Mental health: equity investment

The government’s commitment to increase spending on mental health services as a proportion of the overall NHS budget has been widely welcomed. However, with significant challenges and pressures, mental health provider trusts are keen to see how this extra funding translates into practice before getting too excited.

The government has previously committed to deliver parity of esteem between physical and mental health. It subsequently backed this up with a mental health investment standard (MHIS) that aims to ensure that clinical commissioning groups increase spending each year on mental health at least in line with their increase in total funding.

The new commitments go beyond this. When prime minister Theresa May announced in June that NHS funding would increase by £20.5bn in real terms by 2023/24, she was clear that better access to mental health services would be one of the key priorities alongside cancer, prevention and restoring performance standards. This was reinforced in chancellor Phillip Hammond’s Budget with his commitment, within the overall increase, to boost mental health spending by more than £2bn a year by 2023/24 and for it to grow as a share of the overall NHS budget.

Mixed reception

There was immediate praise for the rhetoric around prioritising mental health spending, which was seen as a ‘welcome step on the journey towards true parity of esteem’.

However, there were also plenty of commentators keen to stress that the extra funding would not solve all the mental health service’s problems. Richard Murray, director of policy at The King’s Fund warned that ‘years of underfunding have taken their toll’ and that services needed ‘more than money to meet demand’. In particular, he highlighted a chronic shortage of mental health staff as a major obstacle. But there has also been a little confusion about what the government’s funding promise really adds up to – £2bn, at 10% of the overall £20bn, looks very close to being simply mental health’s proportional share of the funding increase. (Take current spending and multiply it by the average 3.4% per year increase and you’ll get growth very close to £2bn).

National mental health director and chief executive of Central and North West London NHS Foundation Trust Claire Murdoch has used Twitter to point out that the Budget reference was to an increase of ‘at least £2bn’.

Wendy Burn, president of the Royal College of Psychiatrists suggests that mental health services need closer to £2.5bn if mental health is to achieve a higher proportional spend. And a report from the Institute for Public Policy Research, just ahead of the Budget, called for funding to increase from £12bn in 2017/18 to £16.1bn in 2023/24 and £23.9bn in 2030/31 to achieve real parity of esteem. On average this equates to increases over the next five years of 5%, compared with the 3.4% being applied to the overall NHS budget.

Unsurprisingly, the government’s new funding promise came with new spending commitments – £250m for new crisis services, for example. Amber Jabbal, head of policy at NHS Providers, while welcoming the recognition given to specific mental health pressures by the government, is concerned that core services should not lose out. ‘Targeting limited funding in this way risks leaving investment in the wider mental health services stretched thinly,’ she says. ‘Given previous commitments on mental health funding, it is particularly important to ensure that this time any additional money reaches the frontline and is deployed to strengthen core services.’

Finance directors have also been quick to welcome the commitment made to mental health. They too underline that more than £2bn will be needed to make further progress towards parity of esteem, but insist that the increases need to realise their intended purpose – and not be a retrospective exercise in justifying that spending meets targets.

‘The mental health investment standard is to ensure that mental health investment keeps pace with the general level of increase for all services,’ says Paul Stefanoski, director of finance and business at West London NHS Trust. ‘In effect, an increase of £2bn merely delivers this commitment.’

He accepts the reality that the £2bn announced in the Budget is unlikely to be wholly in addition to the mental health investment standard, but suggests it does need to be somewhere in between.

Investment standard

There has been some dispute in recent years about whether the MHIS is being achieved. In some areas, trusts argue that their contract income has not increased in line with their commissioners’ overall growth. But commissioners say overall mental health spending has increased by the required amount – including (sometimes unplanned) increases in spending on continuing healthcare, drugs and non-NHS services.

And in some areas spending on Five-year forward view targets has been at the expense of core mental health services – either in terms of actual cuts or in failing to recognise demand growth for core services.

Mr Stefanoski says the investment standard was supposed to support trusts in achieving the goals of the Five-year forward view and if providers don’t receive this, it will inevitably impact on their ability to hit those goals.

A recent HFMA survey of its Mental Health Finance Faculty provider members shows that nearly 90% have no (19%) or low (69%) confidence of receiving anticipated funding under the MHIS this year. There is more confidence that commissioners will achieve the target in terms of spending, but providers just don’t see it being passed on to them (a further survey is being undertaken of commissioners).

Faculty chair and finance director of North Staffordshire Combined Healthcare NHS Trust Suzanne Robinson acknowledges the competing pressures facing commissioners, but says it should not be a competition between spending on different areas or sectors.

