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The Royal College of Psychiatrists Improving the lives of people with mental illness

At last, the Taskforce speaks

I know that all of you have been only asking one question in recent months - when will the recommendations of the Mental Health Taskforce be available? I know I have been promising this as long as Sepp Blatter has been promising to tell us where the money went, but finally I can deliver.

A brief recap. Sepp Blatter is the disgraced head of FIFA, but the Mental Health Taskforce is something completely different. It started out as the brain child of Norman Lamb, who was the Minister of State for Mental Health in the coalition government and is a champion of mental health issues. The Taskforce was then commissioned by NHS England, as part of the Five Year Forward View vision, and chaired by Paul Farmer, Chief Executive of Mind. The brief was to create a five-year all age national strategy for mental health in England to 2020, about which I have said much in previous blogs. As you know, everything these days has to be in units of five years – Joe Stalin would have been smiling. What is new is that this was set up to incorporate not just those bits of the NHS that we all know, but also what we call the arm’s-length bodies. This includes NHS England, Public Health England, Care Quality Commission, Health Education, the recently formed and NHS Improvement. These are pithily named because they are all supposed to be at arm’s-length away from government, and thus not susceptible to the previous command and control model of the NHS that might have pleased Joe Stalin. Or alternatively if you prefer, a clever mechanism for Ministers to distance themselves from blame.

So where do we fit in? Over the past eleven months, many of us have been actively involved. I am on the Task force, and together with Dr Adrian James, our Registrar, and the Policy Unit we have played our part in shaping the final report. Indeed one poor soul has been seconded to NHS-England part-time for the duration of the project. Most of those in the Taskforce came from the arm’s-length bodies or the voluntary sector, so for us one of the main tasks was to ensure that the voice of the NHS workforce was heard as loud and clear as possible. We have worked closely with all Faculties and Sections of the College to ensure the views of people working across all psychiatric specialties were incorporated.

So what is the end result? Well recommendations have been made to the five arm’s-length bodies to achieve the ambition of parity of esteem between mental and physical health for children, young people, adults and older people, as well as to other government departments. This covers five core themes: a 7-day NHS – right care, right time, right quality; an integrated mental and physical health approach; prevention at key moments in life; building mentally healthy communities and building a better future.

Not many would disagree with these. But how to bring them about? As you would expect in a report of this complexity, there are a lot of recommendations. These are centred around the following areas: commissioning for prevention and quality care; good quality of care for all/ 7 day NHS; innovation and research to drive change now and in the future; the workforce; transparency and data revolution; incentives, levers and payment; fair regulation and inspection and, finally, leadership and governance. If you want to know more about this, we have put together a briefing paper on the key implication of these recommendations on our members and the wider NHS workforce.

Many of these recommendations are focussed on the aforementioned arm’s-length bodies. Indeed, if a Martian fell to earth and read the report, he or she might conclude that it is they who actually deliver mental health care in this country. But that’s not true – it’s the mental health professionals, not those who belong to organisations that can be reduced to three letter acronyms. People like us. And I am pleased to say that in the end, it was people like us who did perhaps have the biggest impact on the final set of headlines.

But in order to deliver this strategy, significant financial investment is required.  Today, the NHS in England has committed to the biggest transformation of mental health care across the NHS in a generation, pledging to help more than a million extra people and investing more than a billion pounds a year by 2020/21. This investment is in addition to the previously announced new funding for children, young people and perinatal mental health care. This is ground-breaking.

But those of you who did miss it might still be thinking “hang on, this sounds familiar, hasn’t this been promised before?” Yes, you have a point, some of it has. But before you succumb to an apoplexy of cynicism, it was still important. Many things are announced and then disappear. Indeed, it is a very rare spending promise that is only issued once. Let me rephrase that. It is a very rare spending promise that is issued once, and also happens. What was important was that these promises have been made by the Prime Minister, in the first ever speech by a Prime Minister that was concerned with mental health, and then taken further by the boss of NHS-England. And that does matter. This money may have been trailed, mentioned, hinted at, even directly spoken about before, but this was the moment it moved from aspiration to policy.

All of that is good news. Truly. I am confident that we will see significant improvements in perinatal, liaison and crisis care. So for example all hospitals should have liaison psychiatry in emergency departments, and at least half will meet the “core 24” service standard. There will be a real investment in perinatal – requiring a lot more consultants (more later on where they are going to come from). We should and did welcome all that. There will be more investment in improving the physical health of those with severe mental illness – a deal has been struck to ensure that by 2020 at least 280,000 more people with SMI will get improved support for their physical health.

