The news that London’s mental health services are still
struggling comes as little surprise. The King’s Fund’s
report into the state of mental health care in London simply
highlights what most people already suspected – that the
government’s ambitious modernisation agenda is having a
limited effect in the capital, just as it is elsewhere.
London’s State of Mind, published this week, looks at how
mental health care in London has changed since the fund’s
previous inquiry into the issue in 1997. It finds that many of the
problems experienced by services then are still present now,
despite the introduction of policy initiatives such as the National
Service Framework for Mental Health and the NHS Plan.
One of the key questions raised by the report relates to the
whereabouts of the £700m allocated by the government in 1999
for the improvement of mental health services in England and Wales.
Tracking the money has proved difficult and it has long been
suspected that only a small proportion of it has reached the
“There is a definite issue around where this money has gone,”
says Simon Lawton-Smith, senior policy officer for mental health at
the King’s Fund. “It would appear that a lot of the money
committed to mental health has actually been siphoned off for other
services or to cover deficits. If you speak to people on the front
line, they say they don’t seem to have seen much of it.”
The fact that not all of the money allocated to mental health is
getting to where it is needed is worrying enough, but the new
research also challenges the government’s declaration that
mental health is at the top of its agenda.
It estimates that, since 1997, the increase in spending on
mental health care in London has been just 14 per cent, compared
with a 28 per cent increase in the NHS generally.
“Given that mental health is meant to be one of the three
clinical priorities, this seems to us strange,” says
However, it would be wrong to suggest that none of the allocated
money has resulted in progress. Assertive outreach, for example,
has been implemented successfully with most areas now having a
team. But although this is welcome, it is also indicative of the
general direction of the cash stream towards the acute end of
mental health services, for people with more severe and enduring
While nobody denies that these services are needed, there is
concern that they are not being balanced with good community
services, and early intervention and prevention services at the
other end of the spectrum. In addition, despite being standard one
of the NSF, not enough resources are being put into mental health
“It’s fine putting resources into the severe end of mental
health care, but the community services which allow people to live
ordinary lives are missing out. If you ignore mental health
promotion and low level mental health problems now, you are setting
yourself up for many more problems later on,” says
It is little wonder that money has been targeted into provision
for those with more severe mental illness given the explicit
targets set out by the government on this area. Andrew McCulloch,
chief executive of the Mental Health Foundation, believes this
reflects a national picture and is the result of the
government’s strong risk-management agenda. “Assertive
outreach is seen as a way of managing risk,” he explains.
Too much focus on risk is also something that was picked up by
the King’s Fund, which found that the number of low and
medium secure beds, for those unable to be managed safely in local
communities, had almost doubled.
On the disappearing millions, McCulloch has his own theory: “The
money is being creamed off for higher political priorities like
waiting lists and acute physical medicine. It disappears at health
authority and primary care trust level.”
He supports the King’s Fund’s recommendation for a
better and more transparent system of tracking mental health
funding, and believes the government should take a more proactive
role and stop its “disingenuous claims”.
“They must have known full well that the money wouldn’t be
spent on mental health. There’s evidence from history that
money for mental health does not get there,” he says.
Lack of appropriate housing for people with mental health
problems is also raised as a major problem in the report, which
states that while demand has grown, the supply has not. And
McCulloch says that the situation is getting worse.
“We believe people are getting booted out of their accommodation
more frequently now than they have done in the past as local
authorities are taking a hard line with troublesome tenants,” he
Once again, workforce difficulties are also highlighted. The
report says staff shortages are severe, workloads are demanding and
wards are considered unsafe and unattractive. All the nurses
interviewed said they had felt concerned for their personal safety
Peter Horn, chief executive of the London Development Centre for
Mental Health, says that while measures can be put in place to
improve the working environment, there is also a wider issue to do
with the status of mental health in society.
“If you ask a bunch of kids what they want to be when they grow
up they will say they want to be a doctor or a heart surgeon or
find a cure for cancer. There’s still an issue about mental
health being a cinderella service. If there was not so much stigma
towards people with mental health problems people would be more
interested in working in mental health services,” he says.
In addition, Horn says that his organisation is willing to
discuss the King’s Fund recommendation for the London
Development Centre for Mental Health to help establish a centre for
excellence in commissioning as a resource for commissioners.
The report blames the weak commissioning of mental health
services by primary care trusts for the slow pace of modernisation
and suggests that commissioners do not always have mental health
The report also proposes the development of a London mental
health strategy to look at how the NSF is being implemented across
London and to concentrate on issues such as housing, which need a
It recommends that the North West London Strategic Health
Authority, the SHA with lead responsibility for mental health,
co-ordinates the strategy.
John Wilkins, director for mental health across the five London
SHAs, welcomes the recommendation but says that it needs further
thought. The approach should certainly be “bottom up”, he says,
with local organisations feeding in what their areas require.
He also agrees that SHAs need to examine the variation in
spending across London, some of which may simply be due to the
different levels of mental illness in different areas.
The King’s Fund’s report highlights problems in
mental health services that are all too familiar. The excuse that
we can’t solve the problems because we don’t know what
they are is no longer acceptable. The problems were identified six
years ago in 1997, and have been brought to the fore again now.
Let’s hope they don’t need to be identified again in
another six years’ time.
– London’s State of Mind: King’s Fund
Mental Health Inquiry 2003 from www.kingsfund.org.uk/publications
King’s fund report
- Slow modernisation of services.
- High usage of acute inpatient beds.
- Community and primary care services remain underdeveloped.
- Money concentrated on secure services.
- Poor environment on acute wards.
- Inadequate health promotion.
- Shortage of appropriate housing.
- Weak commissioning.
- Problems tracking funding.
- Staff shortages.
- Development of a London mental health strategy.
- Establishment of a Centre for Excellence in Commissioning.
- Review of conditions and staffing levels in acute inpatient
- Further development of community services.
- Closer work with service users and carers.
- Action plan for housing.
- More transparent system for tracking funds.
- Examination of variations in spending across London.
- Workforce strategy.