The next steps in achieving parity of esteem

Source: NHE Sep/Oct 15

Luana Salles looks ahead to what we can expect from the final report of the Mental Health Taskforce.

More than 20,000 people had a view on what should be the top mental health service priority list over the next five years, as the system takes slow steps to rectify the historical lack of parity of esteem between physical and mental health in the NHS. 

The Mental Health Taskforce, created in March 2015 and headed by Mind’s Paul Farmer, amalgamated these diverse views into an engagement report launched during the Health & Care Innovation Expo in Manchester in September. The document was published ahead of the taskforce’s final report, probably due in November. 

Speaking at the Expo were influential figures directly or indirectly involved in the upcoming taskforce report, each providing insight into the document’s likely final contents. Paul Burstow, who was care minister for the first few years of the Coalition government, and is the current chair of NHS Providers ‘Right place, right time’ commission on transfers of care, hopes the taskforce will succeed in translating its findings into operational plans that can be picked up by commissioners and providers to develop new service models. Although some of these are already being tested by Vanguards or championed by scattered hospitals across the country, it will beg the “age-old question” of whether the NHS will actually be able to adopt and spread these lessons quickly, he said. 

Psychosocially-minded organisations 

Burstow, both during the Expo and when speaking to NHE, stressed the importance of commissioning a more psychologically- and socially-minded NHS. This component should be present throughout service prevention, commissioning, delivery and staff training. He wants commissioners to think about mental health not just when commissioning mental health services, but when they commission any service at all. 

This also means implementing multidisciplinary training essential to embed a psychosocial approach into the workforce, both in terms of how mental illness is treated and how organisations manage themselves and are run.

Burstow said the clinical and economic cost of the failure to grasp this vital dimension already runs into billions of pounds. The King’s Fund estimated that £13bn is wasted annually when services ignore the implications of mental and physical health comorbidity and do not take a psychologically-minded attitude to healthcare. 

During the Expo, Burstow said: “Commissioning too quickly defaults to procurement. It’s a much richer, deeper thing than just buying something – it’s about people, dialogue and understanding. If you don’t have those things in place, you can’t successfully commission a service that really delivers the outcomes you need. 

“My overall message is that by adopting a psychological and social lens when it comes to commissioning for populations, we can actually ensure we incorporate that insight into the way services are designed. It will help us bend the demand curve.” 

To illustrate the benefits of this new approach, Burstow told NHE about the Primary Care Consultation and Psychotherapy Service in Hackney, helping address comorbid mental health and medically unexplained symptoms. The service supports GPs in managing patients with complex mental health needs that often result in recurrent service use. It has already reduced GP, A&E and outpatient service use by 25% amongst its patients, achieved recovery rates of 50%, and saved the cash equivalent of about one-third of its treatment costs. 

The taskforce is likely to endorse accredited mental health first aid training, supported by respondents whose views were included in the engagement report. Burstow said the final report might mention how this first aid training must be rolled out into other government services. Similar suggestions include training in increased mental health awareness, suicide prevention, LGBT awareness and cultural competency, including working with people from black and minority ethnic communities. Training could potentially be led by those who have previously used mental health services. 

There was also considerable support for the development of a paid peer-support workforce of people with lived experience in mental illness, alongside a general call for frontline staff to have the confidence and skills needed to support individual mental health needs. 

At the very least, Burstow guaranteed that the report will cover the importance of integrating services and, in doing so, commissioning and designing services with both the psychosocial and the biomedical in mind. “I’m absolutely certain [the report will deal with] co-occurring mental and physical health problems and the need for services to be commissioned with both dimensions in mind,” he told NHE. 

Innovation Stage

Investment in mental health research 

Mental health has historically been under-documented and unexamined compared to other specialties. The ongoing NHS Providers Transfers of Care commission immediately found that mental health does not feature prominently in healthcare literature, highlighting again the lack of parity with physical health, including the media attention each sphere receives and the stigma associated with mental disorders. Although Burstow believes that is beginning to change, the gaps in valuable healthcare studies leave holes in our understanding of mental health, its roots and implications, and its comorbidity with physical health. 

