of mental health services. Given the pressures in achieving standards in the first three areas, however, it is not at all clear how easily or quickly standards can be introduced more widely.
2.Structures are not in place to enable joined-up working across government to ensure the most appropriate action is taken to support people’s mental well-being. Responsibilities falling within other parts of government, such as prisons, housing, employment, armed forces support and schools, can all influence outcomes for people with mental health conditions. The ‘crisis care concordat’, established in February 2014, has gone some way to ensuring that people with mental health conditions receive appropriate treatment, and the Department and NHS England have started a dialogue with other departments with the aim of providing better integrated services for people who have mental health conditions. However, more generally, systems for working across government are weak. People leaving prison, for example, have no consistent way to access mental health services on their release. Around half of people with lifetime mental health problems experience symptoms by the age of 14 and schools play an important part in identifying mental health issues among young people, but counselling services are not available in all schools. We also heard that services helping people with mental health problems get back into work are not joined-up between the NHS and the Department for Work and Pensions.
3.It is difficult for people to access the support they need because the way mental health services are designed and configured is complex, variable and difficult to navigate. There are many different ways in which people can come into contact with mental health services. Referrals often start as a result of contact between a patient and their GP, but people can then face a complex process of diagnosis, referral and treatment involving multiple clinical staff in different health settings. This can make it more difficult for people to get the treatment they need. Mental health services have grown up over years and are commissioned in different, inconsistent, ways in different areas, with the result that there can be multiple alternative routes to access services. There is significant variation in people’s experience of access to services and the time they wait depending on where they live and other demographic factors. The National Audit Office found, for example, that in 2014–15, the proportion of people able to access psychological therapy within six weeks of referral varied from 7% in one clinical commissioning group to 99% in another.
4.There is insufficient information about the numbers of mental health staff and their skills, and there is not yet a clear plan to develop the workforce needed to achieve parity of esteem. The Mental Health Taskforce highlighted, in February 2016, high vacancy rates in consultancy psychiatry posts and psychiatry training. Health Education England estimates that implementing the access and waiting time standards will require the number of mental health nurses to rise by 7%, from 39,000 in 2014 to 42,000 by 2020. In contrast, trusts expect their demand for mental health nurses to fall. There is a further problem that, because of the number of nurses leaving the NHS, the number of people completing their training is not translating into an equivalent increase in the number of people the NHS is employing. Health Education England is now starting to develop a workforce strategy for mental health, the first since 1999. In the meantime, the Department has put new waiting time targets in place without a clear understanding of the workforce needed to achieve them.
5.Current structures, practices and payment mechanisms do not incentivise commissioners and providers to deliver high-quality mental health services for all who need them. Governance and accountability structures are complex and lack transparency, undermining confidence that services are being commissioned and provided in the best ways. There is a risk that, because there are are only a small set of targets for a few mental health services, commissioners and providers will have an incentive to prioritise these at the expense of other services. Commissioners currently pay for most mental health services using ‘block contracts’ that pay providers a fixed sum each year irrespective of the quality and timeliness of the services being provided and the number of people accessing services. These contracts lack transparency, and provide few incentives for providers to improve the quality or efficiency of services. NHS England reported that it is now undertaking an ‘open-book’ exercise with clinical commissioning groups to understand better how much local commissioners are spending on different mental health services. In addition, NHS Improvement is developing new mechanisms for how mental health services are priced and paid for.
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16 September 2016