‘We are firefighting': the mental health funding shortage that’s hitting frontline care

A Community Care investigation reveals how staffing and resource shortages are damaging patient care

Picture credit: Photofusion/Rex
Picture credit: Photofusion/Rex

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.

Our investigation, based on Freedom of Information requests to 51 NHS mental health trusts, found that extra investment in mental health services has not kept up with inflation despite rising demand for care. We also found that a lack of resources and staff is severely compromising care in parts of the country, with frontline teams often being left to hold the risk.

Data returned by over two-thirds of the mental health trusts, obtained in two separate Freedom of Information requests, showed that:

  • Overall trust budgets for 2013/14 had shrunk by 2.3% in real terms from 2011/12. Ten out of 13 trusts that provided forecast budgets for 2014/15 are projecting further cuts next year.
  • Budgets for ‘crisis resolution teams’ fell 1.7% in real terms compared to 2011/12 while the average monthly referrals to these teams rose 16%. The teams provide intensive home treatment in a bid to prevent acutely unwell people being hospitalised.
  • Budgets for community mental health teams flatlined in real terms but referrals rose 13.3%. These services provide ongoing support in a bid to prevent people’s mental health deteriorating to crisis point.

In response, care and support minister Norman Lamb said: “It is completely unacceptable for local commissioners to disadvantage mental health in the allocation of funds to local health services. This completely conflicts with the government’s clear position that there must be parity of esteem – equality – between mental and physical health. This must be a priority for NHS England to address.”

The findings – calculated using the government’s official method for working out ‘real terms’ prices – come amid growing pressure on services to treat people out of hospital.

In October, one of the country’s top psychiatrists warned the mental health system was “unsafe” and in crisis as we revealed that the NHS has closed more than 1,700 mental health beds since April 2011. At the time, the Department of health and NHS England pointed to the fact more people are being treated at home by community teams.

Paul Farmer, chief executive of mental health charity Mind, said: “Time and again we are told that, when beds are cut, it is part of an overall strategy to invest resources differently and improve services, but this is clearly not the case at many trusts.”

“The ultimate consequence of these cuts is that people don’t get the help they need in crisis,” added Farmer.

Patient care compromised

NHS trusts that had cut community team investment said they were under pressure from commissioners to make year-on-year cost savings but insisted they had redesigned services to “work more efficiently” while protecting frontline care.

However, our investigation found that community care at some services is being compromised by a shortage of resources. From an analysis of NHS board papers and Care Quality Commission (CQC) inspection reports we found:

  • Urgent crisis assessments are being delayed. An understaffed home treatment team in north London took more than five weeks to act on an urgent referral made by a GP, CQC inspectors found.
  • Patients are not being seen regularly enough. NHS bosses in Bradford admitted two community mental health teams are carrying “unmanageably high caseloads”.
  • Out-of-hours care is lacking. Just two nurses and a social worker were expected to provide out-of-hours crisis response for Cornwall, a county with a population of over 500,000, a CQC report shows. Patients who used the trust’s crisis services received “dismissive” advice. One patient who called a crisis line three times was told to “have a bath”. The patient self-harmed afterwards.
  • Overwhelmed staff are struggling to meet demand. In Kent, carers’ advocates have warned commissioners that community support is “unacceptable” and crisis teams only see acutely unwell people for as little as 10 minutes.
  • Staff at a Surrey crisis team told bosses they feel they are being left to “hold the risk” due to the failure of other services to manage people’s deteriorating mental health, a trust report found.
  • High sickness levels at community teams in Humber have also hit patient care, trust directors found.
  • Trusts are diverting cost savings from vacant staff posts in community teams to offset overspends on hospital care.
  • Community support for people being discharged from hospital is also being hit by cuts to social services budgets and a lack of supported housing.

Norman Lamb said the government’s commitment to introducing waiting time limits for mental health services by 2015 would improve access to care and help end the “institutional bias against mental health” in the NHS.

The mental health trust serving the minister’s constituency of North Norfolk cut spending on crisis and community teams from £39.8m in 2012/13 to £37.2m in 2013/14. Staffing levels dropped from 847 full-time equivalent posts to 793 in the same period.

Frontline staff at Norfolk and Suffolk NHS Foundation Trust claim that cuts to services are leading to unsafe care. The trust denies those claims and said a service strategy introduced last year will deliver cost savings at the same time as putting services within the top 25% of all mental health trusts on several indicators of care (read the trust’s full response).

