As we move into 2021, the year Jeremy Hunt promised to have redressed the “historic imbalance” between physical and mental health, and ended the scandal of patients being treated miles from home, it’s already clear that none of Hunt’s promises made back in 2017, when he was still Health Secretary, were worth the paper they were printed on.

Hunt committed to an extra 21,000 new posts, treating an extra million patients a year to help deliver Theresa May’s promised “revolution” in mental health. But now Hunt, May and their promises have all been overtaken by history.

The 21,000 extra staff were to include “an additional 4,600 specially trained nurses working in crisis centres”: in fact the mental health nursing workforce has increased by just over 3,000 (8%) since the pledge was made, and few of the other promised extra staff are anywhere to be found.

At the end of January the Royal College of Psychiatrists once more issued a grimly familiar warning that mental health trusts are still struggling on with too few beds, too few staff and too little funding.

85% of the 320 psychiatrists who responded to the survey last December said there was more pressure on beds than a year earlier – and 92% estimated that they had fewer than 5% of beds available for urgent admissions. More than a third said they would look for beds outside their area and a quarter said they would delay admission and treat patients in the community.

RCP President Dr Adrian James said:

“The historic problem of shameful mental health bed shortages that Government pledged to end in 2021 is only getting worse.”

“More and more people are in mental health crisis as a result of the pandemic and instead of being able to treat them, psychiatrists are forced to send them miles from home or ask them to wait for months on end to get help.”

The RCP is calling for an extra £150m funding in 2021/22 to ‘bridge the gap’ between inpatient care and community support, to facilitate more timely and effective discharges.  But the College is also asking Government to invest in additional beds that are properly staffed and resourced in high-priority areas – and to commit to building a further six mental health hospitals by 2024/25.

Last autumn the Health Foundation went further noting that: “Over the next 3 years, we project referrals to dedicated mental health services for adults and children could increase by an average of 11%.

On that basis, they estimated that meeting this increased demand could require an average annual increase of £1.1–1.4bn per year, over and above existing funding for mental health services.

Meanwhile the impact of the bed shortage is well illustrated by the efforts by the Chief Medical Officer of the Norfolk & Suffolk Foundation Trust to delay or prevent admissions of seriously ill patients – by issuing a circular requiring that ““All admissions for patients who are not under the care of a CMHT will require agreement from the consultant responsible for the inpatient ward where admission is proposed.”

As the local mental health campaigners (Norfolk & Suffolk Mental Health Crisis) point out, the consultant concerned will almost certainly have beds already full – and have no current knowledge of the patient or their state of health.

But neither will the other consultant who is supposed to take a view: the new guidance states:

The [ward] consultant will liaise with the consultant in the patient’s ‘home’ CMHT [Community Mental Health Team] to establish what treatments or assessments might be required in hospital before agreeing to an admission.” But since the patient is NOT under the care of a CMHT, its consultant will have no knowledge of them either. As the campaigners point out:

“This means that two busy consultants will be diverted from their jobs treating patients … to discuss the treatment or assessment which most likely neither of them will be involved in.”

This raises a thorny question “Can a decision by a patient to agree to an informal admission to avoid a section assessment under the Mental Health Act be overturned by two doctors who have never met them?”.

Even more alarming, given the recent disastrous experiences of failures of care in the Trust: “What will the coroners think if people die having been refused admission by two doctors who have never met the patient overruling mental health professionals who have?”

The whole chaotic situation in the trust arises from the lack of sufficient local beds, compounded by the trust’s attempts to save money by closing beds without having put alternative services in place. During 2020 the rolling 3-month average number of “out of trust bed days” (patients dispatched to distant beds for lack of local space) almost trebled from 350 to over 900.

The RCP points out that out of area placements can harm patients by increasing their distress, separating them from their family and slowing their recovery.

Meanwhile, another 2017 promise by Theresa May, to scrap the “flawed” Mental Health Act as part a drive to revolutionise mental health care, has moved a step closer with the publication in January of a government White Paper on reforming the Act, opening up a consultation that ends on April 21.

However good the proposals, the catch is that reform of the Mental Health Act alone will not be enough to improve mental health services. NHS Providers has welcomed “the government making it clear that new legislation is only part of the story.” Their response continues:

“… We need to address the underlying issues driving the pressures on services and the rising severity and complexity of people’s needs.

“As we have said previously, system and financial pressures on providers, combined with inconsistent investment in mental health services at local levels, are exacerbating bed capacity pressures and increasing the likelihood that a person may reach crisis point ….

“We note the government confirms that reforms will require additional funding and expansion of the workforce, over and above commitments made in the NHS Long Term Plan, and the delivery of the proposals set out in the white paper will therefore be subject to future funding decisions.”

Whether or not this implicit government promise of additional funding and commitment to improve the quality as well as accessibility of services will be worth any more than previous promises remains to be seen.

As patients in Norfolk and Suffolk and many other areas are still finding out the hard way, there is a wide disparity between positive promises and statements and the delivery of actual services on the ground.

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John Lister
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