3People’s experience of mental health services
25.Good access to mental health services matters. Many people can make a full recovery if they receive appropriate, timely treatment. However, a high proportion of people with mental health conditions do not have access to the care they need. Only around 25% of those estimated to need mental health service have access to them.56 People’s experience of access to services and the time they wait also varies depending on where they live. 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.57 Successfully implementing the programme to introduce access and waiting time standards should help to improve services and outcomes for the large number of people who are affected by mental ill health at some point in their lives.58 Mersey Care NHS Foundation Trust told us, however, that there has generally been a low expectation of mental health services, first of all by those people using the services.59
Accountability
26.The system for delivering mental health services is fragmented, involving a variety of national and local bodies.60 We asked who is ultimately responsible for making sure people with mental health problems get the help they need. The Centre for Mental Health told us that parents and young people particularly find it difficult to navigate the system by themselves, meaning that GPs have a really important role as the advocate for somebody to make sure they get access to a service. Mersey Care NHS Foundation Trust agreed that accessing mental health care can be very difficult to negotiate. It explained, for example, that there were about 19 different routes by which people could be referred to the trust for treatment and therefore a multitude of different connections to make. Dr Wannan also agreed that it is very confusing for patients, and said that it is a clinician’s responsibility to explain the system to them.61 The Department assured us that everyone in primary care services should have a named accountable GP who is responsible for the oversight of their care. When a person is referred, for example to secondary care, there should be a lead individual who is responsible for making sure that person’s care is co-ordinated.62
27.The Department emphasised that parity of esteem needs to not just be about the health service but involve other bodies such as schools, prisons, local authorities and employers. The vision for mental health services the mental health task force had set out would only be achieved if all those services had the same sort of positive attitude towards mental health.63 The Department assured us it was working, for example, with the police in relation to crisis care, the Department for Work and Pensions on employment support, and the Department for Communities and Local Government on housing and mental health.64
Improving services
28.Written evidence from the Mental Health Policy Group welcomed the new focus on access and waiting times, but cautioned that it is important that prioritising some services does not lead to disinvestment in other effective, evidence-based services.65 Mersey Care NHS Foundation Trust expressed the same concern that, because targets cover only a limited proportion of mental health services, there could be incentives to focus attention, and funding, on some services at the expense of others.66 Dr Wannan also pointed to the risk of creating perverse incentives. For example, the target that, by 2020, all children and young people should be seen within four weeks of referral was a good thing, but there was a risk of simply extending the time people had to wait for treatment in order to achieve the target time for assessment.67 The Department stated that it thought targets in this case, when it is trying to change behaviour, can be important but tracking against actual outcomes is extremely important. It emphasised that targets were part of a wider package of incentives to change behaviour that included oversight by NHS England and regulatory activity by the Care Quality Commission.68
29.NHS England agreed that there would be a benefit in introducing waiting time standards for other mental health services. Having done that for improved access to psychological therapies and for the early intervention in psychosis service, NHS England confirmed that it aimed to do the same for eating disorder services, and then extend targets to a broader range of services. This would help to highlight the gap between need and treatment availability, focus management and funding efforts, and improve patient outcomes.69
30.We took evidence on the experience of particular demographic groups such as ethnic groups, and children and young people. The Centre for Mental Health pointed out that, if we want parity between mental health and physical health, we also have to work towards parity within it, but that there are serious inequalities in the system. For example, there is a discrepancy in African and Caribbean men and women’s experience of mental health services, in terms of what people are diagnosed with, and what care and support they receive. The Centre for Mental Health also told us that people from lesbian, gay, bisexual and transgender backgrounds have much poorer experiences and much higher rates of poor mental health, and Stonewall raised similar concerns that there was limited understanding of the specific mental health needs of this group of people. Mersey Care NHS Foundation Trust and Dr Wannan both added that part of the task of achieving parity of esteem was destigmatising mental illness. Different cultures have different ways of thinking about mental illness, and cultural sensitivity of how services are offered is a major part of this.70
