Dacre, J;
Fonagy, P;
(2021)
Expert Panel: Evaluation of the Government's Progress against its policy commitments in the area of mental health services in England.
(Expert Panel
HC 612
, pp. pp. 3-87
).
House of Commons: London, UK.
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Abstract
The Health and Social Care Committee commissioned a review of the evidence for the effective implementation and appropriateness of the Government’s policy commitments relating to mental health services in England. This report has been produced independently of the Committee’s inquiry into children and young people’s mental health and examines a broader remit than the Committee’s inquiry. Our findings and ratings in relation to commitments made to improve services for children and young people do, however, contribute to the Committee’s inquiry on this topic. The Expert Panel consists of members with recognised expertise in quantitative and qualitative research methods, and policy evaluation. This core group was complemented by experts with a working knowledge and experience of frontline delivery of NHS mental services, clinical research and policy development and implementation. Evaluations and judgements in this report are summarised by ratings which chart the Government’s progress against specific mental health commitments. While these ratings are in the style used by national bodies such as the Care Quality Commission (CQC), the ratings in this report have been determined by us and do not reflect the opinion of the CQC or any other external agency. The commitments under review are inter-connected allowing an overall rating to be made which forms a combined assessment against all the commitments we evaluated. Separate ratings have also been given to each commitment and its main questions. All ratings are informed by a review process using a combination of established research methods, expert consensus, and consultation with communities (see Annex A for key evidence). Published data and other sources of evidence, including written submissions from stakeholders, and round table discussions have been used to provide evidence for review by the Expert Panel, which are referenced in footnotes throughout the report. The Department of Health and Social Care and relevant non-departmental public bodies were invited to contribute to the evaluation. Selected Commitments The Department of Health and Social Care provided the Panel with its main policy commitments in the area of Mental Health Services in England. Using this information and wider policy documentation, we identified nine commitments across four broad policy areas. These included important and measurable ambitions for improvements in health services, reflecting wider NHS and social care systems. The Panel considers these commitments to provide reasonable generalisable evidence of progress against policy aspirations in the broader area of mental health. The Expert Panel evaluated the Government’s progress against these commitments. The commitments we have chosen to examine are: 10 Second Special Report of Session 2021–22 Policy Area Government Commitment Workforce • we are committed to growing the mental health workforce Children and Young People’s (CYP) Mental Health • at least 70,000 additional children and young people each year will receive evidence-based treatment … • achieve 2020/21 target of 95% of children and young people with eating conditions accessing treatment within 1 week for urgent cases and 4 weeks for routine cases • ensure there is a CYP crisis response that meets the needs of under 18-year-olds Adult Common Mental Illness • All areas commission IAPT-Long term condition services Adult Severe Mental Illness • 280,000 people with SMI will receive a full annual health check • new integrated community models for adults with a severe mental illness [delivery date of 2023/24] • the therapeutic offer from inpatient mental health services will be improved by increased investment in interventions and activities, resulting in better patient outcomes and experience in hospital. • all areas will provide crisis resolution and home treatment (CRHT) functions that are resourced to operate in line with recognised best practice, delivering a 24/7 community-based crisis response and intensive home treatment as an alternative to acute inpatient admission For each commitment under review, the Health and Social Care Committee approved the main questions to guide the Expert Panel’s evaluation. The Panel then developed a set of sub-questions relating to specific areas of the commitment. These main questions and sub-questions were incorporated into a final framework referred to as the Panel’s planning grid. The planning grid was shared with the Department for Health and Social Care and formed the basis of the Government’s formal written response. The Expert Panel used the key questions in the planning grid, as well as its own thematic analysis of 25 written submissions, publicly available data, and transcripts from roundtable events with 24 mental health practitioners as the basis for this evaluation. We invited The Department of Health and Social Care to respond to all main questions and sub-questions in its written response. The main questions set out in the planning grid are:2 • Was the commitment met overall? Or is the commitment on track to be met? • Was the commitment effectively funded (or resourced)? • Did the commitment achieve a positive impact for service users? • Was it an appropriate commitment? 