Likewise, there will be further funding for the IAPTS programme. And in what I hope many of us will welcome, it will be IAPTS, Jim, but not as we know it, as Mr Spock once said. Further expansion of IAPTS (a name which the Prime Minister clearly did not like and whose days are numbered – if you can think of a better name now is your chance -) will depend on two things. First, that it is used in areas that have been rather IAPTS free to date – such as long term conditions, unexplained symptoms and supporting those with mental illness back to work. Second, and perhaps even more important, in a different model of service delivery. The money should be going now to support existing primary and secondary services, rather than as a standalone third service. We really hope that we will see more psychological input into existing services, and a lot more interaction between psychological practitioners and both primary and secondary providers, which includes us.

Also mentioned was the previously announced £1.25 billion for perinatal and child and adolescent mental health, and £150 million for eating disorders. Yes this was announced in the last budget before the election, but heck – if you are going to give over a billion quid to child mental health, you are allowed to trumpet it more than once. Give them a break! I know it’s not enough. I know that it doesn’t make up what has been removed from services in the last decade. But it is at least reason to be cheerful. Not ecstatic. But at least well above depressed.

There is also a lot else to like in the Taskforce. The Taskforce began with a call for feedback from service users and families for their views on mental health care. 20,000 or so answered. And some of it made difficult reading. The initial reaction to what were undoubted examples of less than optimal care was to blame the providers – one heard murmuring of "this is our equivalent of Mid Staffs". But a more nuanced view prevailed. We argued very firmly that health professionals do not go out of their way to deliver poor quality care. Working conditions can be intensely challenging and this can severely affect motivation, cause stress-related sickness absence and create issues with staff retention. Not to mention an avoidable industrial dispute. As the Francis Inquiry so clearly demonstrated, the ability of staff to provide compassionate care depends on organisational culture, staffing levels and skill mix, support from colleagues and managers, and opportunities to reflect on practice.

We are pleased that the Taskforce has recognised that we need a workforce that is healthy and a workplace that has an ‘enabling environment’, rather than one that bears down on the health, morale and practice of NHS staff and, in turn, on patient outcomes and safety. To show this commitment, a whole section of the report is designated to protecting and improving the mental health of NHS staff, including new duties for the CQC and Trust Boards, and a CQUIN to incentivise employers. Again, there is more to be done, especially given the junior doctors debacle. One might say it’s a question of two steps forward, two steps back and one might be right. So we will continue to push and push again for attention to be paid to improving the mental health of the whole NHS workforce. After all, if a Royal College of Psychiatrists cannot make this case, then who can?

There was also a significant shout out for increased investment in mental health research. Unfortunately where that will come from, no one knows. It probably won’t happen until we see real change in the pattern of public and charitable giving – the discrepancies between what the public raise for cancer and heart disease and what they raise for mental health is truly staggering.

And despite trying, some bits just didn’t fly. I don’t think we did enough for drug and alcohol issues – there was £30 million for dual diagnosis, but not much else. Similarly, intellectual disability and neuropsychiatry is almost entirely absent, mainly because of parallel pieces of work conducted by NHS England. Still, we believe this has been a missed opportunity.

All of us owe a major thanks to all of those in the College who worked so hard on this, and also to the team from the major mental health charities who did so much of the leg work. Likewise, it is fashionable to be cynical about civil servants, unless you have seen how hard they work, and can confirm they share a similar commitment to trying to make things better for those with mental disorders. And a special thanks to Paul Farmer who held it all together, which at times was far from easy.

So, where are we? We are better off than we were 12 months ago. We can congratulate ourselves that many of the tangible gains that have resulted from the Taskforce were things that we have been working towards for some time. The work that the College has done, not just in the last ten months but before that, on issues such as perinatal, liaison, crisis care and CAMHS, has been rewarded. I hope we have laid the foundations for similar progress in the health of the workforce. I also believe that we will see benefits from new models for improving access to psychological treatments, something that we all want.

