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Mental health: a plan or a wish list?

Gerald Knight and Julie Nancarrow
LET DOWN: David Knight’s parents, with a picture of their son who was given an out-of-area bed, which may have been a factor in him taking his own life. The plan seeks to end the use of such beds

The Government has pledged to tackle serious deficiencies in mental healthcare. The changes are potentially significant, but the details are sketchy and will there be enough staff to deliver it? Keith Cooper reports

Long-standing flaws in mental healthcare can have tragic consequences for patients – and those who care for them.David Knight

Chronic NHS bed shortages have forced thousands into so-called OOA (out-of-area) beds for years, an endemic practice which separates very ill people from their families and carers – and is a well-known risk factor for suicide.

Almost 200 people in the UK took their own lives after leaving ‘non-local’ hospitals between 2014 and 2016, says the latest study by the University of Manchester. Each lost life is, of course, devastating for families, for example that of David Knight, which the BMA covered in 2017. Mr Knight was given a bed hours away from friends and family, and according to medical evidence given at his inquest, it was ‘very likely’ to have been a contributory factor to him taking his own life.

Hundreds of patients wait more than a year at home for standard talking therapies and hundreds more are ‘warehoused’ on private wards far from home, for want of NHS beds and staff with the skills to get their lives back on track.

 

Care close to home

So, what is the NHS planning to do about the chronic shortages of facilities and skills, which have such an awful effect on patients and frustrate the efforts of doctors in charge of their care?

The latest detail of what’s being done to tackle these seemingly intractable issues are laid out in the NHS Mental Health Implementation Plan, slipped out late July, on the eve of Boris Johnson becoming prime minister.

Its ambitions include a promise to spend £2.3bn to help two million more people. It aims to reduce the long waits for treatment for the severely ill, eradicate OOA beds, and set up new services with new structures to bring care closer to home.

NHS England national director for mental health services Claire Murdoch said she has ‘never seen such a strong commitment to improve mental health in England’ in her blog on the plan last month.

‘There had been an impressive momentum to bring change’ from Government and frontline staff but people now want ‘actions not words’.

The Doctor
Issue 13
16 x 9 graphics
Planned expansion of the NHS workforce by 2023/24
Planned cumulative increase in psychiatrists in England

So, what does it say and how realistic is it?

As with many plans of this kind, it offers more of a sketch than a fully formed picture of what NHS England wants by 2024, the year it runs to. The traces it offers, however, point to some potentially significant changes for doctors and others in mental healthcare.

It suggests, unsurprisingly, a further shift away from hospital care to more ‘care in the community’. Ward stays, if necessary, should be ‘short and purposeful’, close to home, and offer treatment – not just a room and a watchful eye, as some have become. Such basics are sadly lacking in much of the NHS and in the private hospitals to which it increasingly outsources care.

At least five million people live in areas with no mental health rehabilitation beds for the most seriously ill, where stays last months or years, the July edition of The Doctor revealed. Hundreds are ‘warehoused’ in private wards, many hours’ drive from home, where stays last twice as long as in the NHS.

 

New services

On acute wards, where admissions should last weeks, more than 700 were in OOA beds in May, many for more than a month. The Government’s goal of ending OOA beds in the acute sector by 2021 looks increasingly unlikely.

The plan also promises to open services for people with serious gambling problems, rough sleepers, and for people with severe mental ill health, including those with a diagnosis of personality disorder, a much-neglected area in recent years.

It pledges also to extend services already being revamped by an earlier plan, the FYFV (Five Year Forward View). It runs until April next year, when this new one effectively takes over. Perinatal care will, for instance, start to offer limited help to mothers’ partners, such as ‘assessment’ and ‘signposting’. But there’s little or no pledges of extra resources for people with learning disabilities, dementia or for substance abuse services.

The plan itself is sketchy on what these services will look like but does lay down hard figures for how many extra staff it expects will be needed.

The Doctor
Issue 13
16 x 9 graphics
Planned expansion of the NHS workforce by 2023/24
Planned cumulative increase in psychiatrists in England

King’s Fund health policy fellow Helen Gilburt says it is difficult to know what these figures mean in practice without extra detail.

