Mental health stretched to the limit by cuts and demand

(Illustration: Frazer Hudson)

Mental health services are being hit by rising demand and diminishing resources, reports Jeremy Dunning

The government’s mental health strategy comes at a critical time for services in England as they are squeezed between rising demand and impending cuts from the NHS and social services.

News that the economy contracted in the last quarter of 2010 points to increased risks to the nation’s mental health from unemployment, debt or workplace stress.

There is already evidence that the 2008-9 recession and ongoing economic fragility have pushed up demand for mental health services, while in-patient numbers have risen for the first time in five years.

Meanwhile, mental health trusts are finalising their budgets for the coming financial year and some of their plans make grim reading for service users and practitioners, with suggested service and jobs cuts.

Trusts are vulnerable to cuts from both primary care trusts and councils. Local authorities with social services responsibilities are expected to see average budget cuts of 4.7% next year (6.6% in real terms), the first of four years of cuts.

And while the NHS budget, currently worth £100bn a year, is due to only fall slightly in real terms from 2011-15, the service needs to find £20bn in efficiency savings over this period, and there are concerns that mental health will bear a disproportionate burden.

“In the past, mental health budgets have been easy prey for those looking to cut costs because they are funded through block contracts,” wrote Steve Shrubb, director of the NHS Confederation’s Mental Health Network, which represents trusts, in Community Care last month.

By contrast, the payment by results model governing acute trusts means they are paid according to the number of patients they treat, in line with a nationally-set tariff, meaning their income is more protected from PCT cuts, says Shrubb.

The extent of the cuts should become clearer later this month as the Mental Health Network is surveying its members on the situation.

What is clear is the demand pressure facing mental health services, with the first rise in mental health inpatient admissions in England since 2004-5, with numbers rising by 5% to 107,765 last year, according to NHS Information Centre figures issued last month.

Shrubb says this provides “mounting evidence for how bad recession is for the nation’s mental health”.

However, other reasons have been identified. While voluntary admissions went down, there was a 18% rise in the number of patients detained in hospital under the Mental Health Act, from 32,649 to 38,369 between 2008-9 and 2009-10.

Dr Peter Byrne, director of public education at the Royal College of Psychiatrists, says this is evidence of a greater focus on risk to the public within services.

“The greatest contribution to this increase has been in the category of patients perceived to be a risk to others – those sent to hospital by the courts or under the amended Mental Health Act 2007, which prioritises risk to the public.”

Mental health practitioners have voiced similar views on Community Care’s CareSpace forum.

“Are we erring on the side of caution too much and detaining under the MHA, rather than taking the risk of letting people remain in the community?” asks one contributor.

Another issue identified by CareSpace contributors is trusts reducing the number of beds in psychiatric hospitals, and increasing admissions thresholds.

“Where we might have admitted earlier, informally and for shorter periods, we now have no option and end up detaining people, who stay in hospital for longer,” says one mental health social worker.

With councils facing tougher cuts than PCTs, there are fears that community services for people with moderate mental health problems could be worst hit, leading to people’s conditions deteriorating.

Such services are under strain already.

Claire Barcham, national co-ordinator for the Approved Mental Health Professionals Leads Network, says: “There’s a lot of pressure on community teams. There are vacancies which aren’t being filled, and there’s the inevitable amount of pressure on people to cope with rising caseloads.”

Another CareSpace contributor warns that community mental health team budgets are small compared with other services, leading to a focus on firefighting: “I see a year-on-year increase in thresholds. The tools and capacity of teams to prevent serious relapse is limited even with assertive outreach. Hospitals frequently discharge before recovery and to unsuitable accommodation leading to repeat, repeat and repeat admissions.”

The latest downturn in the economy could make matters even worse. A survey last year of 2,000 workers by Mind found that one in 10 had sought support from their GPs as a direct result of the 2008-9 recession and 7% had started taking antidepressants.

“With an economy which is on the down and more people unemployed and with less public support services out there it’s inevitable there will be more people who will become really depressed. Some people won’t be able to cope,” says Barcham.

How providers respond to these pressures while dealing with a contraction in funding will be the keynote of mental health services over the coming years.

A top priority for the mental health strategy will be to offer commissioners, providers, practitioners and service users a set of solutions to managing this squeeze without drastically harming patient care.

Case study: ‘It’s difficult to see where we can go without cutting’

Norfolk and Waveney Mental Health NHS Foundation Trust is faced with the need to make significant savings over the coming years from its £130m annual budget.

Last week, Norfolk Council agreed to cut its funding by a third over the next two years, reducing its annual spending on mental health by £1.6m by 2013, equivalent to a third of its funding for the trust.

Trust finance director Andrew Hopkins says: “Clearly doing that does have a major impact on that part of the service.”

On top of this, it may be expected to make savings of between £5m to £7m a year from NHS commissioners as they seek to make the efficiencies required by government.

Hopkins says the trust was already one of the most efficient in the country, with one of the lowest number of beds, and a focus on community services.

However, he adds: “It’s difficult to see where we can go without cutting services. We can already prove we are efficient. It’s a big concern for us. Being a provider that’s about face-to-face contact between practitioners and patients, between 75% to 80% of our cost base is people. That’s a lot of posts that will disappear from what we can do.”

He warns there could be compulsory redundancies, as well as a significant impact on care.

Lynn Wall, Unison officer at the trust, says staff are already feeling under pressure with many taking sick leave or looking to leave, as they are already facing a two-year pay freeze from 2011-13, while some have been downgraded because of a restructuring of teams.

Wall says the trust should involve staff more on their plans to improve efficiency.

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