The National Service Framework for Mental Health is four years old this month, but there are few reasons to celebrate, argues Andrew McCulloch who says that lack of resources is hampering the attempt to implement the 10-year plan.

While the Department of Health acknowledged from the outset that "implementing the NSF fully across the NHS and social services could take up to 10 years",¹ it is clear at this point that many standards are not being met, and vital targets are shortly to be missed by large margins. And what has become of the well-trumpeted cash injections for mental health services that were supposed to power the reforms?

It is widely acknowledged that the NSF is a hugely aspirational piece of work, but it was suffocated by the prescriptive and over-ambitious NHS Plan that followed it. Where a route map to implementing the framework was desperately needed, professionals were instead handed a shopping list, with few clues about where to find the money.

But there is some good news - policy guidance designed to implement and complement the framework continues to show the sound thinking behind the attempts to reconfigure services.

Recent examples include policy implementation guidance on services for people with the label of personality disorder, and the women’s strategy, Into the Mainstream. Furthermore, assertive outreach services have been widely implemented.

However, overall, self-assessments and external studies across the range of services make grim reading.

Standard One - mental health promotion
The NSF fails to set out a visionary public mental health agenda - indeed mental health promotion in this country is rather narrowly conceived and the NHS has limited public health levers.

According to the DoH’s own public attitude survey, "attitudes towards people with mental illness stayed about the same between 1993 and 2000 and became less positive between 2000 and 2003."2

Many commentators believe the DoH is working against itself by setting up worthy anti-discrimination targets on the one hand and on the other using rhetoric that stigmatises service users, in order to win support for the deeply unpopular mental health bill.

A reduction in stigma and discrimination are fundamental to many other elements of the NSF and particularly to issues such as access and engagement.

Standards Two and Three - primary care and access to services
It’s difficult to judge the performance of primary care in tackling common mental disorders, as there is no systematic audit of this area. We know that diagnosis rates are not high - 60 per cent is quoted by The Sainsbury Centre for Mental Health.3 However, prescription rates for anti-depressants are rising steeply. But there does appear to have been a gradual improvement in primary care’s ability to detect and address common mental health problems. There is also evidence of improvement in the development of primary care-centred mental health initiatives. However it is clear that the standards are not being met. We know from research evidence and stakeholder testimony that many mental health problems are treated with ineffective interventions such as unfocused counselling. And around the clock access is not being delivered - in fact there is not even a delivery system for such access.

Standards Four and Five - effective services for people with severe mental illness
Standards four and five relate to issues such as care planning, access, and in-patient care, but in practice they have been trumped by NHS Plan targets. These prioritise intensive community care, and pressure from the centre has favoured the creation of intensive community teams, the progress of which can be seen below.

Overall, it must be said that implementation of assertive outreach in England has been a qualified success. Better contact is being maintained with many vulnerable people, suggesting much, as yet unproven, potential for better outcomes.

But there is little doubt that we will spectacularly fail to meet the unrealistic NHS Plan target for crisis resolution. The magnitude of change required here was much greater than for assertive outreach. While some progress has been made towards rebalancing, it is unlikely that demand for hospital beds can be reduced by the 30 per cent set in the NHS Plan without other provision such as crisis houses being prioritised.

The cost of delivering the remaining 224 teams, even if the staff were available, would be around £135m per year, and the funds are simply not available. The crisis resolution policy still makes sense, but the DoH needs to put a realistic timetable in place as well as financial and HR plans.

We will also fail to meet the NHS Plan target on early intervention by a large margin. It’s dubious whether, at this point in the development of English mental health services, early intervention teams focused on targeting early onset psychosis are a good use of public money.

There is a pressing need for much broader early intervention work with a huge number of young people, who remain a scandalously neglected group within mental health policy.

The DoH has been saying that the Care Programme Approach has been fully implemented for some years. But a recent survey from Rethink provided a devastating commentary on services. It found that 34 per cent of people engaged with services received no written information, and one in four respondents had been turned away when seeking help over the last three years. Depressingly, this figure rose to 39 per cent for people from ethnic minority groups. Nineteen per cent of respondents did not know how to access services out of hours and 15 per cent had no formal help whatsoever available out of hours.4

Finally, there is continuing evidence of poor standards of care and poor environments in-patient care, despite some modest improvements within specific trusts or regions. Opinion varies as to whether the acute in-patient care model can ever deliver decent quality care or positive outcomes.

There is a consensus that a place of safety is needed for people in crisis but no consensus on what form that place of safety should take.

The Mental Health Foundation and The Sainsbury Centre for Mental Health jointly recommended an alternative strategy, that a spectrum of non-institutional crisis services should be developed.5

Standard Six - caring about carers
It appears little or no progress has been made in quality of care for carers.

This is hardly surprising as the lead here was given to social services, which do not have the resources to support the army of informal carers. The picture is depressing, and there are no realistic plans to make this crucial standard work.

Standard Seven - preventing suicide
The NSF was supplemented last year by the Suicide Prevention Strategy. This set very ambitious targets, given that our suicide rates are not high by northern European standards. They have also been on a gentle downward trend since the 1980s. But targets cannot be met through health care agencies’ actions alone as most people who commit suicide are not in touch with mental health services. However, the international evidence base suggests a concerted multi-sectoral approach can work, and the DoH’s actions to begin this process are commendable.

Broadly speaking, the NSF remains seminal to the development of modern mental health policy. It has many excellent features in that it is progressive, focused, and at least partly evidence-based. But the financial and human resource problems which beset services will continue to undermine and often halt progress unless they are properly addressed.

At this point a thorough review of the NSF might ensure that the targets pursued for the remainder of the DoH’s stated ten-year timeframe are plausible and truly add value.

Dr Andrew McCulloch is chief executive, The Mental Health Foundation.

¹ Department of Health, Modern Standards and Service Models: National Service Frameworks, Executive Summary, 1999

² Taylor Nelson Sofres, Attitudes to Mental Illness, commissioned by the DoH, 2003

³ The Sainsbury Centre for Mental Health, Primary Solutions, 2003

⁴ Rethink, Just One Percent, 2003

⁵ The Mental Health Foundation and The Sainsbury Centre for Mental Health, Being There in a Crisis, 2002