‘There’s quite a lot of “we will have these services” but not much about what the services will look like,’ she adds. ‘It is really difficult to know what this plan actually means.’

What the King’s Fund and other mental health policy analysts can say, however, is that the plans for a massive expansion of the workforce are ‘ambitious’, a byword in policy-speak for unrealistic. Ms Murdoch herself calls the plan’s targets ‘very ambitious’.

It, however, expects an extra 550 psychiatrists and 4,220 nurses to be recruited at a time when many mental health trusts are struggling to fill posts they already have. These extra posts are on top of the staff increases planned in the FYFV. One in 10 psychiatrist and mental health nursing jobs are unfilled nationally, according to the latest official figures, raising doubts that earlier plans for an increase in workforce have worked.

Andy Bell, deputy chief executive of the Centre for Mental Health, agrees the workforce proposals are ambitious but believes the present high profile of mental health – especially among young people – creates a ‘huge opportunity’ to attract new staff.

‘We have to increase the pipeline of people working in this area but this won’t happen very quickly, so we also really need to focus on the people we have got now. We know there are things that need to be done to support the mental health workforce we already have. The NHS isn’t a good employer on the whole,’ he says.

 

Struggling to meet demand

Efforts to support mental health and boost the recruitment of psychiatry trainees and consultants has been a focus of medical groups, such as the BMA and the Royal College of Psychiatrists.

The RCPsych’s ‘Choose Psychiatry’ campaign has helped push the ‘fill rates’ of trainee posts up to 92 per cent in much of the country. The college has also commissioned University College London to find out why so many trainee psychiatrists drop out of specialist training.

‘Although mental health services are seeing reform throughout the UK, too often we hear about services under immense pressure,’ says the RCPsych’s dean and consultant psychiatrist Kate Lovett.

‘It takes courage and hope to remain working and training in services which are struggling to meet demand.’

BMA consultants committee mental health policy lead Andrew Molodynski (pictured below) says the plan’s workforce figures also point to a potential change in the staff mix of mental health teams. Alongside the three-figure increase in psychiatrists’ posts, there are plans for 6,000 extra support staff, 4,700 peer support workers, and large rises in the numbers of nurses, psychologists and others who offer talking therapies.

Dr Gilburt sees the workforce figures as an early indication of a move back to the ‘multidisciplinary’ community mental health team. ‘This is not necessarily a bad thing,’ she adds. ‘Community health teams have been stripped back. They lost social workers and most of the psychologists left to fill gaps in the IAPTs [Increasing Access to Psychological Therapies] service.’

Multidisciplinary teams are the ‘cornerstone’ of good-quality mental healthcare, says Dr Molodynski. ‘We need more of all types of team member but we need also be clear on how they will be recruited, trained and supported to work in what can be a stressful area. The recruitment of large numbers of people with relatively brief training points to the need for even more high trained and experienced staff.

Andrew Molodynski

‘High vacancy and drop out rates for doctors in training and the prospect of many experienced psychiatrists retiring soon raises major doubt about whether the planned increases across all key professions can be achieved. Even the modest targets for extra doctors seem unrealistic.’ he adds.

 

Talking therapies

The plan proposes to boost access to talking therapies for people with more severe mental illness, such as psychosis, bipolar disorder and personality disorder. Many people with these illnesses are excluded from IAPTs, the mainstay of NHS talking therapy services, leaving them waiting years for appointments. The plan says that ‘new training places’ will be created by Health Education England, a Government agency, to ‘increase competency within the workforce’.

The BMA’s Dr Molodynski welcomed the plan’s pledge to address the many shortfalls in mental healthcare. ‘There will, however, be big challenges which we must overcome together. The plan leaves us a long way from having services with the resources to respond quickly and humanely to people with mental health problems, regardless of their age, location, background or diagnosis – that’s the real parity we need in the 21st century.’

Find out more about the BMA's work on mental health

 

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