10 ways the underfunding of mental health services is damaging patient care

How patients are being hit by problems in community and crisis care

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Picture credit: Oliver Rudkin/UCF/Rex Features

A funding shortage for mental health services in England is putting patients and staff at risk, an investigation by Community Care and BBC News has revealed. Here are 10 ways patient care is being impacted:

1. Overstretched crisis teams giving ‘dismissive’ advice

Patients told Care Quality Commission inspectors that they received “dismissive” advice when they rang Cornwall Partnership NHS Trust’s home treatment team for crisis support. One patient who phoned for help was told: “I am the only one working, don’t kill yourself on my shift”.

The CQC’s report of the inspection, published in September, states:

“One person told us they contacted the home treatment team three times and each time the advice was not helpful: “[have a] cup of tea”, “have a bath” and “I don’t know what to do”. The person told us they self-harmed following this advice.”

Staff at the service told inspectors they were under pressure. Teams had less psychiatric nurses on duty and “expectations of people who used services could be much higher than they were able to deliver”. The report also found that problems accessing out-of-hours care from the home treatment team was impacting local police and ambulance services.

The CQC heard how a duty team of one approved mental health professional and two nurses was expected to cover the whole of Cornwall, a region with a population of more than 500,000 people. Patients also told inspectors they felt they had “no allocated support” after being discharged from services.

What the trust said: The trust said it had presented a “business case” to commissioners for improvements to home treatment team provision.

“This seeks their support to bring the home treatment team staffing levels into line with best practice guidelines and provide a more responsive out-of-hours service. We are also working with the Samaritans and a locally commissioned telephone support service – Nightlink – to ensure our clients understand the full range of services which are available to them out of hours.”

2. People in crisis ‘only seen for 10 minutes’

At a September meeting of Ashford Clinical Commissioning Group, the chair of a local carers’ charity warned that the standard of care being provided by community mental health services was “unacceptable” and asked how the local crisis team, run by Kent and Medway Partnership NHS and Social Care Trust, was going to cope with growing demand.

“At the moment, they are spending just 10 to 30 minutes with a patient who is in crisis,” she warned. Commissioners thanked the charity for “raising a number of very serious issues”.

At the same meeting, a member of the public stated that the crisis team were not turning up at the point of crisis and would often turn up 24 hours later.

Data provided by the trust to Community Care shows that crisis team budgets at the trust have increased by £1m compared to April 2011 but investment in community mental health teams dropped by £860,000 in the same period.

What the trust said: “Response times are always agreed with the patient. Our target response time is four hours with a maximum of up to 24 hours. Response times will only ever be longer with agreement from the referrer and the patient.

“On average we spend between 30 to 60 minutes with a patient however, this can vary from 10 minutes to two hours. Most patients will usually be seen at least once a day and spending too long can be tiring for them.”

3. Patients in need of ‘urgent’ assessment not seen for five weeks

An urgent GP referral to Barnet’s home treatment team had not been followed-up when CQC inspectors visited the service five weeks later. The issue was one of several problems flagged up by CQC inspectors in an inspection report into community services at Barnet, Enfield and Haringey Mental Health NHS Trust.

The report, published in May, also warned that staff at the trust’s home treatment team in Haringey felt “the workload was too much for the number of staff available”. Service users complained about problems getting staff to visit them and “inconsistency in care” from services.

What the trust said: The trust said it had taken “swift action” to resolve the issues identified by inspectors.

“As a result, our home treatment teams no longer exist in their previous form, and have been replaced with our new crisis resolution home treatment service which went live on 4 November 2013. There has also been extensive work done around capacity modelling to make sure that workloads are manageable, and medicine management.”

4. ‘Unmanageably high’ caseloads

Two community mental health teams run by Bradford District Care Trust have “unmanageably high caseloads”, board papers reveal. The situation risks service users not being seen often enough and “potential for increased risk to self and others”.

What the trust said: “This is limited to two teams working within inner-city Bradford, where demand for services is greater and can prove challenging. We are taking the risk very seriously and have acted to introduce a single point of access and ‘stepped care model’. The model makes sure that patients are assessed by the appropriate team member and that their care is co-ordinated at the right level.”

