No more top-down reorganisation in mental health but much more funding, experts urge

BMJ 2015; 350 doi: (Published 21 January 2015) Cite this as: BMJ 2015;350:h387
  1. Matthew Limb
  1. 1London

Mental health experts have called on all political parties to commit to radically boosting mental healthcare spending and cautioned against further major structural reorganisation.

They said that the quality of services varied too much and that patients needed far better access to treatments including psychological therapies, community support, and crisis care.

Paul Farmer, chief executive of the mental health charity Mind, estimated that a minimum 10% increase in real terms spending on mental health was required by the end of the next parliament. He said, “We can do all kinds of efficiencies, we can do all kinds of things to try and make the system as good as it can be, but there quite simply isn’t enough resource in the system.”

Claire Murdoch, chief executive of Central and North West London NHS Foundation Trust, said it was a “disgrace” that mental healthcare had suffered from real terms “disinvestment” in recent years and from “fractured commissioning.” Calling for a new revolution in mental healthcare, she said, “The answer is not big structural reorganisation; it’s about developing pathways of care that are truly integrated.”

The pair spoke on 20 January at a breakfast debate on mental health, staged by the King’s Fund in London to launch a series of debates probing health and care issues ahead of the 2015 general election. Farmer said, “We anticipate all parties being vocal on mental health over the next few months,” but he said that questions remained about the “disconnect between the rhetoric and reality.” He said that progress had been made on mental health over the past five years “at policy and political level” but that decades of underfunding now needed to be corrected.

“Last year we saw the institutional bias of the tariff deflator in mental health which led to further significant challenges for providers,” he said. “But the bigger gap is the treatment gap. We know that only one quarter of people with mental health problems receive effective treatment, so 75% don’t.”

Farmer highlighted the challenges facing a future government, including the “colossal rise” in antidepressant prescribing; long waits for treatments, particularly for psychological therapies; and the need to ensure good access to crisis care 24 hours a day, seven days a week. He said, “The mental health of children and young people and of people in and out of work is hugely important for our economy and society; it requires a national strategy for wellbeing and resilience.”

He said that it was vitally important to “embed” mental health in the new models of care envisaged by the NHS’s Five Year Forward View,1 adding, “There’s always the tendency, the risk for the NHS to go into default mode when it comes to mental health and put it on one side rather than bringing it into the middle of the system.”

Murdoch said that prior warnings about the deleterious effect of “separating out” specialised commissioning for mental health from local commissioning by clinical commissioning groups had come to pass. And investment in prevention and intensive community support was insufficient to help young people “at points of crisis” in their lives, she said. Tier 4 child and adolescent mental health services (CAMHS), which provide inpatient and outreach services to adolescents, had “overheated,” said Murdoch. “That’s why we have young people waiting for hours and hours in A&E for a bed and being shipped across the country.”

She added, “We’re closing beds, yet acute admissions have gone up, length of stay is getting shorter, acuity is increasing. I don’t think bed closures are necessarily a bad thing. Alternatives to admission are a very good thing, so we just need to make sure they’re happening.”

She said that more could be done to build on “huge successes” in mental health and the many good examples of evidence based practice in areas such as peer support, user engagement, work across housing and local authorities, and partnership working in primary care.

Richard Layard, professor emeritus at the London School of Economics and founder of Action for Happiness (, said that patients were entitled to “parity of esteem.” Like physically ill patients, mentally ill patients should have the same access to treatments recommended by the National Institute for Health and Care Excellence, he argued.

But Layard said, “We are miles from that. A major part of the transformation of mental health in the coming parliament has to be much wider access to psychological therapies.”

He said that the programme to improve access to psychological therapies (IAPT) had made good progress under the Labour and coalition governments. In 2015 nearly 15% of some six million adults with depression and anxiety disorders were being seen by IAPT, noted Layard.

But he said that a large unmet need remained and that “ambitious” new targets needed to be set: first, for 25% of adult patients to be seen by 2020 and, second, an IAPT target of 33% for children and young people with diagnosable mental health problems to be seen by CAMHS.

This would mean training more therapists, he said, and more work being done in schools so that “CAMHS is much more of an outreach service, seeing people early rather than waiting for them to reach that horrific threshold when they have to go to some clinic.”

Layard said that a wider range of therapies should be made available, such as interpersonal therapy and couples therapy. “Whatever government we’ve got will want to deal with the crisis of conflict in the family and domestic violence through a much wider roll-out of couples’ therapy,” he said.


Cite this as: BMJ 2015;350:h387


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