Comment

Real possibility that mental health will slip through the net once again

Former care minister Norman Lamb MP writes for NHE about the danger of mental health services becoming further disadvantaged unless a concerted effort is taken to deliver a holistic approach that places mental health at the heart of STPs.

Successfully delivering the Five Year Forward View (FYFV) will be a massive challenge. Contending with enormous financial pressures and record deficits, NHS organisations and local authorities have the monumental task of planning how their services will evolve to meet demanding efficiency requirements whilst maintaining or improving standards of care in both physical and mental health. Sustainability and transformation plans (STPs) have become central to this purpose. However, if initial preparations are anything to go by, there is a real danger that mental health will be further disadvantaged – with potentially disastrous consequences. 

We know all too well the disparity between mental and physical health in terms of timely access to evidence-based treatment, emergency care, and the rights of patients. The imbalance of access standards and financial incentives in the system only cements this inequality, impeding momentum towards genuine equality for those who suffer from mental ill health. 

Importantly, there has also been a remarkable lack of attention paid to the close link between mental and physical health. Year after year, we have managed spectacularly to neglect the physical health needs of people with mental health conditions, and to neglect the mental health needs of people with physical health problems. 

This is a major factor in the higher mortality of people suffering from severe mental illness, who are at risk of dying on average 15 to 20 years earlier than the general population. Most of these premature deaths are the result of avoidable illnesses including heart disease and cancer, often related to inactivity, smoking, alcohol and obesity. At the same time, people often do not feel that they receive adequate support for their mental wellbeing when struggling to cope with chronic physical conditions. This results both in poor outcomes for people but also increases costs to the NHS and social care. 

If we are to achieve equal priority for mental health and support people across the whole range of their healthcare needs, there is an overwhelming case for a co-ordinated, holistic approach that places mental health – and the integration of mental and physical health – at the heart of service planning. And yet there is a real risk that this common sense principle will not shine through in reality. 

Fears that STPs will fail to address mental health provision 

By the end of June, every health and care locality in England was expected to submit their draft STP setting out how they would redesign local services to deliver the better care, better health and improved efficiency mandated in the FYFV.  

The drafting process has been beset by well-publicised difficulties, including question marks over the strength of collaboration in some regions. And while it remains to be seen what they will contain, there is an anxiety among mental health groups and campaigners that mental health will not properly be taken into account in the final plans. 

When I recently challenged the government to ensure that STPs properly address mental health provision in a locality, as well as the integration of mental and physical health, the response was predictably ambivalent. I was told, in effect, that only those areas with “more advanced plans” will be expected to set out how they will deliver improvements in mental health services as one of a number of national priorities, unless mental health is expressly identified as a key local priority in the STP. This simply isn’t good enough. 

We are confronted with the real possibility that mental health will slip through the net once again. My fear is that the focus will be too heavily on the financial state of acute hospitals: crisis management will trump genuine re-engineering to achieve better use of resources and better outcomes. 

Mental health can no longer be an optional extra 

Our approach to service planning in the NHS is often hopelessly fragmented. The Five Year Forward View presented a real opportunity to change course and address mental and physical health on an integrated basis. Instead of grasping this opportunity, we appear to see mental health treated yet again as an optional extra in the development of STPs – an important element of the NHS’s five-year blueprint – while we await a separate programme for implementing the recommendations of the Mental Health Taskforce. 

It should not be forgotten that the government’s precarious strategy for the NHS hinges on the delivery of unprecedented, indeed heroic, efficiency savings, worth around £22bn by 2020. If we are to have any hope of getting anywhere near efficiency gains on this scale, it is imperative that we look at the place of mental health in the wider healthcare system – its causes, its impact on other services, and its relationship with physical conditions.  

Nothing can be more important when mental illness accounts for around 23% of the burden of illness in the UK, placing an enormous burden on all parts of the NHS from primary care to the acute hospital sector. More than a third of GP consultations are related to mental health, while those suffering mental ill health are three times more likely to attend A&E with a physical health problem. 

How absurd it is, then, that mental and physical healthcare are still so often treated like separate parts of the NHS, planned in silos with an apparent expectation that joined-up, whole-person care can be engineered at a later date. It is a completely nonsensical approach. 

The Early Intervention in Psychosis (EIP) model shows what can be achieved with a stronger focus on integrated care around the needs of the individual. This is one of two access and waiting time standards for mental health I introduced under the Coalition government, and support for physical health is identified as a central component. 

In a NICE-concordant EIP service, adults with psychosis or schizophrenia are to be offered comprehensive physical health assessments, healthy eating and physical activity programmes, and smoking cessation support to aid recovery and overall wellbeing as part of a wider multidisciplinary care package. The potential cost savings in the long term are also vast, with one London School of Economics study estimating £15 saved for every £1 invested in EIP. 

Just imagine what could be achieved if a similar approach was adopted throughout the health and care system. We will not get far if we continue our disjointed approach, where mental health ends up being unintentionally marginalised to the detriment of the entire system. A concerted effort to break down silos, tackle institutional biases, and change the culture of how we think about health services should be an absolute priority if we are to achieve a more sustainable system but most important of all, if we are to secure better outcomes for people.

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