5. Community team budgets cut despite promises of investment

A Community Care and BBC News investigation published in October revealed that Surrey and Borders Partnership NHS Trust had closed 33 adult acute mental health beds since April 2011. At the time, the trust said that savings from the closure had been invested in ward staffing and “additional resources invested in home treatment teams”.

Data provided by the trust this month shows that the budget for home treatment teams fell from £4.5m in 2011/12 to £4.2m in 2013/14. The budget for community mental health teams dropped from £15.3m to £14.5m in the same period.

What the trust said: “The majority of resources freed up from the closure of 33 working age adult mental health beds in 2011/12 were re-invested in staffing our remaining inpatient and rehab services. We ensured that all available resources were put back into in service redesign or that they contributed to cost improvements in our community services.”

6. Crisis team budgets cut by up to 17%

Crisis resolution and home treatment teams at Birmingham and Solihull mental health trust saw their budgets fall from £6.3m in 2011/12 to £5.3m, a 17% fall (this was the largest percentage drop of the trusts that provided data). The trust’s budget for community mental health teams dropped from £13.4m in 2011/12 to £13.3m during the same period.

What the trust said: A trust spokesperson attributed the reduction in crisis team funding to “the merging of some our home treatment teams and implementing a slightly different skill mix within the new team in order to implement a new model of care.”

On the fall in community team budgets the spokesperson added: “Our community teams have been working for the last couple of years on a fundamental redesign across the service pathway in order to better meet patient need and improve patient experience. Again, this has included a review of staff skill mix and in addition, as a result of the trust’s estates rationalisation we moved to fewer, more suitable buildings by consolidating some services.”

7. Crisis teams left ‘holding risk’ of acutely unwell people

A ‘customer journey mapping exercise’ by Surrey and Borders Partnership NHS Trust that looked at care at its home treatment team identified a number of concerns. Staff felt “they had to hold the risk” of people in crisis after other services had failed to contain it. There was a “lack of clear standards” in the team and GPs’ “clearly reported dissatisfaction” with the ability to reach teams and key staff.

What the trust said: “We are still in the process of reviewing these findings with our stakeholders but our clinical commissioning group has been pleased with our work so far. This is already resulting in improved relationships with, for example, accident and emergency services in our general hospitals. There have been specific actions for the local team this was trialled with and our next step is to use this feedback in our improvement plans for all our home treatment teams.”

8. Teams facing double the workload despite staffing cuts

Board papers show that the crisis resolution teams at Coventry and Warwickshire Partnership NHS Trust delivered 893 home treatment episodes in the first quarter of this financial year, more than double the trust’s planned activity level of 389 episodes. The trust’s budget for crisis teams dropped from £3.26m in 2011/12 to £3.25m in 2013/14 and staffing levels fell from 82.43 funded posts to 77.1 funded posts in the same period.

What the trust said: “We believe these and other figures show we have increased the cost effectiveness and productivity of our service, and continued to meet the needs of our patients. Like many trusts we are having to achieve more with less resource. As a result we are conducting a fundamental redesign of our secondary care mental health service to ensure people with most acute need receive the right service even faster.”

9. Services ‘unable to provide safe alternative to hospital’

In recent weeks frontline staff at Norfolk and Suffolk NHS Foundation Trust have launched a campaign protesting against cuts to services that, staff say, are “decimating” community services to the point that crisis teams can “no longer provide a safe alternative to hospital”. The trust says the claims are inaccurate (read the full story, and the trust’s response, here).

10. Staff sickness rates affecting care

Board papers from a May meeting of Humber NHS Foundation Trust reveal a number of concerns around services. Directors who visited the trust’s Avondale service in February noted that community mental health team “sickness is affecting clients and difficulty in moving patients on due to social care issues”.

Data provided to Community Care showed that the trust’s spending on community mental health teams dropped from £9.8m in 2011/12 to £9.3m in 2013/14. Staffing levels dropped from 272.8 full-time equivalent posts to 261.7 posts in the same period. The trust did not respond to a request for comment.

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