Real-terms cuts

The pressures in Norfolk are far from unique. Data obtained from 44 mental health trusts showed that, when inflation is factored in, overall budgets have shrunk by 2.3% in real terms compared to 2011/12. Investment rose in cash terms from £8.1bn to £8.2bn over the same period. Ten of the 13 trusts that provided forecast budgets for 2014/15 plan to make further cuts next year.

Frontline teams are also seeing investment outstripped by inflation. Data obtained from 36 trusts showed that spending on community mental health teams rose from £397.7m in 2011/12 to £412.4m in 2013/14. Accounting for inflation, budgets have shrunk 0.03% in real terms compared to 2011/12. The average referrals being handled by these teams rose by 13.3% in the same period.

Of the 32 trusts that had specialist crisis resolution teams for all three years, investment rose in cash terms from £128.4m in 2011/12 to £130.9m in 2013/14. This amounts to a 1.7% reduction in real-terms. The average number of monthly referrals to these teams rose by 16% over the same period.

The findings raise questions over claims from NHS trusts that savings from bed closures are being used to boost community services.

In August, Surrey and Borders Partnership NHS Trust told Community Care that savings from the closure of 33 adult psychiatric beds had been reinvested in ward staffing and community and home treatment teams. Yet spending on the trust’s community mental health and home treatment teams fell from £19.9m in 2011/12 to £18.7m in 2013/14.

The trust said it had redesigned services to help them “work more efficiently” and reduce back office spend.

“Proportionately, we now spend more on frontline services than ever before – with £75 in every £100 going on patient care, as opposed to £65 in every £100 a few years ago,” a trust spokesperson said.

But one patient who uses the trust’s services told Community Care that getting help from home treatment teams had become “extremely difficult”.

“It feels like the reduction in beds has resulted in a greater pressure on teams and higher threshold for acceptance. The teams still provide out-of-hours assessments in A&E departments but, apart from that, people like myself are left with a ‘crisis helpline’, which really is inadequate and, I believe, dangerous,” she said.

Morale at ‘all time low’

Leading social workers and mental health campaigners said the funding crisis needs to be addressed.

Faye Wilson, chair of the British Association of Social Workers’ mental health forum, told Community Care that staff morale in many community mental health and crisis teams is “at an all-time low”.

“Staff want to give a good service but in many teams they are not getting the resources they need to do their jobs. They also feel that if anything goes wrong, they’ll be hung out to dry. So you end up with a defensive rather than a defensible system,” she said.

Ruth Allen, chair of The College of Social Work’s mental health faculty, said:”If the government is serious about parity of esteem for mental health – and I believe the care services minister certainly is – it is vital the impact of changes to funding across mental health, and the knock on impact of reductions elsewhere including social care, are recognised and acted upon.”

Dinesh Bhugra, ex-chair of the Royal College of Psychiatrists, said: “We have warned before that the economic downturn will increase demand. To have resources cut further at the time when we need them most is stigmatising to people with mental illness.”

Mind’s Paul Farmer said:”Mind hears all the time from people who have lost the community health care that was helping them to cope and who now find themselves unable to get through to their local crisis team, or feel ‘fobbed off’ when they do, because there simply aren’t enough staff to cope with the numbers of people in desperate need of their help.”

That’s certainly the experience of Emma Bardney. She suffers from complex post traumatic stress disorder but says she’s been failed by her mental health trust.

“Its been really tough…fighting for the right to get better,” said the 42-year-old paramedic. “There’s been no community mental health support available to me. So my care plan has been sporadic out-patients with a consultant or crisis support and nothing in-between and the only way you can access support is when you are in crisis. So you have to get to a very low point before you get any type of support or help.”

Frontline staff are feeling the pressure too. One social worker based in a crisis resolution team said her team was “firefighting” due to an “abysmal” shortage of resources.

She said: “We are having to manage a caseload of very unwell clients without the support to do so. Because of sickness rates at our community teams, people are not being seen by their care coordinators and they end up coming to us at a point when the only option is hospital admission.

“Yet there are no beds locally so our crisis team staff are spending all nights at a client’s home waiting for transport to an out-of-area bed meaning that they can provide no service for other emergencies. The stress is overwhelming.”

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