Mental health trust funding down 8% from 2010 despite coalition’s drive for parity of esteem

Funding for NHS trusts to provide mental health services has fallen by more than 8% in real terms over the course of this parliament, according to research by Community Care and BBC News.

Figures obtained from 43 of England’s 56 NHS mental health trusts through Freedom of Information requests, an analysis of financial reports and other research, show that total funding for the trusts’ mental health services dropped in cash terms from £6.7bn in 2010-11 to an expected £6.6bn in 2014-15. The figures amount to a real terms reduction of 8.25%, or almost £600m, once inflation has been accounted for.

At the same time referrals to community mental health teams, the services designed to stop people’s mental health deteriorating to crisis point, have risen by nearly 20%.

The funding pressures have left some community services handling caseloads double the recommended levels and several are falling short of Department of Health (DH) staffing guidelines.

Official figures show the pressure on inpatient services has also risen. Mental Health Act detentions to hospitals hit a record high last year while bed availability dropped to its lowest level in four years of data collection.

One mental health chief executive called the situation “a car crash”.

Care minister Norman Lamb said the budgets did not represent “the full picture” for mental health spending.

He added: “Mental health care is given through a range of services including the voluntary sector.”

A consistent official dataset on mental health funding trends has not been available since the government axed its national survey of spending on mental health services in 2013.

Funding pressures

Simon Wessely, president of the Royal College of Psychiatrists, said commissioners did not have to pay attention to government calls to boost mental health funding

The funding pressure on NHS mental health trusts has contributed to the closure of more than 2,100 beds since 2011. Problems accessing beds or alternatives to admission have been linked to a series of deaths and led to acutely unwell adults and children being sent to out-of-area hospitals for care, often hundreds of miles from their homes.

NHS providers say that moves to reduce bed numbers and shift more care into the community is the right therapeutic approach. However, they admit that the funding squeeze on NHS trust budgets, combined with local authority cuts to social care, has damaged the community ‘infrastructure’ that is vital to keeping people well and out of hospital.

Local authority spending on working-age adults with mental health needs fell by 13.2% in real terms between 2010-11 and 2013-14, the most recent year for which official figures are available. Frontline social workers told us these cuts have seen key preventive social care and low-level housing support being stripped back. Those services, staff say, can play a vital role in building people’s resilience and preventing isolation.

Commissioners ‘ignoring policy’ 

As much as politicians and NHS England tell commissioners to do the right thing, they are not doing it

The coalition has guaranteed the NHS budget will rise by 0.1% in real terms over the course of this parliament. Since 2012, ministers have also mandated NHS England to make progress on delivering ‘parity of esteem’ between mental and physical health.

The deputy prime minister, Nick Clegg, and the care and support minister, Norman Lamb, have urged NHS England and local clinical commissioning groups to properly fund mental health services.

Stephen Dalton, chief executive of the NHS Confederation’s mental health network, said those requests, while welcome, were being ignored.

“As much as politicians and NHS England tell commissioners to do the right thing, they are not doing it and the question is has the Health and Social Care Act [the coalition’s 2012 NHS reforms] disenfranchised the Secretary of State because they don’t seem to be able to do anything about it,” he said.

Sir Simon Wessely, president of the Royal College of Psychiatrists, said he was surprised the picture was not worse.

“We are being asked to do more with less. We are campaigning and saying that people need to be more open about mental health problems and come forward earlier.

“But when they do, we find ourselves with less resources to treat them and they are getting short-changed.”

Sir Simon welcomed the coalition government’s recent funding announcements, but said messages from the top often failed to be passed down to the people actually making the decisions.

Last month Health Service Journal revealed that several commissioners were disregarding national guidance to increase real terms spending on mental health in 2015-16.

Social workers’ perspectives

Faye Wilson, chair of the British Association of Social Workers’ mental health forum, said the breakdown in community support being driven by funding cuts was leading to the level of “risk in the system going up” as services couldn’t intervene early enough or effectively enough for many patients.

“We keep talking about parity of esteem. Well that needs parity of attention and parity of resourcing but commissioners keep showing they are reluctant to give mental health what it needs,” she said.

“Staff are effectively having to work with one hand tied behind their backs but I feel most for the people depending on our services. If you’re in crisis, you don’t care about the political wranglings between NHS commissioners and providers, you care that you can get a good service.”

Steve Chamberlain, chair of The College of Social Work’s Approved Mental Health Professionals network, said our findings reflected the experience of frontline mental health and social care professionals.

“Staff are facing working with increasing demand and shrinking resources. It’s not just when they are responding to crises but also in the lack of community resources to work with people day-to-day to keep them well,” he said.

