Comment

Are STP mental health plans destined to fail?

Norman Lamb MP, the health spokesperson for the Liberal Democrats, warns that it would be a huge mistake to waste the opportunity sustainability and transformation plans (STPs) present to fix struggling mental health services and encourage parity of esteem.

Twelve months ago in NHE, I wrote that I was sceptical as to whether STPs would succeed in their aims of transforming and modernising the way that health and care services are delivered. 

The original purpose of STPs – now known as sustainability and transformation partnerships – is undoubtedly very welcome: bringing the different parts of the health and care system together to deliver better-quality care that is integrated around both the physical and mental health needs of the individual. But despite the heightened political attention that has been paid to ‘parity of esteem’ in recent years, my concern was that mental health services would ‘slip through the net’ in the development of these plans as they are eclipsed by other priorities. 

We know that mental health has historically been neglected in the NHS. Mental health services are often the first to be cut when funding is tight, and the brutal truth is that warm rhetoric has not translated into meaningful improvements to services in many parts of the country. With the STP process taking place against a backdrop of severe financial constraint and pressure on services across the entire health and care system, it seemed a fantasy to believe that the ‘Cinderella’ service of the NHS would be front and centre of these plans.  

Slightly clearer direction of travel 

At the time of these gloomy predictions, STPs were still in development. Now that they have all been published, we have a slightly clearer picture of their direction of travel. However, despite some encouraging sentiments and commitments in these plans, I remain highly doubtful that they will make significant headway in improving support for people with mental ill health. 

On the face of it there is much to celebrate in the STPs, with many local health systems outlining bold ambitions for improving mental health support. A number of plans contain a focus on promoting mental wellbeing and preventing illness, along with proposals to strengthen early intervention and integrate mental health services into primary care. Others commit to improving access to services such as psychological therapies, crisis care and eating disorder teams.  

There are various proposals to improve community-based support for specific groups, including children and young people and women experiencing perinatal mental health problems. I was particularly encouraged by commitments in some areas to move people with learning disabilities out of inpatient settings and into the community, with a new programme in north west London to strengthen employment support for these individuals. 

However, the devil is in the detail – which appears to be sadly lacking in most areas. When my local plan was published in Norfolk and Waveney, I welcomed its vision of integrating physical and mental healthcare and supporting more people in the community to reduce hospital admissions. Yet the plan contains high-level aspirations with very little detail about how they can be achieved. Similar concerns have been reported in other parts of the country: STPs setting an attractive destination, with no detailed roadmap for getting there. 

This worrying lack of detail may provide some explanation as to why NHS England has reportedly rated mental health plans in the majority of STPs as ‘requires improvement’ or ‘inadequate’. 

Are ambitions realistic? 

My greatest fear, however, is that the ambitions for mental health are simply not grounded in reality given the current financial constraints in health and care. Health budgets are under significant strain at a time when demand for services is rising rapidly, and mental health is no different. We see an endless stream of reports about mental health services struggling to cope with increasing need, especially among children and young people. 

Yet some areas are still failing to meet the ‘parity of esteem’ requirement to increase mental health spending at least in line with overall budgets. According to an analysis by the Royal College of Psychiatrists, mental health spend in four of the 44 STP footprints fell last year as a proportion of overall CCG allocations, while spending in a further nine rose by less than 2%. Whatever your politics, this makes absolutely no sense. 

On top of that, some parts of the country are facing new pressure to cut back on mental health spending under the ‘capped expenditure process’. This includes staggering proposals to scrap a planned £900,000 boost to the mental health budget in Cheshire and the Wirral, according to leaked NHS documents. It would make a total mockery of the rhetoric around equality for mental health if these pernicious and damaging plans are forced through. 

Upfront investment vital 

Mental health plans in STP’s will ultimately be destined to fail unless their ambitions are matched by extra funding. Upfront investment will be vital in order to improve patient care and work more efficiently in the future – but funding that was originally intended to support service transformation continues to be used instead to plug deficits and prop up a failing system. 

There is already a consensus that the national focus on immediate cost savings has trumped the imperative of delivering better and more co-ordinated services. Indeed, the King’s Fund recognises that balancing the books has become a “more prominent” theme as STPs have progressed, and warns of a significant financial shortfall if they fail to realise heroic assumptions about efficiencies. 

A survey of NHS trusts in late 2016 revealed that achieving financial balance was viewed as the most important priority in their STPs, while investing in preventive services was shockingly considered the least important. This lamentable false economy sums up the short-term approach that many localities have been forced to adopt, which I fear could prove fatal to the whole process. 

None of this takes into account the urgent need to build up capacity and skills in the workforce. We are still waiting for Health Education England’s mental health workforce strategy more than six months after it was scheduled to be published; but a strong and properly-funded plan to train and recruit sufficient numbers of staff, especially those based in the community, will be critical if we want to create a mental health system fit for today’s needs. 

We are still at the beginning of a long and evolving process. At their best, STPs could still provide a much-needed impetus to encourage new partnerships in the mental health system, deliver better and more holistic patient care, and keep people well in the community. What is clear is that this ambition will only be credible with increased investment in new services. If the government is willing to make that investment, the pay-offs could be huge – both in terms of the future sustainability of services and the quality of care for people suffering from mental ill health. It would be a historic mistake to squander this opportunity.

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