Transforming mental health services – at what cost?

The transformation of health and social care has almost universally been viewed as positive. NHS’s Business Plan for the next five years is firmly committed to transforming healthcare. The pace of change is increasing, and organizations are clamoring to join successive waves of vanguards. Is this confidence warranted?

Mental health services are leading the charge when it comes to transformation. Can learn from the sector’s transition away from hospital-based care to community-based services and its subsequent specialization to meet new needs. The industry continues to transform its services. However, rising pressures within the mental health system, as well as ongoing concerns with care quality, raise questions regarding how successful this transformation has been.

In our new briefing paper, Mental Health under Pressure, we examine transformation programs in mental health and find that despite their potential, they are impacted by the context of their implementation as well as their drivers.

A review of the strategic plans of mental health trusts shows that cost reduction has been a major driver for transformation. Mental health trusts face funding pressures, as 40 percent of them saw their incomes fall between 2012/13 and 2013/14. This happened again between 2013/14 to 2014/15. One trust said: “Traditional methods to improve costs have been exhausted. A new transformational approach will be taken in order to avoid significantly impacting the quality of care that we provide.”

Many transformation programs in mental healthcare reflect national policy. They include recovery-focused care, a greater focus on the community, and the expectation that investing in self-management and preventative maintenance will reduce pressure on acute care. There has not been much recent guidance from the national level on how to implement these changes in practice or solid evidence that shows improved outcomes.

The King’s Fund’s and Health Foundation’s report on supporting successful transition highlights that time and money are needed to support the development, implementation, and evaluation of change. Funding is also required to ensure double-running services during the transition phase. The majority of trusts, despite the lack of evidence and guidance, have launched transformation programs with a high pace and scale. They also had little or no funding allocated to the process. This has led to trusts making leaps in the dark.

In light of this, it is not surprising that some service changes did not have the desired effect. They may have even had a negative impact and caused a lot of variation. The pressure on inpatient bed numbers has not decreased despite these changes. In most cases, it has actually increased. Once redesigned, many evidence-based care models, such as Early Intervention in Psychosis (EIP) and Crisis Resolution Home Treatment Teams (CRHT), fail to achieve the desired outcomes. While there have been some new developments, such as recovery colleges and peer-support programs, the evidence supporting their widespread implementation is limited.

Many mental health trusts chose to reconfigure care rather than cut services. This has led to cost savings over the short term, with most mental health trusts being in surplus by the end of the calendar year. However, it has also reduced the quality of care.

Commissioners are often blamed for the poor quality of care. Commissioners, who are often tasked with finding additional efficiency savings but have limited knowledge of mental health commissioning, may overestimate the mental health trusts’ ability to achieve further cost savings. There is the risk that mental health trusts, through their ambitious transformation programs and pace of change, will support the expectation of high quality at a lower cost.

Trusts may feel uncomfortable when they acknowledge the limitations of transformation and the negative impact of decisions made to manage costs on outcomes and quality. However, a genuine recognition of the relationship between funding, service transformation, and quality may provide a better foundation for mental health services in the long term.

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