The need for a fair deal
Fair access to healthcare – through
the principles of universal eligibility and the removal of
financial barriers – underpinned the formation of the NHS. Sixty
years on, national government strategies continue to stress the
importance of these founding principles.
Despite many improvements, the reality
of equitable access to healthcare by people with mental health
problems and learning disabilities remains far removed from
political rhetoric. Psychiatrists nationwide report frustration at
the lack of places available for patients in community services and
are further discouraged when services are closed down. In a
target-driven culture the recent funding shortages in some NHS
trusts are felt to have particularly prejudiced mental health.
The nature and degree of difficulty
people face in receiving the care and treatment they need varies
considerably at regional and local levels and the solutions lie
with the regional and local service providers. There are
nevertheless country-wide issues; in England, these issues are
being addressed as part of the Darzi and Bradley
reforms.1,2 Comparable initiatives are taking place in
Northern Ireland and Scotland.3,4 The College welcomes
these plans.
What we are calling for
- Better access to high-quality physical and
mental health services for all age groups and for people with
different conditions and needs including people with learning
disabilities, addictions, sensory disabilities and personality
disorder.
- All health services to ensure ‘reasonable
adjustments’ (as required under the Disability Discrimination Act)
are made to facilitate greater access to services by people with
mental health problems and learning disabilities.
- Adequate mental health services for
convicted and remand prisoners, including for those with substance
dependence, of a comparable standard to those provided in the
general population.
- The development of policy and services to
divert mentally disordered people in the criminal justice system
into appropriate healthcare services.
- The transition of young people with mental
illness to adult services to be achieved as part of a seamless
pathway of care.
- Access to care for older people to be
enhanced to meet the level of need.
Examples of what the College will do
- The College will work through its Divisions
to highlight areas of deficiency in order to improve access to care
where there is a significant need.
- We will continue to work with partners to
identify the standards required to provide an equivalent level of
care for convicted and remanded prisoners.
- We will consider options for service
delivery at the interface between child and adolescent services and
adult services.
- The College will continue to survey, monitor
and develop standards to improve access to child and adolescent
mental health services and learning disability community
services.
Availability of services
Despite improvements, significant gaps in
access to healthcare remain. Older people,5 people with
learning disabilities,6 prisoners,7 substance
misusers,8 and Black and minority ethnic
groups9 have all described a lack of services. A
shortfall in provision for people with personality disorder has
been longstanding. Community rehabilitation services have been
jeopardised, particularly through the use of out-of-area
services.
There are also barriers – personal,
physical, financial and organisational – which prevent different
groups from full use of existing services.10
Difficulties are compounded where individuals are in transition
(e.g. from child and adolescent to adult services),11 or
require care across service boundaries (e.g. prisoners requiring
transfer to a psychiatric hospital bed).7
Consultant Child Psychiatrist
in Yorkshire
There
is a poor availability of tier four beds for CAMHS for children and
young people with moderate to severe learning disabilities. Having
supra-regional resources for these young people is not helpful. All
other young people have local services, yet this group who have the
highest need to be near their families developmentally do not. It
is not logistically possible to set up ad hoc arrangements for each
young person, and is poor practice. Local solutions need to be
sought and found, and adequately commissioned.
There is also much local and regional
variation. For example, there has been a serious deficit in child
and adolescent mental health services in Northern Ireland: staffing
levels and the quality, consistency and accessibility of services
are inadequate due to shortfalls in investment.12 In
England, although the total staffing levels of professionals
working in child and adolescent health services increased overall
by 15% from 2003 to 2004, local staffing levels were geographically
variable.13 In some areas, staff reductions of 5% were
recorded, while elsewhere, staff levels were increased by
40%.13
Older people are a particularly neglected
group. Over the next 15 years, more than 1 in 15 of the population
will be an older person experiencing a mental health
problem.5 However, although 1 in 4 older people living
in the community have symptoms of depression that are severe enough
to warrant help, only a half are diagnosed and treated.5
Services for older people have been particularly affected in terms
of funding. A 2008 UK survey of old age psychiatrists found that
58% experienced service cuts in 2007 with financial losses up to £2
million in individual services, and 31% report commissioning
intentions to dismantle older people’s mental health services.