‘We want to see investment in mental health as part of the whole solution for the health system,’ she says. ‘For example, investment in crisis services, if done in the right way, can reduce acute attendances and admissions. So you might make targeted investment to ensure patients receive the right care in the right place and don’t incur unintended costs elsewhere in the system.’

Ms Robinson says the long-term plan has to support more of this holistic approach to investment rather than looking at meeting investment targets in separate sectors.

Rob Pickup, interim director of finance, performance and information management and technology at Dudley and Walsall Mental Health Partnership NHS Trust, also wants investment to be seen in the round. ‘We are seeing a lot of core services suffering because of other pressures,’ he says. ‘Because some community services have been stopped, we are not seeing people identified and supported in the community at the points they need it.

‘And that leads to growth in numbers and higher acuity coming through into the mental health system.’

Mr Pickup adds that the trust has seen an increase in the level of specialling it has to provide as a result of this higher acuity. He suggests the widespread retendering of drug and alcohol services may have contributed to a reduction in the service provided. And broader cuts to community groups have exacerbated loneliness – another key contributor to worsening mental health – and removed another opportunity to identify people in need of support earlier in the pathway.

New 'must-do's

There is a danger that funding is poured into one area only for cuts further upstream to increase demand for services and cancel out the benefit of the investment.

Mr Pickup acknowledges that some of the ‘must-do' requirements attached to the new funding – such as increasing the number of crisis cafes – will support existing plans to reduce out-of-area placements. But he says there also needs to be recognition that different service models in different areas will demand different solutions.

‘For one organisation, reducing out-of-area placements may not be about extra local beds. Its answer might be to reach people before they require beds,’ he says. ‘Some areas may not have assertive outreach teams anymore, which can really help with readmissions and patients with frequent admissions. In other areas, it will be about increasing inpatient capacity.’

He also warns that significant staff shortages in key areas – psychological wellbeing practitioners to deliver IAPT (improving access to psychological therapy) services, for example – will affect the pace at which the mental health sector can increase service levels. 

The most important thing about the long-term plan, he suggests, is that it needs to deliver a joined-up strategy. It needs to align with the existing Five-year forward view and be built around a comprehensive staff strategy. It will still take time before new staff can be trained, so thought needs to be given to how other professional staff can be trained up to deliver new models of care.

‘So it may be that we need money for transformation up front and then growth once we have extra staff available and new models proven so we can start to expand services to meet demand,’ he says.

It is arguable that mental health has been easier to ignore in recent years because mental health providers don’t exhibit the financial deficits that are increasingly common across acute providers. But they face many of the same demand pressures for core services without increases in funding. Many are reliant on sustainability funding and other non-recurrent sources to achieve control totals. And rather than deficits, the pressures play out in terms of gaps in services.

Ms Robinson says the lack of an engineered payment system has contributed. ‘We’ve fallen behind acute providers in terms of the information and data we capture and present,’ she says. ‘And we don’t have the same level of understanding of our demand, activity and capacity. We need to step this up, if just to show the increase in activity that services are delivering for the same funding.’

However, she says finance practitioners in providers and commissioners are unconvinced about the proposals for a blended payment approach for mental health from 2019. While links between funding and activity levels might be welcome, there are concerns about the time it might take to properly understand and agree baseline activity levels. Instead, many think the service should be concentrating on new payment systems to support integrated care and population health approaches.

Sean Duggan, chief executive of the Mental Health Network, part of the NHS Confederation, underlines that mental health practitioners are looking for a package of different measures in and alongside the 10-year plan. More funding for mental health services is certainly needed – £2bn won’t deliver parity of esteem – but this is only one component.

A long-term social services settlement is also vitally important for people with mental health problems, and the long-term plan also needs to set out how it will increase funding for associated areas such as learning disabilities, autism and long-term physical conditions.

He says there has been good progress in areas such as perinatal mental healthcare and the roll out of IAPT, although more needs to be done, and major strides forward are needed with services for children and young people. Services should also take more advantage of digital opportunities.

‘Two reports [Institute of Fiscal Studies and Institute for Public Policy Research] confirm  that £2bn will only keep the ship afloat,’ he says. ‘It won’t do much in terms of the large-scale journey to parity of esteem.’

However, he says it is ‘quite clear’ that the new funding is ‘over and above the existing promises for the Five-year forward view commitments’.

The chancellor’s Budget statement was really just the trailer for the coming long-term plan. All eyes are now on this key report to see if the detail matches up to the rhetoric.