Underfunding of mental health services has cost thousands of lives

We should welcome the Five Year Forward View for Mental Health with cautious optimism

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Yesterday saw the publication of the Five Year Forward View for Mental Health, containing a series of recommendations which will now be rolled out up to 2020/21. The report represents an important next step on the road towards improving England’s mental health.

But with the scale of the challenges currently facing services, the best way to manage need in the long-term will be to direct investment towards early intervention and prevention services based in the community.

Unfortunately, the headline statistics setting out the scale of the challenge do not become any less sobering even as they become more familiar. The report starts out by telling us that one in four adults experience a mental health condition every year; that one in ten five-to-16-year-olds have a diagnosable condition; that one in five mothers experience mental ill-health after childbirth; that suicide is now the biggest killer among men aged 15-49; that 40 per cent of older people living in care homes are affected by depression; and that people with severe and enduring mental health conditions are at risk of dying 15-20 years younger than they otherwise would.

There are various social, cultural and technological factors driving rates of mental ill-health, many of which are common across developed countries. But the current picture in England is partly the result of years of underinvestment, with the NHS traditionally having directed a disproportionate amount of funding to physical health services.

Despite mental health accounting for 23 per cent of NHS activity, NHS spending on secondary mental health services is equivalent to just half of this.

This chronic underinvestment has continued even during the recent period of increased policy emphasis on the need to improve mental health services. The budgets for mental health trusts fell by 8 per cent between 2010/11 and 2014/15.

What is more, recent analysis by the Health Foundation has found that the fall in mental health trusts’ budgets of 2 per cent between 2013/14 and 2014/15 came at the same time as a rise in hospital trusts’ budgets of 2.6 per cent over the same period.

This calls into question the seriousness with which government has pursued its ambition to achieve true ‘parity of esteem’ between mental and physical health services, and suggests that the gap between the two may in fact be widening.

The Five Year Forward View for Mental Health therefore contains a pledge to spend an additional £1bn on mental health services each year up to 2020/21. This money is to be found from within the additional £8bn per year that was pledged to the NHS in the Conservative Party manifesto.

The ambition is that this will help one million more people with mental health conditions to access high quality care by 2020/21. However, such is the scale of the unmet demand that even this ambition sounds insufficient when placed in context. If one in four adults experience mental ill-health every year, then there are roughly 11 million who require some form of care or treatment.

Given that 75 per cent of this group currently receive no treatment whatsoever, the new funding will not be enough to significantly reduce underlying demand on a whole range of mental health services.

So while the £1bn annual investment will help to improve some services that have experienced historic underfunding, the only way to achieve sustained improvements in the long term will be to invest more in early intervention and prevention. This is necessary to stem the flow in the numbers requiring access to more prolonged and expensive forms of treatment.

Identifying mental ill-health and intervening early before problems escalate has been shown to reduce the likelihood of a number of detrimental life outcomes, particularly for young people. For example, there would be an annual saving of £100 million to public services if just one in 10 of the young people sentenced to prison each year had benefited from early intervention relating to their mental health.

Despite this, the funding pressures on mental health trusts and local authorities in recent years have resulted in early intervention services losing out. For example, the 2014 Health Select Committee investigation in to children and young people’s mental health heard how these services had been cut or reduced in many parts of the country.

Where these services are unavailable, low-level mental health problems can worsen in the absence of treatment and drive pressures on parts of the system further down the line.

Crucially, the Five Year Forward View for Mental Health does appear to create the space for opportunities to bring about lasting improvement in the provision of early intervention and prevention services. But the real test will be in whether this opportunity is grasped.

The recommendation that local areas compile ‘mental health prevention plans’ should provide an incentive for clinical commissioning groups to create links between the various parts of the system with an interest in keeping people well. Early intervention and prevention are enabled by better joint-working and the sharing of information and expertise, and also requires that services are easily accessible.

Commissioners and service providers should therefore work together to create opportunities to deliver preventative care in a range of settings. For example, schools and workplaces could be well placed to identify risk and act as the ‘hubs’ from which early support can be delivered.

The Five Year Forward View for Mental Health should be welcomed with cautious optimism. But the real test over the next five years will be the extent to which local areas really do begin to put early intervention and prevention at the heart of their commissioning decisions. Without this, there is every chance that an even bigger pot of money will be needed by 2020/21.

Craig Thorley is a research fellow at IPPR, where he leads work on mental health policy

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