And now we have to turn to delivery. That won’t be easy. It is a long way from a Prime Ministerial speech to seeing resources deployed where they should be, and there will be many slips on the way, we can be sure of that. But we and our colleagues will be there, trying to make sure that doesn’t happen. Well, not too often. We are getting more and more involved in what is called the New Care Models programme. No, not a modern version of Cromwell’s New Model Army, although a little bit of Roundhead efficiency wouldn’t go amiss. This is one of the ways in which the Five Year Forward View is being realised on the ground. I know that you are now at a fever pitch of excitement and begging for more, but on that cliff hanger it’s time to delay gratification and curb your enthusiasm until the next instalment.

Professor Sir Simon Wessely

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Comments

Re: At last, the Taskforce spe
How about AGT to replace IAPTS - Actually Getting Therapy?
Dr
spent hundreds of hours in late 90S and early naughties trying roll out Fox and Blake New Hampshire model modern psychiatric service containing 4 tranches of care;SMI, Co morbidity, Borderline and pure addiction services.separate crisis and intensive outreach in each.
In the end that black hole,the "trust" as a functional unit pulled everything ideas,energy,clinical innovation into centre and turned it into dark matter.
Happy to have another shot as an advisor/planner-have only been trying to make it happen for 35 years!!!
Re: At last, the Taskforce spe
There are always going to be winners and losers in an initiative such as this. There is no mention of Old Age either way however. A surprise given the undeniable demography in the UK.
Re: At last, the Taskforce spe
thanks Simon, a few comments please
1. In terms of the limited numbers of both consultants and senior nurses / O/Ts etc., i am concerned that the newly growing (i.e. posh) services like liason and perinatal will suck staff from the 'core' services such as crisis, in patients and older preople's CMHTs. Obviously this will not be good for a bigger number of service users and carers, and potentially worsen already precarious generic (non posh)services.
2. You touch on a tad more efficiency. Can I be unpopular (more like deeply unpopular) and say that most mental health delivery is groissly inefficient (looking more like a gravey train) because of lacking joined up working, with the only solution being tight control and guidence exerted from the new primary care Vanguards (which we do have in Sunderland).
3. As Consultants, I suspect 2/3ds will be working in primary care joined up to cpommunity high intensity teams, with the remaining working in I/Ps on a shift basis? not sure if the Forward View took account of this major change in coomunity working practivces.
4. in the North East we are aware of a number of legal firms targeting legal aid by challenging Psychiatric ACs and RCs on practices impacting on Human Rights law. This will surely create a drain on trust resourses both in time and money, taking away some of the new innvestments and associated optimism?
Re: At last, the Taskforce spe
Good morning Simon,
One of the sad things about mental illness is that patients end up being off work for longer than necessary because they cannot access appropriate services. And that is apart from the tragedies where suicide is the end result.
I cannot find anything in your blog on beds. I agree beds are not the complete solution to the problem but a part of it. It is sad to see so many patients being transferred hundreds of miles for inpatient treatment. How do we organise aftercare? Why are so many PDs admitted when we know admission does not help in the long term.
In my experience IAPTs are only suitable for the mild to moderately ill. We need more skilled psychological therapists
Furthermore can we ask that everyone (including doctors) in the Mental Health Services (and indeed the entire NHS) on 6 figure salaries justify their salaries and release money if they are not actively needed.
Re: At last, the Taskforce spe
Further to Johnny's idea, should mental health trusts have an annual bonus created by pooling all the excellence awards given to medical and non medical 'leaders'? I think this will massively increase our morale and productivity.
Re: At last, the Taskforce spe
Thinking about prevention, if a SAFE emotional literacy method used in some schools to promote mentally healthy adjustment AND to reduce vulnerability to radicalisation, could be rolled out at low cost in a self-sustaining educational mode, would funding for this come within the recommended actions from this Task Force? If it reduced referrals to CAMHS and enabled young people to cease self-harming after just one learning event, which it can do, could that be 'health funded'? The Inclusion Unit at Thorne Academy in Yorkshire, which has a programme designed entirely around Emotional Logic, has received a 'highly approved' status from Ofsted for its excellent results, and its method could be rolled out. However, it is not based around de-stigmatising anxiety and depression (or normalising it with mental illness education in schools, which we believe increases anxiety and depression), but rather takes a re-humanising approach to understanding grieving when faced with accumulating disappointments and setbacks. Could the roll-out of this sort of 're-habilitation of emotions' as 'NOT just a side effect of thinking but a core feature of shared humanity', and its integration between schools with mental health services (CAMHS especially) by CPD of health staff, be funded within the Task Force recommendations?
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Professor Sir Simon Wessely

        

Professor Sir Simon Wessely

President