28 September 2007
Mental health used to be the NHS's Cinderella service. Now it gets more funding than any other clinical area and has modernised its methods. But could the controversial new mental health laws roll back the advances? Vivienne Russell weighs up the evidence
The upmarket flats at Southdown Park on the edge of Haywards Heath in Sussex enjoy stunning views over the South Downs, but they are also a stark reminder of just how much mental health services have changed in England.
Housed in a large and eye-catching Victorian building, the complex was once St Francis Hospital, the 'lunatic asylum' for the county of Sussex. Opened in 1859, and accommodating at times more than 1,000 people, the asylum was eventually closed in 1995 and sold off for redevelopment.
Back in the nineteenth century, care was often confused with confinement and asylums were forbidding, remote places where patients – or inmates as they were called – were shut away, out of sight of society. Effective treatments and therapies were unheard of and there was little, if any, hope of discharge.
Modern mental health care is a far cry from the asylum system. In the postwar era, a series of enlightened reviews and legislative changes have shifted the focus from institutional to community care. More recently, services have evolved to become more proactive and responsive, intervening early to offer home-based support and treatment in an effort to keep people out of hospital. An early and striking move of the present government was to elevate mental health, along with cancer and heart disease, to one of its three clinical priorities in 1999. A ten-year National Service Framework was implemented and the following year psychiatrist Professor Louis Appleby was appointed national director for mental health services.
And the money has followed suit. It might come as a surprise to some, but primary care trusts in England spend significantly more annually on mental health – almost £8bn – than they do on the other two clinical priorities. Since 1999, an extra £1.5bn a year has been injected into mental health services. This has helped to fund an increase in the main staffing groups: there are now 1,300 more consultant psychiatrists, 2,700 more clinical psychologists and almost 10,000 more mental health nurses. And there are new types of mental health professional: primary care therapists – graduates who have been trained to provide psychological therapies – and 'support, time and recovery workers', who help and advise community patients and their families.
But there has been controversy, too. This summer, after eight years of trying, the government finally got its proposed changes to the 1983 Mental Health Act through Parliament. While campaigners admit there have been some real breakthroughs – every patient will now have a right to an advocate, for example – some proposals have proved extremely contentious. These include enforced treatment in the community and a change in the terms under which someone can be 'sectioned', ie, compulsorily detained under one of three sections of the Act.
Certainly, the government's actions mean that mental health is no longer the poor relation of the NHS, says Simon Lawton-Smith, senior fellow in mental health at the influential health think-tank the King's Fund. 'Five or six years ago, people were writing articles saying mental health has always been a Cinderella service. I would never say it is a Cinderella service now, and I think credit is due to the government for that.'
He warns, however, that standards could start to slip once the National Service Framework reaches the end of its life, particularly if it is not replaced with another mechanism to keep mental health as a priority.
Other voices are less upbeat. Steve Shrubb, director of the NHS Confederation's Mental Health Network, believes the service continues to lose out compared with other areas of health care.
'If you look at the incidence and prevalence of mental illness I think you would probably still determine it to be a Cinderella,' he tells Public Finance.
'There's undoubtedly been an increase in funding, but I think, in proportion to other areas of health care, it isn't that great and we do constantly have to fight to keep mental health on the political agenda.'
In terms of incidence and prevalence, the statistics are stark. Mental illness accounts for a third of all illness in Britain, according to Appleby. One in four adults will experience some kind of mental health problem over the course of a year and about 10% of children are affected at any one time; depression affects one in five older people living in the community and two in five living in care homes. The Sainsbury Centre for Mental Health has estimated that mental ill health could cost the country as much as £64bn each year in lost earnings, productivity and reduced quality of life.
Future costs might also escalate. Sir Derek Wanless's latest review of health spending for the King's Fund focuses on mental illness. Due to be published in December, it aims to estimate the prevalence of specific disorders over the next 20 years and work out required spending levels and related policy implications.
Given the pervasiveness of mental ill health, its effects are felt far beyond the health service itself. Indeed, the government is attempting to refocus its policy to reflect the mental health of the community as a whole and smash the divisions that exist not just between health professional groups and the primary and secondary care sector, but also between the NHS and other public services.
'There is [a] boundary between mental health services and agencies that offer employment and training, better housing and social support,' Appleby said in his May report Breaking down barriers. 'Increasingly, services aim to go beyond traditional clinical care and help patients back into mainstream society, redefining recovery to incorporate quality of life – a job, a decent place to live, friends and a social life.'
A key area is employment. The largest cohort of people claiming Incapacity Benefit – 40% and rising – are signed off work with mental health problems and the government is keen to get them back into employment. A Healthcare Commission survey published in September revealed that only 20% of people using community mental health services were in paid employment.
'There's a strong macroeconomic argument for helping people with their mental health problems,' says Shrubb. 'Most of that economic argument comes from keeping people at work, because clearly the biggest cause of lost hours is not 'flu or heart disease, it's anxiety or depression or what most people call stress.'
The Sainsbury Centre for Mental Health last week called for GPs to do more to support people with depression back into the workforce.
A possible solution, posited by the economist Lord Richard Layard in an influential report published last year, is an expansion of the type of psychological treatment known as cognitive behaviour therapy, which attempts to modify everyday thought and behaviour and discourage negative thinking. Yet despite guidance from the National Institute for Health and Clinical Excellence, which shows that the treatment is effective, service provision is patchy and access often very restricted. Investment has plateaued since 2003/04.