A significant result of this is the lack of comprehensive research into how mental health can interact with every other aspect of a person’s life: determinants like good quality housing, debt, poverty, employment, education, access to green space and tough life experiences. Lord Victor Adebowale – who sits on NHE’s editorial board and spoke during the taskforce event at the Expo – stressed that “virtually every single service to the public impacts mental health”. 

“What’s the point in spending what we spend in mental health in the NHS if it’s then sucked out by the social security or welfare system? Or sucked out by the education system or criminal justice system? And let me tell you, that is a massive withdrawal, not only from the public trust but the public purse,” Adebowale said. 

Taskforce respondents overwhelmingly felt the causes of mental ill-health, including its social and psychological factors, should be a priority for research funding – and that it should have parity with other areas of health research. This should ultimately help to recognise that “much mental ill-health arises from poverty, lack of social cohesion and feelings of lack of agency created by unequal society”, as one consultee put it. 

The taskforce is also likely to recommend more research into the long-term effects of psychiatric medication. 

Many respondents said they were not always given enough information about potential side effects, were put on medication before exploring other support options, or could not reduce or come off treatments due to a lack of available help. Again, this fresh research is likely to be best led by ‘experts by experience’. 

Home-based and 24-hour services 

As with social care services for the elderly, there was extensive demand for mental health services to be made available remotely. Thousands of respondents described needing to access help 24 hours a day, seven days a week, most prominently during a crisis. The report highlights: “People said that if they were acutely unwell, there needed to be sufficient high-quality services available locally to enable them to be treated close to home, so that individuals could remain rooted in their communities and near people within their support networks.” 

Home-based services may also help lift a considerable burden from strained mental health units, which in turn force patients to travel outside of their own CCG area because of the lack of inpatient beds. Poor-performing A&E services worn down by heavy demand would also benefit from in-house mental health services, considering patients are currently forced to go to the emergency unit if they need any help during the night or at weekend and holidays. One respondent said there was “no support out there during these times”. 

In fact, home treatment was among the top five overall mental health service priorities identified by respondents. There was a resounding call for good quality home treatment or access to short stay crisis and recovery houses – where those experiencing the onset of a crisis can optionally stay in a ‘respite setting’ providing intensive treatment and support. The taskforce is likely to recommend long-term specialist residential services, especially as a replacement for long stays within inpatient services. 

Personalised and psychosocial home-based services were what Isaac Samuels, a former crisis patient, wanted to talk about at the Expo conference, where he provided first-hand insight: “Service is not fit for purpose. We have caseloads that are not manageable, systems that are process-heavy, people that are 20 years into a process and nobody knows anything about them. 

“People don’t lose hope – the system prevents people from being hopeful. The system that is supposed to support people to recover actually imprisons them. People don’t live in silos or institutions. [They] may have extended stays in hospitals and be sent home without any support – where do you think they’ll be back next week? Back within the system.” 

The taskforce could potentially acknowledge the need to look at the ‘person behind the process’ to the extent that it will recommend something akin to NICE’s recent guidelines on home care visits, where staff must build a familiar relationship with service users. But regardless of the extent of the recommendation’s service-specific details, we can expect it to devise a workable solution to the lack of consistent – and consistently good – residential care. 

We expect to see a marked emphasis on self-care in the final report, helping those with mental health problems self-manage their issues between service uses. Burstow said: “I would be very surprised if the report, given it has a very strong influence from people who have lived experiences of mental health services, doesn’t have quite a strong empowerment thread within it, in terms of empowering patients to gain control over their own treatment and be able to better self-manage their condition.” 

Dawn of a new day 

Although the thinned budget across the entire mental health sphere does beg for additional “transitional transformation funding” in the Spending Review to support changes to its models of care, it is expected that the taskforce will provide an invaluable how-to manual helping to bring failing services back above water. As Farmer, head of the taskforce, told those present at the Expo: “We are at the start of a new era for mental health.” 

That is the exact sentiment we can expect to see running through the report.


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