Impact on patients and staff

Polly Allen said she was let down by her local mental health team

Documents obtained by Community Care highlighted the impact the resourcing shortages can have on patients and staff. We found that:

• A senior coroner warned commissioners that a community crisis resolution home treatment team – the service model that is now the most commonly used community alternative to hospital admission – “was not sufficiently funded” following an investigation into a patient suicide. A report drawn up five months after the coroner’s warning showed the team was still short staffed.
• Some crisis teams have been carrying caseloads double the recommended limits and others have had staffing levels an estimated 70% below what managers believed was needed “to meet national expectations”.
• Out-of-hours responses are a particular issue. Some community crisis services do not offer home visits after 9pm.
• Patients face long waits to be assigned a care coordinator due to a lack of capacity in some community mental health teams.
• Research findings from a major study suggest most crisis teams are falling short of several DH guidelines drawn up for the services.

Freelance journalist Polly Allen has experienced depression since she was 17. Last April, the 26-year-old was going through a particularly difficult period. “I was a mess, I couldn’t concentrate, I was having suicidal thoughts.”

Polly approached her mental health trust seeking help but she says they failed to provide it.
“The hardest point was when I went into a deeper level of crisis and my psychiatrist was actually on annual leave, which was unfortunate but there was nobody there to cover his workload. So for three weeks I was basically in limbo. It was one of the hardest times of my life and I really didn’t want to be here but there was no-one in the psychiatric team who was able to listen.

“The level of treatment that was given to me wasn’t really enough for my needs. They just don’t have the staff or the funds to go round to help everyone who needs help.”

Government response

Care minister Norman Lamb said the government was investing more in mental health services

In response to our findings, Norman Lamb acknowledged that mental health had “lost out” in NHS spending decisions for too long but insisted the government was taking action to address the situation.

“The payment system in the NHS, which disadvantages mental health, and the total imbalance of rights of access between mental health and physical health which was introduced in the last decade, dictates where the money goes.

“That’s why we are taking action, including introducing new standards for mental health services that local areas will have to meet, just as there are for physical health services – this is backed by £80 million investment,” he said.

This week the government also announced a budget commitment to put another £250m a year in to children’s mental health services from 2015-16.

About the research

For the research we asked mental health trusts to provide income figures for 2010-11 and 2014-15. We requested mental health-related income, rather than total budgets. This is because many trusts took on community health services, such as sexual health services, from April 2011 onwards under the government’s ‘Transforming community services’ programme.

Figures were provided by 43 trusts. The data showed that total mental health funding across the organisations dropped by 8.25% in real terms. The scale of funding changes varied at individual providers. Five trusts saw real terms reductions of more than 15%. Providers attributed the drop to factors including “disinvestment” by commissioners and loss of contracts to non-NHS providers. Two trusts saw real terms increases of over 15%. Both had taken on new mental health contracts since April 2010.

The real terms calculations are based on the latest GDP deflator estimates – the Treasury’s official model for calculating inflation. The deflator assumes that a 2.1% uplift on 2013-14 funding was required to protect 2014-15 budgets from inflation. The same assumption was used by NHS England when deciding funding allocations for local commissioners in 2014-15.

Community service funding

In a separate Freedom of Information Act request, we asked mental health trusts to provide their annual budgets for five key community services between 2010-11 and 2014-15. There were 34 trusts that were able to provide full data for this enquiry. The five services we looked at were:

• Assertive outreach. These teams work intensively with people who are not engaging with services and are at high-risk of relapse.
• Early intervention in psychosis. These services, which have been praised internationally, work with 14 to 35 year-olds experiencing their first episode of psychosis.
• Community mental health teams. These teams provide ongoing community care coordination and monitoring to prevent people’s mental condition deteriorating to crisis point.
• Crisis resolution home treatment teams. These services offer intensive home treatment to people during a crisis as a home-based alternative to hospital. They are the main community alternative to beds for people in crisis.
• Liaison psychiatry services. These teams are based in general hospital settings, including and A&E departments, order to provide assessment and treatment for patients’ mental health needs.

This request found that overall funding across all five team types had fallen by 5% despite rising referrals. Crisis teams had seen an 8% cut in funding despite an 18% rise in average monthly referrals, while community mental health teams had seen a 19% rise in referrals despite a slight fall in real terms funding.

Staffing shortages

Segment of a report drawn up by Berkshire Healthcare in January 2015

Documents obtained from trusts under the FOI Act also revealed concerns over staffing levels at several community services:

• A report produced by Berkshire Healthcare in January 2015 revealed that one of its home treatment teams was handling caseloads of 180 patients, double the recommended 90 cases. The report said an extra 36 staff were needed at crisis teams across the trust.
• The Berkshire report also raised concerns over some teams’ responses to out-of-hours emergencies, with particular issues around weekend cover. The trust said its crisis services had experienced “higher than expected” demand and it was in talks with commissioners over funds.
• A draft report produced by Cornwall Foundation Trust in July 2013 revealed that its crisis resolution home treatment services required staffing increased by approximately 70% “to meet national expectations”. The trust said the draft report had since been revised but it was talking to commissioners about additional investment in the services.