2 First Special Report of Session 2019–21: Process for independent evaluation of progress on Government commitments (July 2020), p. 3 Second Special Report of Session 2021–22 11 The ratings for the nine commitments within the four policy areas and main questions were used to inform the Panel’s overall rating for the area of mental health. The ratings for each of the nine commitments in the four policy areas are summarised in the following table. Overall rating across all commitments Requires Improvement Workforce Commitment A. Commitment Met B. Funding and Resource C. Impact D. Appropriate Overall Grow the workforce Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Children and Young People’s Mental Health Additional treatment Good Good Good Inadequate Requires Improvement 95% CYP accessing treatment for eating conditions Requires Improvement Good Requires Improvement Outstanding Good Crisis response Requires Improvement Requires Improvement Requires Improvement Outstanding Requires Improvement Adult Common Mental Illness All areas commission IAPT-Long term condition services Requires Improvement Requires Improvement Good Requires Improvement Requires Improvement Adult Severe Mental Illness Physical health check Inadequate Requires Improvement Requires Improvement Requires Improvement Requires Improvement Integrated community models Requires Improvement Inadequate Requires Improvement Requires Improvement Requires Improvement Improved therapeutic offer Requires Improvement Requires Improvement Requires Improvement Inadequate Requires Improvement 12 Second Special Report of Session 2021–22 Commitment A. Commitment Met B. Funding and Resource C. Impact D. Appropriate Overall Crisis resolution and home treatment Requires Improvement Good Requires Improvement Good Requires Improvement The overall rating for the nine commitments across the four policy areas evaluated is: Requires Improvement This rating relates to how the government have progressed overall against nine commitments across the four policy areas based on guidance outlined in the anchor statements (Annex B) set out by the Health and Social Care Committee. While an overall rating of progress against all nine specific commitments is challenging to determine and the ratings of individual commitments are standalone, the evidence we assessed shows that the Government’s progress against its commitments to improve mental health services in England requires improvement. Because of this concern, each of the nine commitments have been rated separately. Although significant efforts have been made across the four main policy areas evaluated (with some notable success), the Panel’s evaluation shows that more progress is required to achieve success in all nine commitments. We recognise that many, if not all, of the commitment areas have been impacted by the COVID-19 pandemic, which services could not have reasonably prepared for in advance. We have considered factors related to the COVID-19 pandemic throughout our evaluation, acknowledging where commitments were on track to be met prior to the pandemic. As the pandemic has been associated with a rise in mental health conditions,3 demand for services is greater than when these commitments were made, which could not have been anticipated by services. Therefore, continued and expanded resources for mental health services will be required to ensure the capacity for services increases with the need for mental health support. We recognise the effort by mental health services and frontline workers to support the health of the nation during the COVID-19 pandemic, which have been conducted under unprecedented circumstances. The rationale to support the ratings and our findings is summarised below. Workforce Commitment: Grow the mental health workforce (Requires Improvement) • Overall, the mental health workforce has increased by 17,778 FTE staff since 2016, meeting the targets set for 2021. 3 Fancourt, D., Steptoe, A., & Bu, F. (2021). Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. The Lancet Psychiatry, 8(2), 141–149; Saunders, R., Buckman, J. E. J., Fonagy, P., & Fancourt, D. (2021). Understanding different trajectories of mental health across the general population during the COVID-19 pandemic. Psychological Medicine, 1–9. doi: 10.1017/ S0033291721000957 Second Special Report of Session 2021–22 13 • However, key staffing groups such as mental health nurses and consultant psychiatrists (and specific sub-specialities relevant to priority policy areas) have not increased in line with targets set in the Stepping forward to 2020/21 and Mental Health Implementation Plans.4 • Funding has been allocated to train new staff; however, this funding was designated for overall mental health staff and has not been used to increase staff in specific professional groups. The increase in numbers is only meaningful if they represent appropriately trained and professionally governed individuals. Funding is also insufficient to retain and upskill existing staff. • Workforce shortages represent the single biggest threat to national ambitions to improve mental healthcare, impacting delivery across all mental health services. Children and Young people Commitment 