wearable technology. Interoperability with physical .... Wellbeing of staff: a career working in mental health attracts
October - November 2015
Consultation response form Setting the mandate to NHS England for 2016 to 2017 Response from the Royal College of Psychiatrists
Consultation Questions 1) Do you agree with our aims for the mandate to NHS England? While we support the overarching aims of the Mandate, we are very disappointed that continued commitment to achieving a 'parity of esteem' between mental and physical health is not stated prominently, as in previous Mandates. The statement in paragraph 3.2, 'to reduce inequalities in physical and mental health outcomes', while very welcome, is easily missed. To achieve the Government's stated commitment to closing the gap between people with mental health problems and the population as a whole should, we believe, be a clear, overarching objective for the NHS. The absence of a such a specific commitment to improving mental health services implies - to NHS England and to people using mental health services - that delivering supportive and high quality mental health services, on a par with physical health services, is no longer a priority for the Government. Parity of esteem would entail an overall increase in funding of mental health care, and not, for example, the transfer of funds from general adult mental health to child and adolescent mental health services. Moreover, we are disappointed to see that the forthcoming Mental Health Taskforce report is not mentioned in the document. Everything that is recommended in the Mental Taskforce document should be incorporated into the NHS Mandate, in the same way as it is stated in paragraph 3.12 that the Cancer Taskforce Strategy will be taken forward.
2) Is there anything else we should be considering in producing the mandate to NHS England? While we understand that the Mandate priorities have been presented in the document at a very high level, pre-the Sending Review (SR), we have similarly commented at a high level, though for some areas we have provided supporting detail to make the case for the importance of an issue. However, we would welcome an opportunity to contribute at the post-SR stage to the detail that will underpin each objective.
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3) What views do you have on our overarching objective of improving outcomes and reducing health inequalities, including by using new measures of comparative quality for local CCG populations to complement the national outcomes measures in the NHS Outcomes Framework? This is a significant and welcome change to the requirements of CCGs to deliver indicators. We want to see a good proportion of indicators that measure mental health and inequalities, mental wellbeing and mental ill health, including access to screening. They should be evidence based and tested for sufficient sensitivity, specificity, validity and reliability. We need the right indicators to show if local areas are improving early identification, intervention and access to treatment. Personal Health Records must be built with usability at the forefront and the ability to evolve - otherwise they are unlikely to be economically viable or clinically effective in the longer term. While record-sharing is very important, it should be done in a way which is accessible, has meaning to patients and has the ability to evolve, incorporating data from apps that people might want to use, and incorporating ‘future-proof’ functionality for evolving methods of interaction such as video consultations and information from wearable technology. Interoperability with physical health information will also present a key opportunity to reduce the health inequalities gap for people with serious mental illness.
4) What views do you have on our priorities for the health and care system? Preventing ill health and supporting people to live healthier lives We welcome the acknowledgement of the costly issues that “demand a renewed focus on public health and preventable diseases”. Reducing these morbidities and their costs will require consistent action at multiple levels and from childhood onwards, for example economic interventions to increase the cost of some activities (specifically smoking and alcohol) and promoting diet change and accessible forms of exercise to targeted populations. However, we recommend that drugs be added to the list. 8.4 per 1000 of the adult population is dependent on opiates and/or crack/cocaine (around 330,000), and approximately 155,000 are in specialist treatment each year.1 Patterns of substance misuse are dynamic. There has also been a steep rise in presentations for treatment for Novel Psychoactive Substance misuse such as mephedrone, methamphetamine and synthetic cannabinoids many of which have psychiatric complications. 2 Since 2010, there has also been a rise in the use and harmful consequences of over the counter medications. 1
National Audit Office (2008) Reducing Alcohol Harm: Health Services in England for Alcohol Misuse. NAO. Bowden-Jones, O et al. (2014) One New Drug a Week: Why novel psychoactive substances and club drugs need a different response from UK treatment providers. Faculty Report FR/AP/02, Faculty of Addictions, Royal College of Psychiatrists. 2
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In addition to the public health considerations we have outlined above, we wish to highlight that there is a high level of comorbidity between substance misuse and mental disorders. Up to 50% of patients admitted to psychiatric inpatient units are hazardous drinkers, and 25% are alcohol dependent.3 Up to 44% of community mental health team patients report past year drug misuse or harmful alcohol use, with even higher prevalence rates in prison and probation populations.4 5 The introduction of the 2012 Health and Social Care Act and the transfer of commissioning of substance misuse services from the NHS to local authorities has accelerated a trend of substance misuse treatment being provided by 3rd sector organisations outside of the NHS, and the closure of most NHS addiction treatment inpatient units. This has added complexity to referral pathways and processes, with the risk that patients with comorbidity will fall between services, and by default present to emergency acute medical and psychiatric services or be excluded from services altogether, rather than receiving planned holistic care. The loss of 50% of training posts in addiction psychiatry in England since 20076 is likely to present future challenges to the NHS with the lack of a suitably trained workforce to meet demand for treatment of patients with complex comorbidity.