But change is in the air. The expansion and greater use of psychological therapies to help people back into the workforce was one of Labour's 2005 manifesto commitments and there are rumours that one of the 30 new Public Service Agreements to be announced alongside this autumn's Comprehensive Spending Review will focus on this very issue.
Two pilots are under way – one in Doncaster in south Yorkshire and another in Newham in London – to test ways of delivering the therapy. The results so far are reported to be good. In July, mental health minister Ivan Lewis approved 11 new pilot projects to provide better access to psychological therapies. 'These pathfinders point the way to a radical overhaul of mental health services, with a much greater focus in future on creating access to talking therapies, which ensure people are supported to make a rapid and sustainable recovery,' he said.
Lawton-Smith says that there's now a genuine push for more psychological therapies. 'I don't think it's happening yet in real terms because of the resources. The amount of money spent on it hasn't shifted,' he says. 'We will see an increase in money spent on psychological therapies, but it won't happen unless commissioners are convinced.'
Angela Greatley, the chief executive of the Sainsbury Centre, says she is 'extremely optimistic' now that the employment problem is starting to be tackled but says that in other areas, both within and beyond the NHS, the outlook is much gloomier.
The condition and quality of psychiatric inpatient wards is a long-standing problem. Not only are they difficult to staff and often in quite poor physical condition, but patients have limited access to recreational activities and outdoor space. Surveys have revealed that inpatients are much more dissatisfied with their treatment and care than those in the community.
Housing is also an immense problem, Greatley told PF. Mentally ill people are poorly represented in the privately owned sector and often very reliant on the already pressurised arena of social housing. There are also high rates of mental illness among homeless people.
She says that they not only need access to housing but support from mental health workers and others to stay housed – 'so they know how to manage a tenancy, know how to keep it clean, how to relate to and live alongside other people'.
Mental health problems can be compounded by drug and alcohol addictions and people can find themselves bounced between services – a problem that can be tackled only by effective inter-agency working and good commissioning, she adds.
'They're the same people who are of concern to community safety partnerships, they're the same people who are of concern to the providers and managers of public housing, they're the same people who come into contact with the courts, they're the same people who are parents and therefore of concern to social services. It's a big cross-public service problem.'
Many in the mental health sector are currently facing up to the impact of the long-awaited and controversial new Act. The Mental Health Network takes a pragmatic line, stating that the Act is better than it would have been if earlier government proposals had been passed unchallenged. 'It's time to get on and implement it,' Shrubb says.
A code of practice spelling out what the Act means in practice is being drawn up and is due to be published for consultation soon. 'A lot of the areas that people are still frustrated with are covered by the code,' Shrubb says. 'That means there's still a great opportunity to change and shape the way the Act is actually implemented on the ground.'
For Andy Bell, chair of the Mental Health Alliance – a coalition of organisations that lobbied hard to improve the Bill – the new Act represents a missed opportunity to have modern mental health legislation fit for the twentieth century. Some of the shortcomings with the old Act persist in the new one, he explains. People with decision-making abilities can still have compulsory treatment thrust upon them, and the Act makes no provision for those who are well to make advance decisions about how they want to be treated when they are ill. 'They are very, very serious omissions indeed,' says Bell.
A major and particularly contentious change is the introduction of Compulsory Treatment Orders, a set of conditions placed on a patient being discharged from hospital, such as requiring them to continue taking their medication. If they breach their conditions, they are readmitted to hospital.
Bell believes CTOs are the biggest change in terms of how the legislation is going to work. 'It is a very different form of care and treatment,' he says. 'Coercion, or the threat of coercion, has never happened before in a community setting and will require all community mental health teams to work in a different manner. It certainly has an impact on primary care because, for the first time, GPs and their staff will be working with people outside hospital who are under compulsory powers, whereas previously all those people had been inside hospital.'
There will also be significant resource implications, as many more staff will have to be trained to handle CTOs. Lawton-Smith has researched the use of CTOs in Scotland, where they were introduced 18 months ago. Based on this, he estimates that in England there will be some 2,500 people under a CTO a year after their introduction. But, as more people will be put on them than come off them, this is likely to creep up to somewhere between 8,000 and 13,000 over the next ten to 15 years.
Both Lawton-Smith and Bell agree that, as the number of CTO patients increases, ordinary community patients could lose out, as staff devote more time and resources to keeping CTO patients out of hospital.
Another big source of argument was the government's proposal to remove the 'treatability test' from the conditions under which a person could be sectioned. This meant a person could be compulsorily detained and treated in hospital only if their condition could be made better, or at least stabilised. Removing this test would extend the reach of the Act to the small number of people with so-called dangerous personality disorders, which, it was claimed, could not be treated. But mental health professionals were concerned that it could mark a dangerous shift in their roles – from clinicians and carers to jailers.
A compromise was reached and the Act now states that if a person is compulsorily treated there must be a purpose of making them better or less worse, but no requirement that such treatment will work.
'How much of a compromise it is depends crucially on what comes next in the code of practice,' Bell says. 'We'll have to see how the code is written and interpreted by both practitioners and inevitably in the courts.'
With court actions looming and coercion set to become a more prominent feature of mental health treatment and compulsory treatment for the untreatable, campaigners will be working hard to ensure the Act does not represent a return to Victorian values.
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