The latest dire revelations of the state of mental health services provided by Greater Manchester mental health trust, which has been declared ‘inadequate’ by the CQC, need to be seen in the context of rising staff shortages, underfunding and government neglect.
So bad has the situation become that the chief executive of the NHS Confederation’s Mental Health network, Sean Duggan, has raised the alarm with a recent HSJ article headed ‘Mental health is now barely acknowledged by this government’.
Duggan contrasts the promise in Boris Johnson’s 2019 Conservative Manifesto that mental health would be treated with the same urgency as physical health with the miserable performance of ministers since then.
He notes the recent government Mandate to NHS England makes only a few vague passing mentions of mental health, while the lack of capacity is starkly exposed. He notes 1.2 million people are currently waiting for mental health support, “and, despite the best efforts of hard-pressed staff, recent data suggests one in five people attending accident and emergency needing mental healthcare, spend more than 12 hours there.”
He points to the dire lack of capital investment, with only one mental health provider included in the government’s flagship 40 new hospitals, while “Our members tell us time and again that many parts of the mental health estate are not fit for purpose.”
In the autumn of 2021 the Royal College of Psychiatrists set out a clear case for rapid investment of £3bn in capital projects and £1bn in revenue to drive forward improvements – but no such funding has been forthcoming as NHS England faces the need for £12bn in “savings” by 2025.
Duggan notes the “positive news” that the recent NHS Long Term Workforce Plan commits to increasing the number of mental health and learning disability nurses at a faster rate than other part of the workforce, but warns: “given we are starting from a low baseline, there will continue to be a significant shortfall for some time to come.”
Previous government promises of extra staff have proved worthless. In fact NHS vacancy statistics show the under-staffing of mental health has significantly worsened since records began, from 8,900 unfilled posts in Quarter 1 of 2018/19 (21% of the total nursing vacancies) to 12,872 in March this year, 32% of the total nursing vacancies.
And while the NHS lacks resources to cope with existing demand and the predicted massive post-Covid increase in demand for mental health care, local government budgets, too have been hugely reduced, often leaving local police to carry out the role that mental health services should be covering.
But now, after a campaign by police and crime commissioners and the Metropolitan Police a new deal has been agreed with the government in which the police will step back from responsibilities they are not funded or trained to undertake, leaving council social services to fill the void – but with no extra funding.
Once the new arrangement is in place police will only attend a mental health call if a crime has been committed or if there is a real and immediate risk of harm to a person’s life. This is likely to herald a new postcode lottery, with wide variations in the resources available and the policies implemented by local authorities.
David Fothergill, chair of the Local Government Association’s Community Wellbeing Board, told Public Finance: “We are concerned that this is being rolled out too quickly, with inadequate local engagement and partnership working meaning that other agencies risk being unable to pick up any increases in demand for their services.
Meanwhile the Greater Manchester mental health foundation trust, which provides mental health care and treatment for more than 1.2m people living in Wigan, Salford, Bolton, Trafford and Manchester, was downgraded by the CQC last month from “requires improvement” to “inadequate”.
Poor standards of care at the trust’s Edenfield Centre in Prestwich were exposed by a BBC Panorama programme last September which uncovered a “toxic culture of abuse”. But subsequent CQC visits to other local facilities have shown that the Trust’s patients are still being cared for in some wards that “were not safe”.
Ann Ford, CQC director of operations in northern England, told the BBC said there were “areas of concern we’d highlighted at the last inspection” that had not improved. “There were… ligature risks, broken furniture and fittings, and poor safety audits in the acute wards for adults of working age and psychiatric intensive care units, which continued to put people at risk of harm.”
Inspectors identified more than 1,000 ligature incidents on adult acute and psychiatric intensive care wards in a six-month period. And in the year to January, four deaths had occurred by use of ligature on wards which the CQC said “demonstrated that actions to mitigate ligature risks and incidents by clinical and operational management had not been effective”.
The Trust is running without an established senior management team after previous chair Rupert Nichols stepped down in December last year following the BBC revelations and former CEO Neil Thwaite departed in April, after the CQC inspections were carried out. The chief operating officer and chief nurse had been absent from work for several months, with interim and deputy colleagues providing cover.
Not surprisingly the CQC found staff battling to keep services afloat had little if any confidence in senior management, with only one in five staff across the Trust having confidence in the executive team, and 60% of nurses disagreeing or strongly disagreeing that they had any confidence.
But it’s not entirely surprising that a large Trust with inadequate or absent senior management should fail to magically heal itself, given the lack of impact of the “special measures” imposed upon the Trust at the end of last year.
Manchester Evening News revealed that the “Shamed” trust had been put on the “highest level of intervention” by the NHS, summed up in a letter to staff which said:
“This means the Trust has been given access to intensive support from national and regional partners, who will work collaboratively with us to analyse and pinpoint the root causes of the challenges we face.
“A mandatory intensive package of support will be agreed and delivered, and progress will be monitored against an improvement plan. Once progress and improvements are sustainable, we will exit this programme.”
It seems from the most recent CQC report that absolutely nothing has been changed or improved by this “intervention,” which seems to have consisted of holding one big meeting:
“At the end of November 2022, the trust were placed into Segment 4 of the NHS Oversight Framework which meant it entered the national Recovery Support Programme and was in receipt of mandated intensive support. A NHSE System Improvement Board was set up to support the delivery of the programme which was chaired by the Regional Director for Strategy and Transformation for NHS North West, with representatives from the trust, Greater Manchester Integrated Care Partnership, Care Quality Commission, Health Education England, Bury Local Authority (as safeguarding lead), General Medical Council and the Nursing and Midwifery Council.”
The only subsequent intervention seems to have been when NHS England North West wrote to Greater Manchester Mental Health NHS Foundation Trust, to inform the trust it would be commissioning an Independent Review. On the 6 February 2023, NHSE announced they had appointed a chair to undertake this independent review, which is to report at the end of September.
Meanwhile a major mental health trust is categorised as inadequate overall, and specifically on safety and well-led, and ‘requires improvement’ on effective, caring and responsive services.
It’s hard to believe ministers and NHS England – and the opposition – would be as relaxed about this situation if the trust was a major acute hospitals trust rather than mental health. As Sean Duggan says, mental health is now hardly even acknowledged by this government.
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