Striking the balance for mental health

Paul Briddock, director of policy for the Healthcare Financial Management Association, discusses the doubts over mental health investment promises and why clarity is needed for the necessary investment to reach the right people

There has often been disparity between mental and physical health provision in the NHS, which is something that needs to be rectified. To achieve this providers and commissioners need to work collaboratively towards the same goal. According to research earlier this year, the government’s commitment to deliver parity of esteem between mental and physical health services is not being achieved as the planned funding is currently not reaching all frontline NHS trusts.

A survey of mental health trusts and clinical commissioning groups (CCGs), published by NHS Providers and the Healthcare Financial Management Association (HFMA), found that only a half of mental health trusts in England received the required real terms increase in their services last year (based on survey responses by 55 per cent of mental health providers). This is despite a directive to increase investment in line with commissioners overall allocation.

The research in May 2016 revealed that: only half (52 per cent) of providers reported that they had received a real terms increase in funding of their services in 2015/16; there is a limited confidence that funding increases will be delivered this year, with only a quarter (25 per cent) of providers saying they were confident that their commissioners were going to increase the value of their contracts for 2016/17; a higher proportion of providers received a real terms increase from CCGs than from NHS England teams in 2015/16; there is a lack of alignment between commissioners and providers over what it means to implement parity of esteem – there is confusion over what services should be covered, and how much investment should be made; and that over 90 per cent of providers and 60 per cent of commissioners were not confident that the £1 billion additional investment recommended by the Mental Health Taskforce and supported by NHS England will be sufficient to meet the challenges faced by mental health services.

Creating alignment
There are clearly a number of challenges faced as we try to get the balance right. There is a lack of alignment between commissioners and providers over what it means to implement parity of esteem. A number of themes emerged from our joint report in March, highlighting a lack of shared understanding about how parity of esteem can be implemented. Many of these inconsistencies need to be clarified by system leaders at national level so that local mental health services.

Feedback from the survey clearly indicated a disjoint between commissioners and providers about whether the requirement in the planning guidance to increase the real terms investment in mental health services was being met. Commissioners highlight that they have invested in mental health services, and frontline providers argue that they have not always seen this investment play out as they expected it to.

There is some confusion around what organisations deem as mental health spend. According to respondents, commissioners might be investing in areas not provided by secondary care trusts, such as primary care, drugs, the mental health component of continuing healthcare and out of area services. This means that commissioners might report that they have increased their spend on mental health services, while some providers will have seen no direct evidence of this.

Ideally some funding should be aligned at local level, such as through Health and Wellbeing Boards, and there are a number of positive examples of how providers can be better involved and engaged in their work.

Conflicting guidance
Feedback from the research highlighted that it is difficult for local organisations to understand how payment rules interact with the planning guidance. The national tariff is the payment system for the secondary care system, covering £70 billion worth of NHS spend. It is set annually by NHS England and NHS Improvement and determines the efficiency requirement and cost adjustments for prices and contracts across the sector. In 2015/16, prices and contracts were reduced by 1.6 per cent - this is intended to be the starting point for discussions between commissioners and providers for locally priced services, such as mental health.

A number of respondents to the survey highlighted that their contracts were simply reduced by this amount, making planning guidance requirement to increase investment much more difficult.

Competing priorities and funding pressures
In a difficult financial climate, the survey bears out that CCGs continue to face competing service pressures in 2016/17 which will have implications for how much of their resources can be dedicated to mental health services.

As in 2015/16, these include the ringing-fencing of part of CCG allocations for direction into the Better Care Fund; inflationary pressures in relation to primary care contracts; continued pressures in acute services (both emergency and planned activity) and prescribing budgets, as well as increases in continuing healthcare costs.

What needs to happen next?
The additional funding for mental health services, and the on going commitment in the planning guidance for commissioners to increase their real term investment, represent a real opportunity to reset the way mental health services are prioritised.

HFMA believes that four things need to happen if we are to better support NHS organisations to meet their parity of esteem commitments over the course of this Parliament.

Firstly, clarity from the government and system leaders about how much is being made available for mental health services, and in which areas. We know that there is £1 billion to implement the recommendations from the Mental Health Taskforce, but it is not clear whether this separate or in addition to the £600m previously announced in the 2015/16 Autumn Statement and the £1.25 billion for children and young people’s services. It is also unclear whether this is incorporated in to commissioner allocations or will be funded through sustainability and transformation funding.

Additionally, explicit alignment is needed about what it means to meet parity of esteem commitments. At both national and local level, organisations are interpreting the requirements in different ways, leading to a patchwork of investment and services for patients. This also creates mistrust between local organisations and frustrates commissioners and providers in their attempts to work more closely together. NHS Improvement and NHS England need to support providers and commissioners respectively to agree an understanding of what parity of esteem means in practice at local level, and key questions need to be clarified.

Thirdly, better enforcement and support for local organisations. Our research highlights a great deal of local variation about how the rules are being interpreted and responded to. NHS England needs to work with local organisations to ensure that the rules are consistently and fairly implemented. Where organisations are struggling to invest in line with the guidance, support will be required to ensure that challenges are addressed.

Finally, greater transparency across the system about how much is being spent on mental health services. The recommendation in the taskforce for commissioners to publish in detail spend on services is helpful, but NHS England will need to support organisations to implement this in a meaningful and simple way. We also need to recognise that this in itself is not enough to achieve parity, and we need to avoid this simply being a measure to create a league table of commissioners.

It’s clearly a work in progress and there is no quick way to fix the issues. However concerted efforts will need to be made at local and national level to ensure that money for mental health services reaches the front line.

Key to this will be creating an environment for commissioners and providers to work more closely to determine how and where additional investment is spent. It is not sustainable to have a situation in which commissioners report that they have increased their overall spending, yet individual providers have seen no direct investment, despite their services being under intense pressure. Clarity and transparency will be the most important factors in trying to get this right, alongside working collaboratively and positively together.

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