Background
This year sees the publication of the Chief Medical Officer’s (CMO) Annual Public Health Report for England—the topic for 2014 was Public Mental Health. This brings together the best evidence in the field, set within a contemporary policy context, and informs the CMO’s recommendations for the further development of mental health in England. Although one in four adults experience at least one diagnosable mental health problem in any year, there is emerging evidence that most people with mental disorders in England receive no relevant healthcare [
1].
As part of the CMO Report, we were commissioned to write an overview of gaps in mental health service provision in England. The aim of this paper is to summarise these gaps in terms of funding, access, treatment and care. We draw upon all the available data on resources (and disinvestment) in mental health services in England in recent years, in relation to population levels of need. We go on to consider whether recent cuts in NHS mental health services are comparable the resource levels available in acute/physical care, given the recent governmental legal commitment to ‘parity of esteem’.
Mental health services in England have been historically characterised by significant variations in service provision, quality of care, and acceptability to users [
2]. The National Service Framework for Mental Health (NSFMH) for England imposed a standard models of care, and was substantially implemented through a financial incentives system, and led to improvements in the availability and quality of provision in mental health services in England [
3]. In 2011 the Coalition Government’s mental health strategy for England (entitled ‘No Health without Mental Health’) [
4] recognised the need for ongoing improvements in quality and provision. It set six key targets including improvements in safety, patient-centeredness, recovery and physical health. Yet this emerged at the same time as considerable structural change in the NHS, related to the ‘Nicholson Challenge’ to hold overall expenditure steady, and with substantial restructuring for commissioners and providers in the NHS, governed by the 2012 Health and Social Care Act.
In terms of the national mental health service context, about a quarter of people with depression and anxiety in England receive treatment, most often in primary care settings [
5,
6], while the large major of specialist mental health care is provided by National Health Service (NHS) staff. At the same time there has been a trend over the last decade for governments to stimulate a ‘mixed economy’ of NHS, for-profit and non-for-profit service providers. Until 1999 the pattern of mental health services was largely determined by local planners. A national 10 year plan for England was introduced in 1999 that set a clear profile of community mental health services to be provided in each local district [
7]. Since 2010 a greater degree of ‘localism’ has been encouraged by the subsequent national mental health plan, in which local service commissioners can purchase services on the basis of a local assessment of needs, and not on the basis of a nationally specified pattern of care [
4]. Some of the most important system wide key performance indicators, such as a maximum waiting time of 18 weeks to be seen by a specialist after a referral from primary care, especially excluded mental health care from this requirement, until a policy change in 2015.
Mental health services have long been considered to be the poor relation to physical/acute care, often described as being subject to less investment or greater disinvestment in times of plenty or scarcity [
8]. Yet to date hard data on this alleged disparity have been difficult to identify. Conflicting Governmental guidance has emerged. The Department of Health’s 2014 policy guide on according equal value to mental and physical health (so-called ‘Parity of Esteem’) [
9] is an important step forward in principle. Conversely, the imposition of a ‘tariff deflator’ (i.e. resource reduction), a fifth higher for mental health than for acute healthcare appears to undermine the overall policy intention [
10].
Method
In this context the method used in conducting this overview paper was to identify all available sources of information on governmental mental health investment (both health and social services) in England over the last decade. The sources used were: government Budgetary Programme Data, online searches of MedLine, PubMed, Ovid, Department of Health policy documents, Freedom of Information request reports, charitable and other grey literature reports, data from experts in the field (using a snowballing technique to identify all possible sources of relevant material), and other material from internet search engines. We also received detailed time trend budget data from one mental health provider trust in England.
Discussion
Disregard for the needs of people with mental illness has been described by some authors as ‘structural discrimination’ [
31,
32]. This concept can also be applied to lack of investment in information infrastructure to be able to know whether services are improving or not.
There are several important limitations of this study. The research deliberately sought all relevant sources of information about the levels of investment in mental health care in England, and recent trends, and this meant that these sources were very heterogeneous and drew upon a wide variety of official data, research reports, the grey literature and case studies. We therefore would not place very heavy weight upon individual sources, but rather wish to interpret the overall pattern of results. Second, the time frame used for the data sources varied somewhat, with some referring to the period since 2008 when the economic recession began, and other to the period of the government at the time, which came into power in 2010. Further, we have brought together information across a wide range of sources, but it is true that there are few sources of information about true prevalence and treated prevalence across all diagnostic groups, and such data are not routinely and repeatedly collected and reported by the government. It also needs to be kept in mind that rates of service utilization (and deductions about rates of unmet need) may differ when reported by service users or by service providers [
33,
34]. In addition, it is possible that there were types of substitution (for example with fewer community services in recent years has this been associated with a greater demand for psychiatric beds?), but we were not able to identify data to bear upon this issue.
The recent governmental commitment to ‘parity of esteem’ [
9] is long overdue. Yet the policy requirements which have been applied to acute/physical healthcare, such as the 18 week waiting time limit, have still not been applied equally to mental health care. It is also clear that unintended consequences of the tariff system (cut more in recent years for mental than for mental health care) have systematically disadvantaged both commissioners and providers of mental health care. Poorly integrated financial monitoring processes have contributed to a failure to alert all parts of the NHS to how far resource reductions have harmed the quantity and quality of mental health care in recent years. In the post 2013 structure of the NHS separate health, social care and public health outcomes frameworks are making it even harder to commission joint or integrated services, to avoid gaps in provision, and to monitor progress or deterioration in services. At the same time it needs to be acknowledged that within this context of overall disinvestment in mental health care, some services are being expanded, particularly the remit of the Improving Access to Psychological Therapies (IAPT) services. Taken as a whole, these findings are far from reassuring for everyone dedicated to better mental health care in England.
Authors’ contributions
MD is an Academic Clinical Fellow at King’s College London, Institute of Psychiatry, Psychology and Neuroscience, and is a Specialty Registrar at the South London and Maudsley NHS Foundation Trust. She was formerly a Medical Advisor to the Director of Research and Development at the National Institute for Clinical and Health Excellence. She undertook the primary data retrieval, and wrote the first draft of this paper. GT is Professor of Community Psychiatry at King’s College London, Institute of Psychiatry, Psychology and Neuroscience, and is Consultant Psychiatrist at the South London and Maudsley NHS Foundation Trust. He has published extensively on mental health services, and their evaluation, on stigma and discrimination, and on global mental health. He supervised the design, conduct and writing up of this paper, which is based upon a chapter on Service Gaps in the UK Chief Medical Officer’ 2014 Annual Public Health Report on Public Mental Health. GT is the guarantor of the paper. Both authors read and approved the final manuscript.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (
http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.