1: Access to treatment (Requires Improvement) • The number of children and young people accessing treatment has increased greatly since this commitment was made, though this has also coincided with a probable increase in the need for services. • Children and young people who access services have reported significant improvements to their mental health. • However, the target that only 35% of children and young people should have access to treatment is inadequate and leaves the majority of children and young people who require support for a mental health diagnosis without access to services. Commitment 2: Eating conditions (Good) • The target to ensure 95% of children and young people receive treatment for eating conditions within one week for urgent cases and four weeks for routine cases has not been met. • Progress on this target has been significantly impacted by the COVID-19 pandemic, which has led to a dramatic increase in the prevalence of eating conditions. • Given the association between eating conditions and high mortality rates, the ambitious target outlined in this commitment was highly appropriate. The specificity of this commitment meant that services had a clear target to aim towards. Commitment 3: CYP Crisis Services (Requires Improvement) • The provision of 24/7 crisis support lines to provide support, advice and triage has been achieved; a target that has been met in advance of the deadline. 4 Health Education England, Stepping forward to 2020/21: The mental health workforce plan for England (July 2017) 14 Second Special Report of Session 2021–22 • However, in most regions less progress has been made with other functions of a crisis response service, meaning these services cannot provide treatment for the range of mental health symptoms children and young people present with at these services. • The absence of functioning crisis response services has led to children and young people being inappropriately placed on adult wards. Adult Common Mental Illness Commitment: All areas commission adult Increasing Access to Psychological Therapies-Long-term condition services (Requires Improvement) • Significant work is required before the commitment to establish Increasing Access to Psychological Therapies (IAPT) services for adults with long term conditions across all areas can be met by the 2023/24 deadline. • The provision of specialist services for adults with a long-term condition has the potential to have positive impact on service users’ ability to manage their physical conditions. • In treating long term conditions through IAPT, savings could be made across the NHS and reduce the burden on these services, but this has not yet been achieved. Adult Severe mental Illness Commitment 1: Annual Physical Health Checks (Requires Improvement) • Progress on this commitment has been inadequate, as only approximately half of the target numbers have been achieved as of Q1 2021/22. This commitment was not on track to be achieved prior to the COVID-19 pandemic. • Recent investment has been made to accelerate progress on this commitment, but we are unable to evaluate the impact of these additional funds as this is reliant on the capacity of general practice to deliver the health checks. • This is an important commitment as the average lifespan of an individual with a severe mental illness is 15–20 years shorter than the general population. Commitment 2: Community Models (Requires Improvement) • Progress on the commitment to deliver new integrated community models for adults with a severe mental illness requires improvement, as some services continue to rely on inpatient, residential models of care. • Early implementer sites report positive outcomes from community models, demonstrating the positive potential of this form of care. Second Special Report of Session 2021–22 15 • This commitment is not specific enough and requires improvement, as it is unclear which services comprise a community model, or which metrics can be used to evaluate community services. Commitment 3: Improved therapeutic offer (Requires Improvement) • Measures of length of stay in acute services suggest that progress on this commitment has been made, but the quality and scope of activities is not sufficient to provide an improved therapeutic offer. Although it is possible to measure length of stay this does not necessarily reflect improvements in outcomes. • There is a disparity between the measures used by services and the views of service users, who report the inpatient therapeutic offer to be insufficient. • The physical estate for mental health services is poor and presents a barrier to achieving this commitment, as service users report a lack of a therapeutic environment. • The insufficient mix of workforce skills and disciplines within inpatient facilities also constrains progress on this commitment. Commitment 4: Crisis resolution and home treatment (Requires Improvement) • Despite all services providing phone lines, the services are not operational 24/7, limiting their effectiveness. • Staffing issues, exacerbated by COVID-19, have contributed to difficulties establishing coherent and high-quality crisis services. • However, commendably, the specification of ideal services is clear, which will support their implementation in services across the country in futu
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