Mental health is often talked about as a Cinderella service, failing to get the attention it deserves. This has started to change in recent years, most notably with the NHS Five-Year Forward View and the supplementary Five-Year Forward View for Mental Health. Although we have been talking about ‘parity of esteem’ between mental and physical health for some time, we are now seeing evidence of that talk converting to action, but there is a risk that it is happening in silos.
Mental health is often talked about as a Cinderella service, failing to get the attention it deserves. This has started to change in recent years, most notably with the NHS Five-Year Forward View and the supplementary Five-Year Forward View for Mental Health. Although we have been talking about ‘parity of esteem’ between mental and physical health for some time, we are now seeing evidence of that talk converting to action, but there is a risk that it is happening in silos.
There are pockets of innovative work going on around the country that are making inroads into some of the most challenging mental health conditions. There are still significant barriers to overcome, however – from understanding the true cost and impact of mental healthcare to developing sustainable solutions for the huge variety of complex conditions that fall within this area.
Delivering change in mental health services undoubtedly requires patience, determination, bravery and understanding. But in our enthusiasm to improve services, we must find effective ways to track and share successes that will enable emerging best practice to be shared swiftly across the country.
Understanding the conditions
Mental health is a very broad term, covering more than 200 disorders from depression and dementia to substance abuse and addiction. Some conditions are neurodevelopmental and others arise as a result of life trauma or another trigger. But all mental health conditions have the potential to impact on every other aspect of a patient’s health and wellbeing, to greater or lesser degrees. Those living with mental illness are more likely to feel isolated from their social network and can often experience difficulties with employment. That has a knock-on impact on where and how they live, which can lead to or exacerbate physical health conditions.
This complexity makes it very tempting to see change as too difficult, and yet there are good examples already emerging that are improving access to services and outcomes for patients.
As a member of a judging panel for an industry mental health award, I have had the privilege of reading about positive work to provide access to specialist support in the community. For example, the North East Hampshire and Farnham clinical commissioning group (CCG) Safe Haven project, delivered by Surrey and Borders Partnership NHS Foundation Trust, provides a drop-in, out-of-hours service to those experiencing or on the verge of a mental health crisis. The service was developed following feedback from mental health users. According to figures published by the CCG,1 it was attended 5,027 times in 2015. On 748 of these occasions, people said they would otherwise have gone to A&E.
Looking closer to home at a project we were involved with, Arden & GEM worked in partnership with the three CCGs in Warwickshire to establish a regional perinatal mental health service. Perinatal mental illness affects around 135,000 women per year, with long-term costs to society of £8.1bn annually.2 Of postnatal women who die, one in four deaths are due to mental illness and one in seven has committed suicide. There is evidence that babies whose mothers suffer with perinatal mental illness can experience long-term emotional, social, behavioural and developmental deficits. Thanks to proactive partnership working across organisational and clinical boundaries, patients in Coventry and Warwickshire now have fast access to perinatal psychologists and psychiatrists throughout pregnancy and postnatal care. In addition, the multidisciplinary team is providing perinatal mental health training to GPs, health visitors, midwives and obstetricians, ensuring early identification of risk and vulnerability.
Closing the data gap
Mental health is some way behind other conditions when it comes to understanding, tracking and predicting patient behaviour.
Work is still needed to unpick how various services are used and what impact they are having. Since acute services moved away from block contracts in the 1990s, the shift in payment method has led to richer understanding of patient pathways. By contrast, the introduction of new payment methods for mental health services is still in its early stages, so we have less understanding about patient pathways through local systems.
As providers and commissioners work together to implement new payment mechanisms, the fog will start to lift on where money is being spent, who is accessing which services and the long-term outcomes for those patients. In the meantime, shaping new services across health systems requires a leap of faith, albeit grounded in assumptions based on the evidence.
For example, Arden & GEM first began working with South Warwickshire CCG, Warwickshire North CCG and Coventry and Rugby CCG on a mental health repatriation programme designed to reduce reliance on out-of-area mental health services. We couldn’t predict how many patients would be repatriated from which area, and where the savings would be. We succeeded because of the willingness of the CCGs to accept shared responsibility for the project and recognise that they may benefit from savings at different stages in the project. This progressive approach has resulted in a programme that has not only delivered over £12m in savings on out-of-area contracts but has seen local services develop so that fewer patients require specialist treatment out of area.
