We have seen huge strides made in challenging the stigma of mental ill health, growing awareness of the need to improve care and starting to turn the tide on the lack of equity in terms of treatment and access to mental health services.

A decade or more of campaigning and cross-party commitment to bring about change has made an impact and transformed attitudes. National initiatives, notably the Five year forward view for mental health and the recent long term plan, have delivered a national, timed implementation programme and committed additional funding. Results from our recent survey of mental health trust leaders confirm that we must celebrate the impressive progress but also be clear sighted about the challenges that remain – which are contributing to and maintaining a significant 'care deficit' across mental health services:

  • rising demand emanating not only from raised awareness but critically from socio-economic factors, including the impact of the roll out of universal credit, increased deprivation, unemployment and housing issues
  • an enduring workforce shortage that undermines the frontline’s ability to staff services efficiently and effectively
  • despite welcome additional investment, mental health funding is constrained and does not always reach the frontline services that need it most
  • the impact of cuts to wider public services, in particular those commissioned by local authorities such as drug and alcohol services.


Across health and care the focus is often on the pressures that hospital services face in winter. They act as a litmus test for the performance of the system as a whole and provide a snapshot of its capacity and resilience. Winter pressures emanate from the combination of cold weather, flu, an increasingly frail population, a stretched workforce and delays in discharging patients from hospital. What is often overlooked is that mental health services experience these winter pressures too and also face unique demand pressures that endure year round stemming from socio-economic factors.

What is often overlooked is that mental health services experience these winter pressures too and also face unique demand pressures that endure year round stemming from socioeconomic factors.

   


Late last year we surveyed mental health trust leaders to gain a deeper understanding of the current operating environment and its impact on those leading and delivering frontline services. Since the survey was carried out the NHS long term plan has been published. This report uses that frontline feedback to identify the key challenges and their impact on the services mental health trusts provide. We give a brief overview of the current policy context and explores three important elements of the current care deficit in mental health provision:

  • the demand challenge
  • the workforce challenge
  • the system challenge.

 

Policy context – the long term plan

The long term plan is clear that making further progress on improving people’s mental health and wellbeing is a priority for the next decade. The plan includes the welcome commitments to increase the real-terms mental health budget and grow investment faster than the NHS budget overall for each of the next five years. Proposals to significantly expand provision for children and young people and improve transition to adult services, deliver more care for adults in the community, and provide early intervention for those in crisis are also extremely welcome. However, we must ensure that these commitments do not come at the expense of funding for and access to core mental health services, particularly for individuals with severe and enduring mental health conditions.

Since the publication of the long term plan, NHS England has confirmed that funding for mental health will only rise as a share of the NHS budget by 0.5% (NHS England, 2019c). The size of the rise in funding for the sector falls far short of the amount needed to close the gap with funding for physical healthcare and raises questions over how much of the plan mental health providers can realistically deliver as a result.

We must ensure that these commitments do not come at the expense of funding for and access to core mental health services, particularly for individuals with severe and enduring mental health conditions.

   


The plan’s success is predicated on having the right workforce, with the right skills, in the right place. The NHS is facing significant workforce gaps across the board and the challenge for mental health trusts is particularly severe. The long term plan’s numerous ambitions for the sector cannot be delivered whilst workforce pressures remain across services and gaps in the mental health workforce continue to grow. A national workforce plan, with appropriate focus on the mental health workforce, must be published as soon as possible, coupled with adequate funding from the comprehensive spending review that meets the plan’s education and training budgetary requirements. Providers also need a detailed implementation plan that sets out exactly what will be delivered and when, with priorities for each year matched against the funding and staff available.

The move to system working at scale and pace is a key feature of the long term plan, envisaging that all areas will become integrated care systems (ICSs) by 2021. ICSs are clearly marked out as the organising principle to deliver health and care services, including mental health. This is a positive step, particularly given the interdependence between mental health services and wider public health and prevention work undertaken by other parts of the local public sector. However, we must also recognise there are a number challenges inherent in this approach, including structural pressures in specific systems and the nature of local relationships which can slow progress.

The long term plan is an ambitious programme, with a host of new commitments for the NHS, including for mental health services . It will be particularly important that there is a clear implementation plan so that trust leaders can balance the transformation and new demands with managing ongoing operational challenges.