October 1, 2009

Ten year ago the government set itself seven targets to meet on mental health provision. How's it got on? Adam James investigates

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Time’s up. It’s now a decade since the Labour government vowed to tackle NHS mental health services with steely vigour.

Mental health would have an equal priority to heart disease, said the then health secretary Frank Dobson in 1999. A national service framework in mental health promised seven standards in care and treatment would be met. And so expenditure in adult mental health increased 6.7% in real terms from 2000-6, and by 3.7% from 2006-8.

The framework ended last month. Care services minister Phil Hope proclaimed NHS mental health care has been “transformed”. But, by honing in on the seven standards, is such high praise justified?

The two standards representing the aim to deliver “effective” services for people diagnosed with a severe mental illness were perhaps the most ambitious. The 1999 targets included such people being able to access mental health services 24 hours a day every day.

The government subsequently recruited 64% extra consultant psychiatrists, 71% more clinical psychologists, and 21% extra mental health nurses to help fulfil this aim. Plus, in a bid to turn around an under-fire community care policy, 740 assertive outreach, home treatment early intervention and crisis teams were set up. This development has, in particular, been welcomed.

"As an alternative to hospital, these services seem to be working,” concludes Paul Corry, director of public affairs at Rethink. There’s “no doubt” these new services benefit patients, says Chris Heginbotham, former chair of the Mental Health Act Commission.

Moreover, such services are credited with delivering progressive recovery approaches. “I know many home treatment teams who are really embracing recovery”, says Marion Aslan, trainer with Elemental, an organisation working with NHS staff.

Yet 45% of service users have no access to crisis numbers out-of-hours. Plus, although NICE has since 2002 been recommending CBT for everyone diagnosed with schizophrenia it’s not happening. Just 14% of patients with psychosis have received CBT, according to Rethink. The framework also promised all patients will have a copy of their care plan. But, as of last year, 40% of community patients had not, says the Healthcare Commission.

As for inpatient care for such severely ill people, Mental Health Act commissioners reported in 2008 that many private and NHS wards are "tougher, scarier places” than 10 years previously. Royal College of Psychiatrists president Dinesh Bhurgra weighed in by even saying that standards were so atrocious he would never allow any of his relative into an inpatient unit.

Such talk infuriates Louis Appleby, national director for mental health. “The commission is completely wrong,” he said. “They [commissioners] can not be looking at the same wards as me.” Appleby highlights that government investment financed many safer and therapeutic units.

It appears that either the Mental Health Act Commission or Appleby is being frugal with the truth. What does Marjorie Wallace, director of Sane, think? “All I can say is what most of the people who contact us tell us,” she responds. “I have a letter here from a woman who says her husband was in a psychiatric ward and it was so bad it made him want to kill himself.”

Plus, black and ethnic minority people continue to be five times more likely to be compulsory detained, despite a Delivering Race Equality plan.

Nevertheless, progress is acknowledged. For example, NHS trusts which from next year fail to provide satisfactory single-sex mental health wards will be fined. “Fifteen or twenty years ago it was difficult to say that any safe and therapeutic ward existed. But now some do,” says Corry.

Another standard was to prevent suicide. In England suicide is now at its lowest recorded level, with a 2007 suicide rate - the most recent year for available statistics – of 7.5 deaths per 100,000 people. In 1995 the rate was 9.2 deaths. “Preventing suicide has been a success story,” says Mind’s policy director Sophie Corlett, before adding, “although we know that rates depend upon the state of the economy which did boom over recent years.”

What about the standard of promoting the nation’s good mental health and combating stigma and discrimination against people with mental health problems? The 2007 adult psychiatric morbidity survey in England revealed that, in fact, there has been a rise in self-reported “common mental health problems” from 15.5% in 1993 to 17.6 in 2007 (although there had been no rise since 2000). Plus, 8.2% of adults had screened positive for ADHD, the first time this statistic had been recorded. With a projected ADHD co-morbidity of 25% that’s around 3million of the population with mental health problems who, until 2007, had never been accounted for.

With such figures, surely the government can not be credited with improving the nation’s mental health? Appleby disagrees. “The survey relies on self-reporting. The suicide rate is a much better indicator of the society’s mental health. And that’s fallen,” he says.

As for anti-discrimination, the government-backed Shift campaign has been ongoing. Nevertheless, this year a department of health survey reported 11 per cent of people said they would not want to live next door to someone with a mental health problem - an 8 per cent increase since 1994. Mental health act debates linked violence and psychiatric illness. Nevertheless, Wallace argues the media has covered mental health markedly more positively. “Mental health stories have been much more of a currency for media coverage over the last 10 years,” she says.

But some service user activists are angry that the anti-stigma message has been infused with a traditional medical model, implying that people will always be a victim to a biology-based illness. “I actually think the anti-stigma campaigns have made stigma and discrimination worse,” says Aslan.
"There’s now a raft of information that people are ill and need to be treated with medication, rather than a holistic approach. The general public believes schizophrenia is an illness only treatable by drugs. It’s not.”

What of the standards demanding an improvement in primary care and access to services? The government points to its drive to provide CBT therapy for 900,000 depressed and anxious people, and the recruitment of an extra 3,700 psychological therapists.

For Appleby this initiative is “one of the most ambitious mental health programmes of this century”. The mental health sector is supportive. Yet Corlett says it’s too early to make a call on the initiative’s success. “From next year psychological therapy funds will go straight to primary care trusts, rather than being ring-fenced as it is now. So we’ll have to wait and see,” she says.

A final standard was ‘caring for carers’. The government promised all carers would have their own written care plan. With less than half of patients having their own written care plans, it is worse for carers, says Drew Lindon, of The Princess Royal Trust for Carers. “But there have been improvements,” he adds, pointing to an extra 700 mental healthcare support workers.

Interest is now moving onto New Horizons - the government’s mental health strategy over the next 10 years - which is out for consultation. Among its priorities are continuing where the framework left off, and stepping up improving the nation’s mental good health and tackling links between poverty and mental ill health. But there could be a spanner in the works. A general election.

How has the government performed on its National service framework for mental health – out of five

· Sophie Corlett – 3
· Marion Aslan - 2
· Louis Appleby – 4
· Paul Corry – 4
· Marjorie Wallace – 3 (community service users); 1 (inpatients)
· Chris Heginbotham – 3.5

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* This article first appeared in Mental Health Today magazine

See also: Service provision

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