18,400 MENTAL HEALTH BEDS IN 2019 – IN 1954 THERE WERE 155,000. WHY? WHY?

18,400 MENTAL HEALTH BEDS IN 2019 – IN 1954 THERE WERE 155,000. WHY? WHY? 

Here are some chilling facts about mental health bed numbers in England:

1954: 155,000

1987: 67,000

2008: 27,000

2019: 18,400

The figures are provided courtesy variously of the Royal Society of Psychiatrists and the British Medical Journal. There are many questions to be asked surrounding these figures. Firstly are we in a better place now vis a vis treating the mentally ill and mentally disabled than we were in 1954? Are there more or fewer mentally ill/disabled now than in 1954? Is bed reduction a function of changing the ‘setting’ or clinical ‘pathway’ for care/treatment? If so, is this ‘transformation’ a successful one?

And what are the mental health bed numbers like in other countries, especially in the context of mental health rates in this and other countries? Finally we attempt to evaluate whether quality of care and treatment has improved over the last 60 years. What qualitative metrics exist now and are planned in order to detect and measure ‘successful’ care and treatment. 

Mental Health Beds/100,000 Population

The UK is not the worst or the best in terms of mental health beds. Belgium tops the table with 180.1 mental health beds per 100,000 population. The UK stands at 60.6 beds/100,000. Italy ranks very low at 10.6, with Germany, Sweden, Denmark and Spain having fewer beds than in the UK.

National Rates of Mental Illness

Again we don’t have the highest or lowest rates of mental illness. We are 16th in the world at 26%. Switzerland is the worst quickly followed by France, Germany and the USA. Belgium, with the most beds stands at 6th with 29.4%. 

1.2 Million Adult Bipolar Patients and 600,000 Adult Schizophrenia Patients in England

There are some 60 million adults in England and 2 in 100 of them are bipolar suffers and 1% are schizophrenics.

And just 14,800 beds……

Measuring The ‘Quality’ of Mental Health Treatment

Victor Leser, Ealing Save Our NHS (ESON) and Keep Our NHS Public (KONP) have mounted a campaign to ensure that all NHS mental health Trusts regularly publish their performance against the 18 week and 52 Week Refer To Treatment (RTT) targets. From 1 April 2015 the NHS target for 18 Week RTT has been 95%. Most of these Trusts are not reporting. Often they justify this (incorrectly) in connection with convoluted reasoning around ‘Non-Consultant led teams’ and the use of ‘Multi-Disciplinary teams’. 

Why anyone would ever agree to a 95% 18 Week RTT target is quite beyond me. If you had broken your leg, would you be happy to wait up to 4.5 months for treatment? If you were diagnosed with cancer, would you be satisfied to wait up to 4.5 months for treatment to begin. But if your mind is broken………

After multiple meetings with my local mental health Trust – West London NHS Trust (WLHT) – it seems to be finally dawning on them that they might have to report these figures. However they are still refusing. Local service users and their carers need to know how long patients are waiting/must wait for their treatment. When all mental health Trusts regularly report on performance against the 18 and 52 Week RTT targets, NHS bosses will have a much clearer picture on the size of this massive national failure. 

IF WLHT with 114 consultants can’t meet the 95% 18 Week RTT target (which anecdotally they aren’t) just how many consultants would it take to meet this target?

Nationally five NHS mental health Trusts have so far admitted to having consultant-led teams providing elective services and will now report on 18 week RTT performance. 11 Trusts have said no and have given excuses that are based upon misconceptions about Multi-Disciplinary Teams. 12 Trusts are still to answer.

If you thought that you might get a simple answer to the question ‘how long will it take on average for my loved one to get some treatment’, then think again – no answer readily comes back from WLHT and most other mental health Trusts. 

However in classic NHS style, new mental health performance metrics are planned for 2020! In March 2019 the Interim Report on ‘The Clinically-led Review of NHS Access Standards’ outlines proposed changes on how to measure access to mental health performance. There are some pilots field testing these proposals. WLHT is one of these pilot sites. 

