Birthday blues

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

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

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

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
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

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

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
, Executive Summary, 1999

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

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

4 Rethink, Just One
, 2003

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

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