Other concerns about community services are flagged up in Care Quality Commission inspection reports published over the past 12 months:

• An inspection report published last April on services in Devon found that patients, including many who had previously been seen by crisis teams, were waiting several months to be allocated to a care coordinator.
• An inspection report on Humber NHS Foundation trust published last October identified “capacity issues within community teams”. There were high referral rates and long waiting lists ranging from 80 to 120 people in some areas, the report found.
• An inspection of services run by Norfolk and Suffolk NHS Foundation Trust published in February found that, on the day of inspection, one of the trust’s crisis teams only had “two health care assistants and a student” on duty from 8 till 11am due to staff sickness. The service’s “rotas showed that understaffing was frequent”.

Patient death

An extract from a coroner’s report sent to commissioners in Wandsworth following the death of a patient under the care of a home treatment team

In some cases, resource shortages have impacted patient safety. In April 2014, a senior coroner wrote to NHS Wandsworth clinical commissioning group and South West London and St George’s NHS Mental Health Trust to warn that the Wandsworth crisis resolution home treatment team was “not sufficiently funded” following an inquest into the case of a man who died by suicide in August 2013.

The ‘prevention of future deaths’ report said that problems accessing “medically qualified personnel” at the crisis team and a liaison psychiatry service impacted the care they could provide.

A report drawn up by the trust in September 2014, five months after the coroner’s report and more than a year after the man’s death, found that the Wandsworth team remained at least four staff posts short of DH guideline levels. If the service was to be resourced at equal levels to other home treatment teams run by the trust, an additional 13.5 staff would be needed, the report concluded.

Asked if funds had been released to plug the staffing gap, Wandsworth clinical commissioning group said it would be increasing its mental health investment in 2015-16, including additional funding for home treatment services “in line with national benchmarks”.

A spokesperson for the mental health trust, which provides services across several clinical commissioning group areas, said not all of its home treatment teams currently met recommended staffing levels but negotiations were underway with commissioners regarding additional funding for next year. The trust’s overall funding had been cut between 2010-11 and 2014-15 due to “disinvestment” by commissioners and national efficiency savings targets, the spokesperson said.

Wider research on the crisis response system

The effectiveness and consistency of current crisis resolution team provision is the subject of a major five year research programme. The Core study, which is being carried out by researchers at University College London and is funded by the government-resourced National Institute of Health Research, will conclude in 2016.

As part of the programme, researchers carried out a survey of 75 crisis resolution teams. The aim was to test their adherence – fidelity – to a set of recommended guidelines for crisis team provision laid out by the Department of Health in 2001. Each team was scored against a series of standards, mostly on a scale of 1 to 5.

The survey findings, shared with Community Care, show that most crisis teams are not currently set up to deliver high performance against several of the standards set out in the official guidelines.

Almost 90% of teams scored 3 or above on ‘time limited intervention’ – this measured whether the service was a distinct service dedicated to only providing crisis assessment and brief home treatment (some trusts have absorbed crisis functions into generic community teams).

However, just over a third (35%) of the services scored 3 or more on their ‘rapid response’ to referrals. Less than a quarter (24%) of teams scored 3 or more for their intensive support, a measure of how frequently they visited service users. Only 3% scored 3 or more on ‘preventing future crises’.

Researchers on the study team told us that all services were doing some thing well and there were many examples of good practice. However, they said that few teams had “put the whole package together to deliver a consistently high fidelity service”.

A Lancet study published last August examined the safety of patients under the care of crisis resolution teams. Researchers found that the rate of suicides of crisis resolution team patients fell between 2003 and 2011 as more patients were treated by the teams. However, the suicide rate seemed higher than inpatient units and researchers concluded that safety of patients under the teams should be a priority for mental health services.

NHS England reaction

Update: NHS England has provided the following statement from Dr Martin McShane, director for people with long term conditions:

‘”Funding for mental health is going up both this year and next – from an estimated £11.4 billion last year to £11.7 billion planned for this year, with further guaranteed real terms increases kicking in next month. On top of that, the Budget has just awarded NHS mental health services a further £1.25 billion. And, for the first time ever, users of mental health services will now have guaranteed waiting time standards, like those that have been in place for people needing operations and outpatient appointments in other parts of the NHS for several decades.”

Here is the full evidence NHS England uses to justify its claim of a spending increase this year. The figures show a real terms decrease in local clinical commissioning group spending on mental health between 2013-14 and 2014-15. NHS England’s spending on specialist services that it commissions centrally – such as forensic inpatient units – rose in real terms.

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