Mental Health Watch - June 2019 summary report
The Five Year Forward View for Mental Health set out to transform mental health care in England and is now more than three years into its implementation. It committed to increasing investment in mental health services by at least £1bn by 2020/21 and led to several new targets aimed at driving improvements in patient access and waiting times.
Building on these foundations, the recently published Long Term Plan from NHS England brings a renewed and welcome focus on mental health services.
This summary examines a selection of the indicators tracked by Mental Health Watch in a bit more detail and unpacks their relevance to the wider sector.
Mental health services are under strain and are receiving ever increasing demand for their services. In the past five months, we found that referrals have been consistently at least 12% higher than in the same months last year. Given the ambition within the Five Year Forward View for 1 million more people to access mental health services by 2021 this can be seen as progress, but services are stretched. Mental Health Watch also uncovers that there are significant differences in the range of pressures in different areas of England, particularly in workforce and rates of people being sent away from their local areas for care.
Near and far
The Five Year Forward View for Mental Health pledge to eliminate inappropriate out of area placements (OAPs) for acute inpatient care focused minds. This is a priority issue for RCPsych as we know that for the significant numbers of patients who are sent long distances from their families and support networks, their outcomes are far poorer, and we are concerned that the cost of such placements is high and has been rising.
After a good start, progress has stalled and numbers remain similar to one year ago, with regional differences increasingly apparent.
The number of inappropriate OAP days over December 2018-February 2019 was up 6% compared to the same period in 2017-18, though in October-December 2018 there were 3% fewer compared to the same months in the previous year.
We also found that seven providers are responsible for more than half of inappropriate OAP days between December 2018 and February 2019.
Access all areas
The NHS Adult Improving Access to Psychological Therapies (IAPT) was a pioneering programme which began in 2008 with the aim of ensuring people with common mental health problems receive National Institute for Health and Care Excellence (NICE) recommended care.
The third quarter of 2018/19 had the best performance in terms of the proportion of people with anxiety and depression accessing IAPT services. This good news provides some cause for optimism that the benchmark for 2018/19 of 4.75% of people with anxiety and depression accessing IAPT services (measured on the performance in the last quarter of the year) can be met.
In 2016 another of the first access and waiting times targets was introduced - Early Intervention in Psychosis (EIP). This was presented as a crucial step towards parity for mental health services.
National performance on this target (which increases year-by-year from 2018/19 onwards) has remained well ahead of the 2018/19 level/benchmark of 53% of people experiencing first episode of psychosis starting treatment within two weeks. Performance looks set to stay above the target of 60% for the next financial year (2020/21).
After a record best performance of 77.2% against the target in Quarter 3 of 2018/2019 (October – December 2018), the latest data shows that this has now slipped a little to 75.3% in the first three months of 2019, which does remain an improvement on the same period in the previous year (74.0%).
There is a similar story told by the data on access to Children and Young People’s Eating Disorder Services. Since data collection began in 2016, progress has been made towards the government target of 95% of children and young people (up to 19) referred for assessment or treatment for an eating disorder to receive NICE-approved treatment within one week for urgent cases, and four weeks for every other case by 2020/21. The latest data for quarter 4 of 2018/19 finds 80.6% of urgent cases were seen within a week. While this up from 79.0% for the same period in the previous year, it is down very slightly from 80.7% in quarter 3 of 2018/19.
A people business
Figures in this edition of Mental Health Watch give some indication that the forecast for the mental health workforce, the most important element in being able to deliver improved patient care, could be set to brighten.
The recently published NHS Interim People Plan recognises that there is a significant challenge in ensuring that the NHS has enough staff to deliver the NHS Long Term Plan. It is crucial that the full report, due later this year, provides a viable roadmap to overcoming these challenges. While Mental Health Watch tracks quarterly data for HEE regions and all mental health trusts, it should be noted that in August 2018 the number of full time equivalent (FTE) psychiatrists working in the NHS hit a record high of 9,218.
The most recent data (for Dec 2018) shows numbers of FTE psychiatrists were 4% up on two years earlier, with increases also seen in mental health nurses (albeit only 1.5%) and applied psychologists & psychological therapists (10%) over the same period.
But there is still a long way to go to meet the expansion in workforce numbers set out in the Stepping Forward workforce plan, which was drawn up to support the delivery of the Five Year Forward View. Furthermore, this upturn does not look to be felt evenly across the country. Between December 2017 and December 2018 numbers of FTE psychiatrists increased in seven of the 13 HEE regions, but dropped in the other six. Of 53 eligible mental health trusts, 29 have more psychiatrists in post, whereas 24 have fewer.
Our new RCPsych Research Panel is made up of RCPsych members who share their perceptions of waiting times, care quality, staff morale and confidence in local leadership every three months. 134 of 251 respondents to our latest survey (May 2019) reported that morale in their multi-disciplinary team had been worse over the last three months.
Panel members were also asked which specific factors were behind any changes in morale. Perhaps unsurprisingly clinical staffing levels, available resources and caseload were cited as the top three issues.
Other top issues cited by the panel members are also worthy of attention. Leadership and culture of trusts were highlighted, both of which were considered in the NHS Interim People plan, as were admin staffing levels, an area which the Carter Review of mental health and community providers recommended is addressed.
Mental health trusts leading the way through challenge
Under the Single Oversight Framework, which enables NHS Improvement to oversee the performance of NHS trusts across the country, the performance of mental health trusts is seen to be relatively strong on the whole, especially in contrast to that of acute trusts.
The performance of NHS trusts is monitored on: quality of care; finance and use of resources; operational performance; strategic change; and, leadership and improvement capability. 91% of mental health trusts received the top two ratings as of 3 June, compared to only 51% of acute trusts, reflecting strong financial management and performance of mental health trusts.
In RCPsych’s submission to NHS England for the NHS Long Term Plan last year, we included expectations about how mental health trust ratings awarded by the Care Quality Commission should improve over time. We felt it was achievable for the ‘outstanding’ or ‘good’ ratings to be applied to at least 60% of trusts for safety, 80% for effectiveness and 90% for being well-led by 2029. Our Mental Health Watch charts reveal the state of play to be 39%, 76% and 76% respectively on 4 June.
However just 32% of respondents to our latest quarterly Research Panel survey expressed confidence in the capability of local leadership to improve mental health services.
What is the bottom line?
We are awaiting final spending data for the 2018/19 financial year with great interest. We hope to be able to share these in time for the next edition of Mental Health Watch, pending on national bodies’ publication schedules. In the meantime, planned spend per head for 2018/19 can be compared to the final figure for 2017/18. Across England the planned spend per person on mental health services is £185, compared to £181.22 actual spend per head in 2017/18. Masked in these figures is wide regional variation with Cumbria and North East STP planning to spend £247 per head while Surrey Heartlands plans to spend £126 per head.
It should be noted that spending data published by NHS England for CCGs and STPs includes learning disabilities and dementia, however the ‘Mental Health Investment Standard’ assessment does not cover spending on these two areas. As a result, it is difficult to get a clear picture of local spending. It is possible for an area to meet the MHIS while having a reduction in spending per head using the reported figures and so this is an area which will be further reviewed in future editions of Mental Health Watch.