A leap in the dark?

The King’s Fund have today published a report which suggests that cuts to the NHS are resulting in serious deficiencies in mental health care, with acute beds unavailable to those in a crisis and NHS trusts relying on cheaper “community solutions” without there being evidence that they will work. The authors say, “Despite the lack of guidance and evidence, the majority of trusts have embarked on transformation programmes at scale and pace with little or no dedicated funding for the process. Arguably this has resulted in trusts taking a leap in the dark.” ‘Transformation programme’ in this instance appears often to mean mergers of previously specialist teams and increasing reliance within medical services upon unqualified staff. It says this has saved money but probably resulted in worsening outcomes and in the longer term, more demand for acute beds.

The BBC Today programme coverage illustrated this with the upsetting and at times surreal story of a man in his 60s undergoing an acute mental health crisis in which he started to self harm and become suicidal. His family were left to cope as best they could until they felt their only option was acute care. They had to call an ambulance, but instead of taking their relative to hospital, the ambulance crew had been instructed to take him to a ‘mental health café’ which could offer a cup of tea and a chat. As the man’s daughter pointed out, they had tea and chats at home: they were looking for emergency care. The man and ambulance crew sat outside the café, which he was too ill to go into, for two hours, before the crew decided to take him to A&E. Eventually a bed was found and he spent several months intensively supervised in hospital.

As Ministers have themselves noted, there has never been equal value (‘parity of esteem’) placed upon mental health services in comparison to physical health services and there seems little doubt that this gap is widening, with 40% of mental health trusts having experienced recent budget cuts despite small overall rises in NHS budgets. That people can be very ill and still no bed available is unacceptable – and terrifying for families. No one wants to see expert clinical care replaced by an ambulance trip to a café. The report cites The Care Quality Commission’s report on crisis care which found that only 14% of people who experienced a crisis felt that the care they received provided the right response and helped to resolve their crisis. (Care Quality Commission 2015c). Meanwhile, more people are being ‘sectioned’, with a quarter of junior staff in one survey saying they were told it was the only way now to get access to hospital. Where they fail to do this, over stretched community teams are asked to visit people who need round the clock support, which may be leading to higher suicide rates.

All of this makes it unarguable that hospital based mental health services need urgent investment. I think it’s worth noting some points in response to this report though, coming from the perspective of a sector which is attempting to scale up as a community embedded mental health service.

Firstly, there is nothing genuinely transformative about a ‘transformation programme’ which is really a cuts and merger programme. Reforms driven by cost cutting usually shunt costs, rather than cut them, and rarely lead to real change, which always starts with building and releasing the creativity and leadership of people who use services, their families and front line staff. And whilst ‘community’ care is the accepted description of the care models mentioned, it is a misleading one. Moving medical responses into smaller buildings or even people’s own homes does not in itself do anything to help people to live safely and well as part of their communities. There is typically no attempt made to help people build their social connections and neither is there routine training, support and emergency back-up for the family carers who make up the individual’s immediate community. The family in the BBC report were providing round the clock emergency care to a very ill relative, but their only access to back-up was to call 999. The detail of the report paints a picture not of acute services being closed and the money reinvested in risky, untried new approaches, but of both acute and ‘community’ care being cut with poor experiences regardless of which kind of care was used or most appropriate.

Equally, there is nothing magical about the hospital. Hospital buildings are containers for beds, round the clock supervision and the expert clinicians which are typically not offered elsewhere. The man in the BBC report desperately needed the support only typically available within a hospital, but whether, months later, it was the most therapeutic possible environment for his longer term recovery is open to question. The BBC report is a nice illustration of the choice we are often presented: keep all the money wrapped up on hospitals, or see them cut and an ambulance may arrive to take you for a spot of basket weaving when you in the middle of a full blown mental health crisis. We need well-funded, fully-staffed hospitals for emergencies. And we also need a mixture of medical, practical and social support available in ordinary homes as people attempt to recover their lives, their social connections and their confidence following a crisis.

An ambulance will never arrive to take you to start a new Shared Lives arrangement during a crisis, because Shared Lives always needs to involve matching, in order to benefit from the social connection which can only happen when that connection is genuine and chosen freely. But Shared Lives schemes are providing support at short notice, and exploring how matching for short stays can take place in hospital for instance. An NHS Trust is drawing heavily on the Shared Lives model for an acute Family Hosts mental health service. These approaches should not be seen as alternatives to the clinical care offered in a hospital, but as alternatives to the hospital ward and hospital bed where, for much of the time, patients are not receiving clinical care, but waiting for the next intervention. Shared Lives works for people with mental health problems when, as is happening in Bradford, the Shared Lives scheme and mental health services are sharing responsibility for designing an integrated support package and recovery model.

Finally it’s worth saying something about the lack of evidence base for the changes cited by the report. I think evidence may be red herring. We already know that most people don’t find a hospital the most conducive place to be to get their lives back. You don’t need research to know that offering a response on a lower budget, with fewer specialists and to fewer people is going to result in poor outcomes. Research funding follows service funding, which means that small improvements to the status quo are well-researched, whilst genuine innovation is the subject only of small pilots and evaluations, which inevitably conclude that more research is needed. The King’s Fund talks of a ‘leap in the dark’. We need to take some leaps, and as austerity bites, it’s getting very dark out there indeed.

Barbara

Barbara is in her 40s. She has been known to mental health services for many years. She has lived in different settings with varying support and had intermittent periods as an inpatient. For the past two years she was staying with her elderly mother who is now in a care home.

Barbara has a diagnosis of schizophrenia. She suffers from extreme anxiety and cannot manage to stay on her own overnight. Barbara moved into a long term Shared Lives arrangement three months ago. She has started participating in community groups, travelling on her own by bus to the town centre. She has been away for a weekend with her Shared Lives carers and is planning a short holiday: this will be the first holiday she has ever had. Mainstream mental health services have long struggled to meet Barbara’s needs in a community setting. Barbara social worker who has known her for several years states that she has never seen her so relaxed. She is extremely happy with the progress in confidence and skills that Barbara has made. Barbara is much less anxious and is hearing voices less.