There are some global patient self-reporting ‘measurements’. The Patient Health Questionnaire (PHQ) 9 is designed to facilitate the recognition and diagnosis of the most common mental health   disorders in Primary Care patients. General Anxiety Disorder 7 (GAD-7) measures severity of anxiety. As PHQ 9 and GAD 7 rely on patient self-reporting, they cannot be relied upon for definitive diagnosis.

In reality though we are hardly scratching the surface on developing and implementing qualitative performance metrics. Are the diagnosis and treatment regimes actually improving the quality of life of mentally troubled people? Well one way of ‘measuring‘ this is by  tracking the physical ailments of the mentally ill. Studies in many parts of the world have illustrated that there is strong correlation between mental illness and physical illness. Greater mental illness severity is often accompanied by a significant number of physical illnesses. NHS North West London (NWL) has begun work on carrying out five physical health checks on its Serious Mental Illness (SMI) population. With an estimated SMI population in NWL of 24,856 this is no mean task. Let’s hope these checks are done on an annual basis, and that the SMI population reduces in number.

In recent years in my region there as been a policy of ‘discharging’ as many mental health patients as possible from Secondary Mental healthcare to Primary Mental healthcare. Presumably the logic behind this is that if a patient is ‘improving’ move them to their local GP so that scarce heavy weight clinical effort can be devoted to those in greatest need. All well and good except from anecdotal evidence many GPs are poorly versed/trained in diagnosing and treating the mentally ill. Added to this we now have Community Mental healthcare. I have yet to grasp what this is, where it talks place and quite how it relates to Secondary and Primary Care.  

We also have the arrant nonsense of integrating mental healthcare with mental social care. It has, to my knowledge, never been achieved, and is of unsubstantiated benefit. Two different business models (NHS and Local Government), with different cultures and mission statements have traditionally not ‘gelled’ very well. With both ‘partners’ under the cosh financially each is afraid the other will steal some of its cash. Opening up their financial books to each other is probably the last thing either will do.

 

Are We Spending Enough on Mental Health and Mental Social Care?

In 2018/19 £12.5 billion was spent on mental healthcare out of a total healthcare spend of £130 billion. For 10 million adult sufferers and some 1.2 million children surely 10% of the total spend is woefully inadequate.

In the private sector a first appointment to see psychiatrist in Harley Street, London can easily cost £600/hour – so no help there for the poor.

 

Are We Getting Better at Treating the Mentally Ill and Disabled?

If you break your arm, the local hospital can deal with it and 6 weeks later your arm could be 95% back to normal. If your mind is broken, it’s entirely possible that with any and all kinds of treatment you will never be ’better’. 

After 25 years of experiencing mental health diagnosis and treatment in West London I have to say that it’s got better over the years. The downside is that I’d ‘score’ it 2 out of 10 in 1994 and 4 out of 10 in 2019.

There are now acres and acres of ’dashboards’, standards, guidelines, statistics and metrics – which I was unaware of (and probably did not exist) in 1994. Internally in the NHS I’m sure there are lots of dedicated knowledge management workers working toward a consistency of mental health treatment reporting. However the unfortunate truth is that there are inadequate numbers of beds, psychiatrists, psychologists, nurses, mental health support staff, social workers, places of safety, residential treatment centres, and carer organisations across the whole mental health and mental social care sector.   

 

National Mental Health Crises for Teenage Girls and Dementia Sufferers

The well documented mental health crisis for teenage girls and young women (2016 research from NSPCC, NHS England/NHS Digital and the Department of Education) is unlikely to improve in the near future. A recent review of dementia studies since 1980 suggests dementia patients are surviving longer and longer, causing the population affected to rise.

 

And What About Mental Social Care? 

I’m not sure anyone has even defined what this is/might be. Thousands of family members provide all kinds of care for their mentally troubled loved ones. Many NHS Trusts and CCGs as well as Local Authorities appear to be unaware of the existence of, and the needs of, these volunteer carers.

 

General Election Perspective

Labour is promising a focus on mental health – part of a £26 billion overall NHS annual increase by 2023/24. The LibDems and the Greens promise equal emphasis on mental and physical health – how that pans out in an increase in mental health spending (and decrease in physical health spending?) is as yet unclear. The Greens make a specific commitment to ‘evidence-based mental health therapies within 28 days’. The Conservatives have as yet made no explicit commitment to increased spending on mental health.

 

Eric Leach