Transforming out-of-hospital care We need explicit recognition of older adults, and people living with an addiction, intellectual disability, or personality disorder. Some people find themselves falling between gaps in services because having multiple needs, such as mental health problems alongside learning disability, or substance use issues addictions, makes them ineligible for services with single issue expertise. As a consequence, fewer people with learning disabilities or addictions access appropriate, evidence based treatment and support. In particular, 25% of people with learning disabilities have mental health needs similar to the general population but 75% also have overlapping and additional needs related to level of learning disability and presence of developmental disorders7. However, only 100-120 adults with LD in a population of 100,000 receive treatment from LD psychiatry7. A further 300-400 cases are open to professionals such as psychology and OT receiving support for mental health/psychological problems7.
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Barnaby, B., Drummond, D.C., McCloud, A., Omu, N. & Burns, T. (2003) Substance misuse in psychiatric inpatients: comparison of a screening questionnaire survey with case notes. British Medical Journal, 327, 783-784. 4 Weaver T, Madden P, Charles V, Stimson G, Renton A, Tyrer P, et al. Comorbidity of substance misuse and mental illness in community mental health and substance misuse services. Br J Psychiatry. 2003 Oct 1;183(4):304–13. 5 Coulton, S., Newbury-Birch, D., Cassidy, P., Dale, V., Deluca, P., Gilvarry, E., Godfrey, C., Heather, N., Kaner, E., Myles, J., Perryman, K., Oyefeso, N., Parrott, S., Phillips, T., Shepherd, J. and Drummond, C. (2012) Screening and brief interventions for alcohol use in criminal justice settings: an exploratory study. Alcohol and Alcoholism, 47(4), 423-427. 6 Survey conducted by the Faculty of Addictions Psychiatry, Royal College of Psychiatrists 7 Royal College of Psychiatrists. College Report 175 Enabling people with mild intellectual disability and mental health problems to access healthcare services Available at: http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr175.aspx
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In terms of available provision, there are currently 2,500 inpatient beds occupied by people with learning disabilities in England. This will be reduced to approximately 1,200 within the next 3-5 years7. In addition to the inpatient population, there are a further 25,000 people deemed at risk of admission to inpatient care if they are not provided with adequate support with their mental health needs and behavioural problems 7.
Supporting research, innovation and growth We are pleased that research has been highlighted as a priority. However, there is a need for commissioned research about how best to apply outcomes in context of complexity, prevention, chronic conditions and neurodegeneration within mental health. There is some concern that the evidence for utility of big data approaches has yet to be established and may distract from established conventional biomedical scientific research. The section 3.24 on supporting research refers to national and local partners should explicitly refer to universities and medical schools. Currently many of the measures and approaches used to assess quality and outcomes are not evidence based. Research needs to be at the heart of such endeavours to make sure that the measures appropriately reflect changes in health. Research is needed to understand why there are regional differences and why for some, they still cannot access NICE recommended treatments.
We suggest that the following priorities are missing from the document: Wellbeing of staff: a career working in mental health attracts many dedicated and caring professionals. Yet working conditions can be intensely challenging for NHS staff, which can severely affect motivation, stress related sickness absence and staff retention. This is important in its own right, as the NHS is England’s largest employer, but is arguably even more important because of the compelling literature that shows how staff morale and wellbeing impact on patient care. A supportive system-wide approach is required, which must address workload and support staff to recover from ill health adequately in order to further prevent illness and burnout. Recruitment: as of June 2015, only 5.3% of doctors who completed foundation training went on to enter core training in psychiatry8. The shortage of addiction psychiatrists is particularly concerning and should be addressed urgently: the number of filled addiction psychiatry senior training posts halved between 2007 and 2014 from 47 to 266.
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Personal correspondence from the Professional Standards Department, Royal College of Psychiatrists, 2015
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Health Education England should encourage more Junior Doctors to specialise in psychiatry, and should ensure that their current and future programmes of work (particularly “Shape of Caring” and “Shape of Training”) have parity of esteem between mental and physical health as a core requirement. 5) What views do you have on how we set objectives for NHS England to reflect their contribution to achieving our priorities?
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