Vulnerable to cuts?

Mental health services, like other areas of health and social
care, have been the subject of a plethora of guidance and promises
of additional funding in recent years. Mental health appears to
have been a priority, yet amid all the other priorities clamouring
for attention will it yet again be the service to lose out as
budget pressures intensify?

The press have highlighted several funding dilemmas affecting
mental health services. Back in December, the Observer ran
an article claiming that “patients with mental health problems
could end up on the streets because councils are faced with
diverting money into different services to avoid new government
penalties”. The article went on to link the £120 per day fines
on local authorities that do not ensure discharge of “bed blockers”
with potential transfers of funds from mental health projects to
residential care budgets.

Other developments, such as the relaxing of ring-fenced use of
funding by “starred” councils, could also see funding for mental
health being transferred to meet other priorities. Meanwhile, the
capping of the mental health grant has created pressures over
meeting the costs of inflation and increased salaries, quite apart
from any growth in service provision.

In order to gain an overview of what is happening to funding for
mental health services, about 20 agencies including social services
departments, primary care trusts, and voluntary sector providers
were contacted in December on behalf of the Sainsbury Centre for
Mental Health.The aim is to follow this up by setting up a panel of
agencies that will hopefully provide regular information on budget
decisions over the coming months.

The focus of the interviews was on current pressures on mental
health budgets with a view to identifying any reductions to
funding, especially to voluntary sector providers. The picture that
emerged was one of great variation across the country. Not
surprisingly, most talked of the budget pressures they were facing.
For some these were seen to be part of the normal process of
managing a service, yet for others there were specific
problems.

Two PCTs mentioned the historic debts they had inherited, while one
mental health care trust was faced with historic problems
associated with staff redundancies from a long-stay hospital and
potential difficulties arising from low pay legislation.

Similarly, social services departments reported a mixture of budget
scenarios, with some reference to severe restraints over making new
residential placements in the light of over-committed budgets.
None, however, referred to closing or cutting services, but clearly
there are pressures to fund inflation costs. On the latter point,
the voluntary sector reported most concern over settlements, or
lack of them, to cover inflation.

PCTs are now the major funders of mental health services, an
activity that clearly should be undertaken in collaboration with
other agencies. It is apparent that there is wide variation across
the country as to how joint commissioning of services is being
undertaken. Not surprisingly the dislocations caused by the
movements of staff between health authorities and PCTs have
fractured previous working relations, disturbed contact networks
and in some instances displaced local “champions” of mental health
services.

A survey by the Sainsbury Centre for Mental Health undertaken in
2000 of the then 481 primary care groups found that while
three-quarters of the 197 respondents had a clinical lead (all
medical) for mental health, only a third had a manager with some
responsibility for mental health. All bar one of these managers
also dealt with other clinical areas, leaving on average just 25
per cent of their time for mental health matters.¹

Three years on and one would expect a very different situation to
prevail, yet there are indications that mental health is in danger
of slipping as a priority amid all the other pressures facing PCTs.
These signs are summarised in the panel above.

However, this is not the only trend. Reports pointed to developing
joint commissioning arrangements involving several PCTs with their
respective local authority. These agreements utilised the
flexibilities of the Health Act in developing a range of services
to address social inclusion in particular with regard to
employment, and involvement of the voluntary sector in developing
crisis services and assertive outreach.

Voluntary sector providers were described by one commissioner as
being in a “bullish mood” at present, especially those larger
national providers of supported housing and residential care.
Supporting People will provide a short-term bonanza for many as
their incomes are boosted during the transition period and before
local authorities gain greater control over the assessment of need
and allocation of funding.

Some also reported benefiting from the strategy adopted by some
PCTs of rolling forward contracts, without scrutinising them.
However, the future poses many uncertainties, especially for
smaller (often locally based) providers, with talk of mergers
already occurring. But this is an area where local rivalries can be
strong and the consequences of the era of competitive tendering
still remain, with organisations wary of one another and unwilling
to work jointly.

Recent reports have highlighted the mismatch between NSF
aspirations and the reality of service planning, co-ordination and
delivery on the ground, and the weaknesses of much primary care
provision for mental health. The creation of PCTs should lead to
the setting of local priorities with joined-up strategies to
achieve such targets. At present, however, the pressure to
demonstrate achievement of NSF and other NHS targets often appears
to be running counter to requirements for a locally developed
service.

Health secretary Alan Milburn, in his speech to the National Social
Services Conference in November, outlined his vision of the future
of social services. This would essentially take the form of
children’s trusts and, for older people, care trusts.

This would also appear to be the future for mental health, with a
few embryonic care trusts already in place. Yet at present the
picture across the country is one of great variation in working
arrangements between health and social services. There is already a
fear that any new money coming into social services will go to
older people’s services, even more so now in light of the proposed
fines for delayed discharges. Similarly, within PCTs pressures on
prescribing budgets and waiting lists for acute services may yet
again leave mental health the worthy but poor relation with
expectations that may never be realised.

Nigel Goldie is an independent researcher and
consultant.

References

¹
Setting the Standard, Sainsbury Centre for
Mental Health, 2001

Signs of a priority slip

• A narrow “cost accountancy” perspective being taken to the
  viability of schemes that by their very nature face difficulties
  to, for example, sustain required high levels of occupancy.
• A narrow focus on those aspects of the National Service
  Framework focused on treatment, with less attention to the
  development of whole systems approaches that require close working
  across a wide range of agencies. Employment schemes appear to be
  being downgraded in this regard.
• A failure to develop needs analysis and commissioning
  strategies that open the possibility for new service developments,
  especially those that could be provided by the independent
  sector.
• A lack of expertise on mental health and in particular the
  diverse range of services required to meet the requirements of the
  NSF.