Case study
1
Juliet Dunmur,
Carer
A care trust provided an excellent
adult acute day hospital. It was a place you could go if in crisis
for a day or up to several weeks. There was a high ratio of staff;
the staff were caring and the environment was safe. It was not one
of the National Service Framework standards and therefore did not
count towards any targets or standards. In the interests of
‘equity’ this service was discontinued.
Older people have further been excluded
from new cash injections for assertive outreach, crisis home
treatment and early intervention services. They do not have the
same access to rehabilitation, psychotherapy and general hospital
liaison services. As reported in Living Well in Later
Life:14
'...the organisational division between
mental health services for adults of working age and older people
has resulted in the development of an unfair system, as the range
of services available differs for each of these groups… Older
people who have made the transition between these services when
they reached 65 have said that there were noticeable differences in
the quality and range of services available.'
Around 70% of people with learning
disabilities may have one or more unmet needs for mental or
physical healthcare, and there is a shortage of mental health
services.6 Limited access to general practitioners has
also been identified among people with learning disabilities who
also have mental health problems and who live in more restricted
environments such as in residential or nursing homes, ‘supported
living’ accommodation and secure accommodation.15
In Northern Ireland, the College reports
that there is a critically inadequate supply of supported living
and other services to respond to the needs of people with
long-term, complex and life-limiting mental health problems. As a
result they have to spend extended and unacceptable periods of time
in acute admission wards.
Among the 4.6 million people from Black and
minority ethnic groups in the UK, barriers to access relevant
services include socio-cultural (health beliefs and mistrust of
services), systemic (lack of culturally competent practices in
mental health services), economic, or individual barriers (denial
of mental health problems).16 The interplay of these
factors means that minority ethnic groups in particular may have
higher rates of mental health problems, lower rates of referral and
treatment, and higher rates of compulsory treatment and forensic
service contact.17
Case study
2
Quality Improvement
Network for Multi-Agency Child and Adolescent Mental Health
Services (QINMAC)
QINMAC is a quality improvement
programme which aims to improve the specialist provision of
community-based child and adolescent mental health services
(CAMHS). Young people with learning disabilities and mental health
needs have often been excluded from CAHMS and accessible mental
health services are the starting point in their getting help at the
earliest stage. The QINMAC service standards are used to evaluate
CAMHS across the care pathway, starting at the point of referral
and access.
Case study
3
Consultant Psychiatrist
Specialising in Eating Disorders
As commercial pressures within the
NHS grow, less profitable areas of mental health fall into neglect.
Arenas that lack explicit government ‘targets’ become vestigial to
mental health services and, more pertinently, those who commission
them. Eating disorder services are one such area. There is a danger
that the primary purpose of mental health becomes management of
‘risk to others’, and psychiatric units become agents of social
control. There are many notable eating disorder services being
downgraded or else re-framed to meet quasi-political rather than
clinical targets.
The transitional period from older
adolescent to adult is a crucial stage of development, and can
coincide with the emergence (or continuation) of serious mental
health problems.11 However, during this difficult time,
adolescents have to transfer from child and adolescent to adult
mental health services. Some commentators contend that adult
services have a different philosophy and operational basis, and are
not appropriate. However, dedicated older adolescent services are
rarely available.
The availability of services for people
with mental health and substance misuse (addiction) problems also
remains an issue. Studies in the UK indicate that 44% of people
receiving community mental healthcare have substance misuse
problems, and 34% of people receiving treatment for addiction also
have a mental health problem.8 Yet mental health
services frequently fail to identify patients who also have drug
misuse problems, and a third of substance misuse patients with
mental health needs do not receive any interventions.8
Critically, where problems are identified, cross-referral between
mental health and addictions services can be poorly managed.
