There are reasons to be cheerful about the NHS Long Term Plan and mental health. As with NHS strategy over the past twenty five years, mental health has a dedicated section and ambitious targets for improving access to mental health support.
Five Year Forward View commitments are reinforced: better support for perinatal mental health, to be integrated with maternity outreach clinics and extended to fathers; improved access and early intervention for children and young people; a 24/7 community based mental health crisis response introducing a single point of access through 111; mental health liaison services in acute hospitals; and employment support for people with mental health problems to find and stay in work.
There are some new additions too, with a recognition of the needs of street homeless people and looked after children; a new approach to young adult mental health services for those aged 18-25; and a focus on the mental health needs of the workforce including including access to specialist mental health support for all NHS doctors. The commitment to testing integrated delivery with primary care and community mental health services also holds promise in addressing the current chasm between primary care mental health and specialist support.
Policy has a symbolic function and, inevitably, the devil is in the detail of the NHS long term plan. Here are my suggestions for five tests to assess whether the plan will deliver substantive improvements in our mental health system
- Test 1: The NHS will achieve parity of esteem between mental health and physical health. There is no specific reference to earlier commitments to achieve equality in funding between mental and physical health. However, there is a plan commitment to increase investment in mental health faster than the NHS budget overall. Nevertheless, there is a real risk that mental health expenditure may be disproportionately disadvantaged in the scramble to achieve the plan commitment to return to financial balance.
- Test 2: The NHS will invest in the causes as well as responding to the consequences of poor mental health. The NHS Plan focuses upstream prevention action on physical health – obesity, smoking etc. There is scant mention of upstream prevention of poor mental health, although there is an emphasis on identifying and responding early. The early years are a critical time for laying the foundations for good mental wellbeing but responding to need is not enough. In the light of a clear workforce challenge to deliver the ambition of ensuring every child and young person requiring support is able to access it, a radical think is needed. Given the evidence base for upstream interventions, both universal and targeted, this is a missed opportunity. The Spending Review could offer some redress by identifying investment for upstream prevention in mental health.
- Test 3: The NHS will radically reduce the number of people detained under the Mental Health Act and the disproportionately high rates for people from African and Caribbean communities. As well as legislative reform, early intervention and timely crisis responses are key, alongside providing services that people trust and enable them to address their underlying difficulties. Pinning our hopes on digital solutions and increasing access to time limited psychological therapy will not deliver this. The range of therapeutic options and community focused support needs to be substantially improved and grounded in a rights-based approach. Only then will we see a reduction in uses of the Mental Health Act.
- Test 4: The NHS will take strong action on inequalities, which are linked to poor mental health. The plan goes some way towards this in committing to action on improving inclusion and outcomes for people with a diagnosis of severe mental illness. It does not go far enough and there is, for example, scant reference to the inequalities in mental health experienced by Black Asian and Minority Ethnic communities or the need to develop mental health support that is gender sensitive and gender specific. The emphasis on self-management and digital solutions may, also, inadvertently lead to increased inequalities.
- Test 5: The NHS will evaluate progress on outcomes based on people’s experience and be accountable for these. There is an emphasis on improving patient experience but the plan lacks detail on how this experience will be reflected and used to improve the experience of people, using mental health services or indeed the wider NHS and social care system. I hope this is a priority for further guidance, coprouduced with people, families and communities and outlining clear accountability mechanism to the people and communities the NHS serves.
Perhaps the biggest test of all facing the NHS Plan in respect of mental health is implementation. There is something of a narrow pot pourri of interventions about the plan rather than a vision for the transformation of mental health services. Local NHS commissioners, providers and system leaders will need to work closely with a wide range of partners to develop this and deliver the transformation that is urgently needed for our mental health system.
Dr Karen Newbigging, Senior Lecturer in Healthcare Policy and Management, University of Birmingham.