Starting today The future of mental health services Final Inquiry report September 2013 Acknowledgements We wish to thank all those who took part in our Inquiry for their support and contributions, and especially the members of our Advisory Panel. We record their names in the Annex to this report. We thank Sam Blausten, Hannah Bullmore, Joanna Carson, Caroline Davis, Alice Inch and Simon Lawton-Smith at the Mental Health Foundation for their help in delivering this report. We acknowledge with thanks the financial contribution to this Inquiry received from the Institute of Psychiatry, King’s College, London and Lilly UK. Contents Forward 1 Summary 2 Background and Terms of Reference 7 Methodology 10 Visions of the future 11 The world in 1983 14 Assumptions about the future, and past and present trends 15 The Call for Evidence: what we were told 19 The six key themes 23 Theme 1 – Personalising services 23 Co-production 24 Self-management 26 Theme 2 – Integrated care 27 Models of integrated care 29 Specialist mental health care in primary care settings 29 Crisis support in the community 31 ‘One stop shops’ and community support 32 Taking integrated care forward 33 Changing the mindset, and the importance of relationships 33 Structural factors that facilitate good integrated care 35 Information-sharing systems 35 Shared protocols 35 Joint funding and commissioning 35 Co-located services 36 Multidiscinplinary teams 36 Liaison services 36 Theme 3 – Lifespan issues 37 Early life 37 Later life 38 Theme 4 – Workforce development 40 The balance between generalist and specialist 40 A potential role for peer support workers and navigators 42 Peer support workers 42 Navigators 43 Theme 5 – Research and new technologies 45 Research 45 Clinical research 46 Research into social interventions 46 Sharing information and patient data 47 Technical compatibility 47 Confidentiality 48 Using new technology 49 Theme 6 – Public mental health 50 The public health workforce and mental health 52 Addressing stigma and discrimination 52 Stigma from the public 52 Stigma from professionals 53 Annex: Participants in the Inquiry 55 References 57 Quotations used in this report Throughout this report we quote from witnesses who attended oral evidence sessions, members of our Policy Panel (some 500 people who include mental health service users, carers and mental health professionals) and respondents to our Call for Evidence. In the latter case, responses are referenced by the number of the question asked (1-6), followed by the number of the respondent (1-1533). Hence, for example, 3.602 is the 602nd response we received to question 3. Foreword Mental health is an integral part of an However there are certain trends which are individual’s well-being. It means different not very clear. For example, rates of migration things to different people, as does mental and speed of globalisation and urbanisation illness. There is considerable evidence to will affect psychiatric vulnerability but we indicate that the health and economic burden cannot predict by how much and how these related to poor mental health in the UK is needs can be met. The impact of the current significant - greater than cardiovascular economic downturn will be felt for a long time diseases and cancer - and yet the emphasis and it is highly unlikely that health and social on mental wellbeing is often very limited. services will ever get the same amounts of generous funding that we have had in the UK Reasons for this relative neglect are many, in the past two decades. Hence we need to but include a perception that mental ill-health look at fresh ways of developing and delivering is somehow self-inflicted, with an external services. locus of control such as an inability to deal with pressures, and discrimination as well What is clear from our Inquiry is that we need in poor recognition of the scientific basis of to start taking action today to address all the psychiatry. Fortunately in the past few years factors we are aware of that challenge good this has started to change with policymakers mental health, and lead to mental illness. We becoming more aware of the implications cannot expect mental health services simply of untreated mental illness. The current to muddle along with no clear sense of what economic downturn around the globe has is required, and sleepwalk into the future. If also led to mental illness, emotional distress we do so, we will be failing both today’s and and resulting physical distress being better tomorrow’s generation of people who will recognised and addressed than before. need mental health services, and their carers and families, as well as the staff who work in There is widespread agreement, though, that mental health services. This is not just about more needs to be done, and that the future is more effective care provided by specialist very uncertain. Accordingly, in 2012 the Mental mental health services. It is also about the Health Foundation, as a leading charitable role of primary care mental health and the crucial organisation dealing with both public mental public mental health agenda. We hope that this health and mental health care, decided to set Inquiry will be a major step in this direction. up an Inquiry to look at the future of mental health services in the UK over the next 20 to To support our Inquiry, we have been 30 years. extremely fortunate in getting a large number of very busy people together who have given We were delighted to chair the Inquiry Advisory up a considerable amount of their time and Panel. The future is always difficult to predict energy to this task and we are grateful for and we recognised the danger in trying to do that. Staff within the Foundation have worked so. However one thing that we can be certain of incredibly hard to deliver the report. We would is that the future will happen, and the present like to thank in particular Andrew McCulloch will affect the future. We know that people are for his support and Simon Lawton-Smith going to be living longer and therefore likely and Hannah Bullmore for their hard work and to experience a greater number of illnesses, energy. While acknowledging the seriousness whether physical or mental – or, as is likely, both. of the issue, Foundation staff have also made We have good predictions of the numbers of it enjoyable for us to work on this project - older individuals in 20-30 years’ time, and we are many thanks. also able to make reasonable assumptions about prevalence rates of mental disorder across all age Dinesh Bhugra groups and the incidence of disorders in vulnerable groups. Alex Carlile 1 Summary We spend more across the UK iii. To consider how to make mental health on mental health services than services fit for purpose to deal with on any other area of health, challenges 20-30 years in the future. including cancer and heart It is estimated there will be nearly 8 million disease. The economic impact of more adults in the UK by 2030. If prevalence rates for mental disorders stay the same (at poor mental health is estimated around one in four), that is some 2 million to be over £100 billion to the more adults with mental health problems than economy each year in England today. It is also estimated that there will be one million more children and young people in alone. Yet despite this, we know the UK by 2030. Again, if prevalence rates for that the care and treatment that mental disorders stay the same (at around one we offer people with mental in ten), that is some 100,000 more children and young people with mental health problems health problems is variable - than today. many people with mental health problems have trouble accessing It goes without saying that future mental health services need adequate funding to services; interventions are not ensure appropriate levels of services and always effective; services can skilled staff. We have not, however, specified any amount or proportion of funding that be poor at providing a holistic should be spent on mental health services, nor response to people’s needs, for from where the funding might come. These instance neglecting people’s are decisions that will need to be taken by politicians of the future, and they do not affect physical health; and many simply our key messages about what mental health get no help at all (some do not services need to do today to start moving seek it, or give up trying due to towards effective mental health care in 20-30 years’ time. difficulties accessing help). Nor do we attempt to resolve all of society’s At the same time, there are many challenges ills, such as inequality, debt, unemployment facing mental health services as we look to and homelessness, which underpin much the future, including persistently high levels poor mental health and mental illness across of psychiatric morbidity, increasing levels of the UK, though these issues were regularly comorbidity and multiple morbidity, an ageing raised in evidence put to the Inquiry. Our population with high health and social care focus is mental health services of the future. needs, barriers to providing good integrated In considering public mental health issues we care and severe constraints on public do touch on the pressing need for a greater spending. emphasis on the prevention of mental illness, to ease future pressures on services, but a It is against this background that in 2012 fuller discussion of this falls outside the remit the Mental Health Foundation established of this Inquiry. its Inquiry into the Future of Mental Health Services (FOMHS), with the following aims: We need fresh ways of working in mental health.