It has been estimated that in England and
Wales 90% of prisoners have at least one diagnosis of mental
disorder and the prevalence of severe mental illness is up to ten
times that in the wider community.18 Government policy
for prison healthcare is based on the principle that the standard
of services in prison should be equivalent to that available in the
wider community, relative to need. Despite extra investment and
many more staff, prison in-reach teams are still unable to reach
those in need.18 In 2007, an HM Inspectorate of Prisons
review concluded that there were still too many gaps in provision
and too much unmet and sometimes unrecognised
need.19
Furthermore, the review noted that need
will always remain greater than capacity, unless mental health and
community services outside prison are improved and people are
appropriately directed to them before, instead of, and after
custody. Those are the two parallel tracks that must be followed.
Unless those gaps are filled, mentally ill people will continue to
fall through them and into our overcrowded, increasingly
pressurised prisons. In England and Wales, initiatives such as the
Bradley Review of Diversion provide opportunities for a substantial
improvement in the situation.
References
1 Department of Health (2007) Our NHS, Our Future:
NHS Next Stage Review – Interim Report. Department of Health.
2 Department of Health (2008) Independent review of the
diversion of individuals with mental health problems from the
criminal justice system and prison (letter). Department of
Health.
3 Department of Health, Social Services and Public
Safety (2007) The Bamford Review of Mental Health and Learning
Disability (Northern Ireland). DHSSPS.
4 Scottish Government (2007) Towards a Mentally
Flourishing Scotland: The Future of Mental Health Improvement in
Scotland 2008–2011. DG Health and Wellbeing.
5 Lee, M. (2007) UK Inquiry into Mental Health and
Well-Being in Later Life. Improving Services and Support for Older
People with Mental Health Problems. Age Concern.
6 Alborz, A., McNally, R. & Glendinning C. (2005)
Access to health care for people with learning disabilities in the
UK: mapping the issues and reviewing the evidence. Journal of
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7 Brooker, C., Repper, J., Beverley, C., et al (2002)
Mental Health Services and Prisoners: A Review. School of Health
and Related Research (University of Sheffield), commissioned by the
Department of Health
(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084149).
8 Weaver, T., Stimson, G., Tyrer, P., et al (2004) What
are the implications for clinical management and service
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substance misuse treatment populations? Drugs: Education,
Prevention & Policy, 11, 329–348.
doi:10.1080/09687630410001687851
9 Bhui, K., Stansfeld, S., Hull, S., et al (2003)
Ethnic variations in pathways to and use of specialist mental
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doi:10.1192/bjp.182.2.105
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(2002) What does ’access to health care’ mean? Journal of Health
Services Research and Policy, 7, 186–188.
doi:10.1258/135581902760082517
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11 Office of the Childrens’ Commissioner (2007) Pushed
into the Shadows. Young Peoples’ Experiences of Adult Mental Health
Facilities. Office for the Childrens’ Commissioner.
12 Department of Health, Social Services and Public
Safety (2006) The Bamford Review of Mental Health and Learning
Disability (Northern Ireland). A vision of a comprehensive child
and adolescent mental health services. DHSSPS.
13 Barnes, D., Parker, E., Wistow, R., et al (2007) A
Profile of Child Health, Child and Adolescent Mental Health and
Maternity Services in England 2007. Durham University.
14 Commission for Social Care Inspection, Audit
Commission & Healthcare Commission (2006) Living Well in Later
Life. A Review of Progress Against the National Service Framework
for Older People. Commission for Healthcare Audit and
Inspection.
15 Disability Rights Commission (2006) Equal Treatment:
Closing the Gap. Disability Rights Commission.
16 Thornicroft, G. J. (2006) Shunned:
Discrimination Against People with Mental Illness. Oxford
University Press.
17 Keating, F. & Robertson, D. (2004) Fear, black
people and mental illness. A vicious circle? Health and Social Care
in the Community, 12, 439–447.
doi:10.1111/j.1365-2524.2004.00506.x
18 Brooker, C., Duggan, S., Fox, C., et al (2008)
Short-Changed. Spending on Prison Mental Health Care. Sainsbury
Centre for Mental Health.
19 HM Inspectorate of Prisons (2007). The Mental Health
of Prisoners: A Thematic Review of the Care and Support of
Prisoners with Mental Health Needs. HMIP.