31.NHS England acknowledged that people from Pakistani or Bangladeshi heritage have about a 10 to 12 percentage point lower recovery rate from psychological therapy than the white British population. NHS England told us that there needed to be more of link between funding to the outcomes providers achieve, but that this would not address the whole problem. For example, fewer adolescents from black and minority ethnic backgrounds were presenting into child and adolescent mental health services, but for adults more black and minority ethnic men are represented, particularly in the in-patient and secure parts of the mental health service. The Department pointed to the taskforce report recommendation that some form of ‘equalities champion’ should be appointed to make sure that the issue continued to be given prominence.71 We asked whether the data being collected to monitor who accesses services show what the outcomes are for people broken down by ethnic group, age, gender and other factors. The Department assured us that changes it had made to the mental health data set give it this information, and also include data about children and young people for the first time.72
Children and young people
32.The Centre for Mental Health told us that it had recently completed a review of children and young people’s mental health. This work had found that it typically takes 10 years between the first symptoms of a mental health condition appearing and a young person having access to effective, evidence-based support. Delays were partly explained by low mental health literacy among parents, who found it difficult to know the difference between a mental health difficulty and ordinary childhood experiences, but also because of difficulty accessing services. Even when people made contact with services this could be a remote, formal and frightening experience.73 Written evidence from Bringing Us Together reinforced concerns about children and young people’s experiences of poor mental health care.74
33.The Department pointed to the “Future in Mind” report by the taskforce on children and young people’s mental health in 2014–15, which had involved over 700 young people in developing its proposals. The Department expressed concern, however, about whether the local transformation plans for children and young people’s mental health across the country were now doing as much as they should to include children and young people’s voices, and suggested that the picture is quite variable across the country, concerns echoed in written evidence from Barnado’s.75 In response to a specific concern we raised that vulnerable children may have to travel a considerable distance to get treatment for eating disorders, NHS England acknowledged that there had been huge geographical inequalities across the country. For example, compared to a national average of about 11 in-patient beds per 1,000 children, there had been five in the south-west, seven in Yorkshire and Humber, 14 in the north-east and 12 in the east midlands. NHS England told us that it had increased the total number of beds, and gave a commitment that it would be specifically increasing capacity in places where there was still under-provision. It also said that it is connecting local children and adolescent mental health services with in-patient units in the same area to try and help flows of patients and ensure there are as few out-of-area placements as possible.76
Criminal justice
34.According to the Prison Reform Trust, 26% of women prisoners and 16% of men have said that they had mental health treatment before they went into prison. However, once they enter prison, 57% of women and 62% of men are diagnosed with a personality disorder. We asked why people with mental health problems are not being identified before entering the criminal justice system. NHS England told us it was rolling out liaison and diversion services. These services provide closer interaction between mental health professionals, the courts and police. NHS England told us that these services currently covered around half the country, but that it aimed to increase coverage to 75% next year, and to achieve coverage across the whole country by 2020. This would mean that a lot more mental health problems would be identified before people reached prison. NHS England added, however, that around half of people who go to prison have an antisocial personality disorder for which it is not easy to access treatment.77
35.We questioned why people leaving prison are not referred into the NHS. NHS England agreed that it would make sense to have a direct referral system for people leaving prison with mental health conditions, but told us that many people coming out of prison with a significant mental health problem are not always willing to engage and are often distrustful of professionals. Mental health professionals have to be very assertive to get to the people who need help.78 The Department acknowledged that this was a very important point, and noted the proposal that the Secretary of State for Justice has made about focusing prison on rehabilitation. The Department highlighted the example of the ‘Through the Gate’ programme, which was piloted in the north-west of England; which emphasised continuity in professional relationships, so the people that prisoners had been working with while in custody were the same people they carried on working with when they were released back into the community.79
56 C&AG’s Report, para 5
57 C&AG’s Report, para 2.5
58 C&AG’s Report, para 12
60 C&AG’s Report, para 1.7
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16 September 2016