A mental health strategy for the next five years

Mental Health

Mental health problems represent the largest single cause of disability in the UK. Mental illness accounts for 23% of the total burden of disease in the UK, yet only 13% of the NHS budget is allocated to it. One in four adults experience at least one diagnosable mental health problem in any given year. One in ten children aged 5 – 16 has a psychiatric disorder and children from low income families have three times the rate of those from the highest. The suicide rate is rising after many years of decline and the rise is most marked amongst middle aged men. For men aged 15 – 49, suicide is the leading cause of death. People with severe and enduring mental illness die on average 15 to 20 years earlier than other people. Three quarters of people with mental health problems receive no support at all and of those that do, too few have access to the full range of interventions recommended by the National Institute for Health and Care Excellence (NICE).

Following the publication in October 2014 of the document “Five Year Forward View” for the whole NHS, NHS England set up a Mental Health Taskforce in March 2015 to create a new five year all-age national strategy for mental health in England. It reported in February 2016 and its recommendations are to be implemented by 2020/2021.

The report, ‘The Five Year Forward View for Mental Health’ makes 57 recommendations, many of them far reaching which immediately brings into question their feasibility both in general and certainly within the time scale. Priorities include

  • a seven day NHS – there has always been a 24/7 assessment service for psychiatric emergencies, but the report recommends a greater availability of crisis/home treatment teams. This is good in its own right and is particularly geared towards avoiding admissions to a psychiatric hospital bed. However, beds have reduced in number by 39% between 1998 and 2012 and the UK has only 63% of the EU average, way below that of France (120%) and Germany (174%). The bed shortage puts a strain on the whole adult service. Detentions under the Mental Health Act continue to rise year on year. The shortage of clinicians makes expansion of the out of hours service unrealistic. Labour has opposed the ill-founded Tory 24/7 policy for the whole NHS.
  • integration of mental and physical health approaches – people with long-term physical illnesses suffer more complications if they have concurrent psychiatric disorder and costs go up by 45%. By 2020/21 at least half of all acute Trusts are to have liaison psychiatric availability to medical services including A&E.
  • prevention at key moments in life – while this is an admirable objective, there is little evidence to show that interventions can prevent mental disorder.
  • building mentally healthy communities – there is welcome acknowledgement of the need for decent housing and stable employment in maintaining good mental health and of the importance of wider social determinants.

Child and adolescent psychiatry is recognised as being particularly under-resourced. “At least 70,000 more children and young people should have access to high-quality mental health care when they need it” including timely access to psychological therapies. Crisis and home treatment teams for children and young people are to be developed – out of area placements for acute care should be reduced and eliminated as quickly as possible. However even for the most treatable difficulties such as panic disorder, 30% have not recovered at the end of treatment and for anorexia nervosa the figure is close to 50%. Treatment also has the potential for harm and one shouldn’t assume that access to a specialist professional is always the best way to address mental health problems. From the outset there needs to be a focus on what the young person wants and shared decision making. Empowering parents may be particularly effective and schools may have a key role in mental health promotion.

For adults there is to be a huge expansion in availability of psychological treatment including for those with psychosis, bipolar disorder and personality disorder. 600,000 people are to be treated, presumably over the five year period. There are recommendations for public mental health in relation to suicide prevention, primary care, perinatal psychiatry, rehabilitation and social psychiatry, old age psychiatry, addictions psychiatry and forensic psychiatry. There is to be a 10 year strategy for research.

The Five Year Forward View for Mental Health states that mental health must remain a priority in the current NHS financial climate and that £1 billion additional investment in mental health is needed. This has been accepted by NHS England. However, it is not clear how much of this has already been allocated in the £10 billion promised for the whole NHS. Currently spending per capita on mental health across clinical commission groups (CCGs) varies almost two fold. In 2011 the House of Commons Health Committee report on NHS Commissioning concluded that there had been “20 years of costly failure” in England in relation to the purchaser-provider split. Scotland opted out of this market in 2004. The Five Year Forward View for Mental Health mentions some of these commissioning problems. Future developments include amalgamating CCGs with clinical services thereby abolishing the purchaser provider split in a few areas with a more widespread emphasis on collaboration between services rather than competition as a means of driving improvement. Labour will promote this development towards a non-marketised NHS.