The introduction of waiting times targets is helping to provide a clearer line of sight across patient pathways, and promotes a sense of urgency, but there is still a long way to go. We may be improving our knowledge of how quickly a patient is referred to a specialist service and when their first appointment takes place, but more work is needed to track what happens next.
This lack of data means getting to the starting line is a challenge in itself. We need to be honest in acknowledging that when it comes to redesigning services, time must be devoted to defining the problem we want to fix and the context in which we are operating.
Developing the right environment to improve patient-centred care
Over a series of projects, we have become very aware of the importance of mutual understanding and support between partners when shaping mental health services. Shared responsibility needs underpinning with appropriate governance so that each organisation feels supported in delivering new solutions.
Although attitudes towards and understanding of mental health conditions are improving both within and outside the NHS, there is still work to be done to challenge perceptions of the ‘right care’.
After the Winterbourne View hospital inquiry, there has been an increased focus on providing alternatives to inpatient care. Working openly with stakeholders to co-commission services and taking the time to ‘walk in the shoes’ of individual patients has proved invaluable.
Developing an understanding of the chain of events that could trigger unplanned hospital admissions has resulted in service changes designed to prevent problems escalating, improving outcomes for patients and reducing acute costs for commissioners.
The potential rewards for patients are huge. As part of the ‘Transforming Care’ project we have been working on, a patient with severe learning difficulties who had been in hospital for 16 years is now living successfully in the community and taking part in supported one-to-one activities. This is just one example among many in what is a much broader project operating across Coventry, Warwickshire and Solihull. Intense, collaborative work with commissioners, service providers, patients and families has enabled brave decisions to be taken, resulting in life-changing improvements that had previously not been thought possible. The next step is ensuring the learning from that project is successfully shared so that other patients may benefit elsewhere in the country.
Change with shared learning in mind
The more systematic we are in how we plan, implement and evaluate our work, the easier it becomes to establish how the different elements of change interrelate and which ones are critical to the overall success of a project.
This is particularly crucial for programmes that are designed to future-proof the health system.
When working on the mental health repatriation project, the long-term intention was to develop local services so that fewer patients would need to be sent out of area for specialist care in the future.
To do that required close collaborative working with the local provider. Individual clinical reviews were conducted for each patient, to establish an up-to-date assessment of needs and identify what additional services would be required locally. This was a very complex process and a great deal of learning took place along the way.
Much work has since taken place to capture and share that learning to help other areas implement similar programmes, provided appropriate adjustments are made according to the local context. This is true of many projects but few offer a complete picture from start to finish.
NHS England has already taken steps to encourage a more comprehensive and cohesive approach to sharing best practice. Vanguards developing new models of care are required to develop a logic model to map out their programme, and commission external evaluation to review progress and ensure work remains on track.
As Dr Sam Everington said in his article ‘We need a dating agency for good ideas’,3 there is no shortage of enthusiasm among NHS staff to share learning and to support service improvement. Replicating successes nationwide is far from straightforward, but there are steps we can all take to make it easier.
Our experience of providing a logic model and evaluation support to vanguard sites developing new models of care has underlined the importance of effective planning and review. This is not because effective planning means you will get everything right first time, but because it means you are more able to adapt and change – or if necessary stop – your project if it’s not delivering the outputs and outcomes you expect. The more commissioners, providers and other stakeholders can be encouraged to adopt a methodical approach to change, the more likely others are to be able to take the relevant elements and apply learning in their own health system.
Mental health remains one of the most complex areas of healthcare. Demand for services is rising and pressure to provide faster, more patient-focused services is now commanding a much greater level of public and political attention. With the impetus set by the Five-Year Forward View for Mental Health, combined with major advances in the way mental health services are commissioned and paid for, the time is right to grasp the nettle and deliver lasting improvements for patients. But in our quest for new solutions, innovators must be mindful of the need to leave a clear path for others to follow.
Wendy Lane is director of consultancy services and transformation at NHS Arden & GEM commissioning support unit
References
1 Safe Haven Leaflet by North East Hampshire and Farnham CCG northeasthampshireandfarnhamccg.nhs.uk/documents/miscellaneous/emotional-wellbeing-and-mental-health?format=html
2 Bauer A, Parsonage M, Knapp M et al. The Costs of Perinatal Mental Health Problems. Centre for Mental Health and the LSE Personal Social Services Research Unit, commissioned by the Maternal Mental Health Alliance.
3 Everington S. We need a dating agency for good ideas. Healthcare Leader, 2017;1:1
