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Research: Specialist mental health services in England in 2014 …


4 Real term investment in priority service areas 2002/3 to 2011/2. Source 34

There are no comparable official data for child and adolescent mental health services (CAMHS). We therefore gathered data by other means, including surveys by the third sector (i.e.

both for profit and not for profit provider organisations) and Freedom of Information (FOI) requests. One survey found that 67 per cent of councils had reduced CAMHS funding between 2010 and 2013 22. Regional cuts in spending were as high as 12 % in the North East and 13 % in the East of England 22 over this period.

The BBC and the Community Care journal published figures in 2013, based upon a FOI request, with responses from 43 of 51 mental health trusts in England.

Comparing 2011/12 budgets with those for 2013/14, they found a real terms reduction of 2.36 %, while funding for psychological therapies increased by 6 % in real terms (source: http://www.bbc.com/news/health-245373041.)

Despite official figures estimating 1 2 % real terms decreases in expenditure, case study information from individual Trusts published in the Chief Medical Officer s 2014 Report suggests that these figures may fall far short of actual disinvestment. One large metropolitan mental health trust reported that over the period from 2009/10 to 2013/14 it had seen a net reduction in funding of 12 m, with the pace of net disinvestment being accelerated and set to do so further . They report that If the funding provided by the Department of Health and which passes through Clinical Commissioning Groups (CCGs) then the net gain to local CCGs from disinvestment and efficiency in local mental health services has been approximately 50 m.

In each of our local CCGs we have seen net savings from mental health services of at least 32 % over the last 7 years. These are far in excess of official estimates, and support a series of concerns summarised in Box 2.

Box 2 Key messages on the treatment gap in mental health services in England

There is a very significant overall treatment gap in mental health with about 75 % of people with mental illness receiving no treatment at all 1

The treatment gap contributes to unacceptably high mortality rates, as the available data suggest that people with mental illness can die up to 15 20 years earlier on average than individuals without mental illness 35, 36

There are significant and inappropriate variations in the delivery of mental health services 9

Information on mental health service expenditure currently lack sufficient detail

There is a clear fall in investment and expenditure despite evidence of an increase in mental health burden 12, 17, 21

It is unclear whether the disinvestment has been greater for mental than for physical health provision

There appear to be considerable discrepancies between overall national figures for resource reductions and the figures available locally from mental health Trusts

There are no available data sets which capture the implications for mental health services of aggregate expenditure reductions across multiple sectors (criminal justice, social care, non-statutory, and the voluntary sectors)

Service accessibility and waiting times

Mental health services are currently exempt from the 18 week maximum waiting time for service access stipulated in the NHS Constitution. Service user data indicates that over 12 % of people wait longer than 1 year to start treatment, whilst 54 % wait over 3 months 23.

The number of people presenting in a mental health crisis have increased in recent years 24, and 40 % of mental health trusts have staffing levels below established benchmarks for crisis services (http://www.mind.org.uk/crisiscare2). Waiting times for emergency assessment, for example in police cells or Mental Health Act Section 136 Suites, have escalated in recent years, along with increasing use of the police and criminal justice system to care for individuals when unwell due to insufficient capacity in mental health services 25. Nevertheless the quality of data about these acute issues is poor.

The Care Quality Commission, for example, has raised concerns about bed occupancy rates for many years 26 yet their most recent report does not report on bed occupancy rates (see: http://www.england.nhs.uk/statistics/statistical-work-areas/bed-availability-and-occupancy/bed-data-overnight3).

Limitations in data sources have led to increased freedom of information requests and professional surveys to investigate these concerns (Box 3). These findings include a reported 9 % reduction in mental health beds between 2011 and 2012 and a doubling of patients being sent out of area for treatment between 2011/12 and 2013/4 27 (see: http://www.communitycare.co.uk/2013/10/16/patients-at-risk-as-unsafe-mental-health-services-reach-crisis-point-24)

Box 3 Summary of recent freedom of information requests and survey findings

A minimum of 1711 mental health beds have been closed since April 2011, including 277 between April and August 2013. This is a 9 % reduction in the total number of mental health beds 18,924 available in 2011/12.


A 2013 survey of members of the Child and Adolescent Psychiatry Faculty was carried out 77 % of respondents to a 2013 survey of members of the Child and Adolescent Psychiatry Faculty about their experience of admitting young people to inpatient unit reported difficulties in accessing admissions to inpatient beds.

79.1 % respondents reported safeguarding concerns/incidents whilst waiting for a bed; 76.5 % reported young people with unacceptably high risk profiles being managed in the community due to lack of beds; 61.9 % reported young people being held in inappropriate settings 37

Freedom of information data from 30 trusts, reported the number of patients sent out of area has more than doubled between 2011/2 and 2013/14 (1301 in 2011/12 to 3024 in 2012/3). The costs associated with this reported by 23 Trusts show an increase in expenditure from 21.1 m in 2011/12 to 38.3 m in 2012/13


Admission, compulsion and suicides

The number of psychiatric hospital admissions is now about double that figure for 2000 19. Use of the Mental Health Act has also steadily grown in recent years, and in 2012/13 there was a 4 per cent increase in compulsory detentions in comparison to the previous year 28.

The Care Quality Commission and service user experience surveys show ongoing poor involvement of service users in their care 29. The Care Quality Commission reports ongoing inappropriate restrictive practices and cultures in many wards demonstrating a significant gap between practice and the ambitions of the national mental health policy 30.


Disregard for the needs of people with mental illness has been described by some authors as structural discrimination 31, 32. This concept can also be applied to lack of investment in information infrastructure to be able to know whether services are improving or not.

There are several important limitations of this study.

The research deliberately sought all relevant sources of information about the levels of investment in mental health care in England, and recent trends, and this meant that these sources were very heterogeneous and drew upon a wide variety of official data, research reports, the grey literature and case studies. We therefore would not place very heavy weight upon individual sources, but rather wish to interpret the overall pattern of results. Second, the time frame used for the data sources varied somewhat, with some referring to the period since 2008 when the economic recession began, and other to the period of the government at the time, which came into power in 2010.

Further, we have brought together information across a wide range of sources, but it is true that there are few sources of information about true prevalence and treated prevalence across all diagnostic groups, and such data are not routinely and repeatedly collected and reported by the government. It also needs to be kept in mind that rates of service utilization (and deductions about rates of unmet need) may differ when reported by service users or by service providers 33, 34. In addition, it is possible that there were types of substitution (for example with fewer community services in recent years has this been associated with a greater demand for psychiatric beds?), but we were not able to identify data to bear upon this issue.

The recent governmental commitment to parity of esteem 9 is long overdue.

Yet the policy requirements which have been applied to acute/physical healthcare, such as the 18 week waiting time limit, have still not been applied equally to mental health care. It is also clear that unintended consequences of the tariff system (cut more in recent years for mental than for mental health care) have systematically disadvantaged both commissioners and providers of mental health care. Poorly integrated financial monitoring processes have contributed to a failure to alert all parts of the NHS to how far resource reductions have harmed the quantity and quality of mental health care in recent years.

In the post 2013 structure of the NHS separate health, social care and public health outcomes frameworks are making it even harder to commission joint or integrated services, to avoid gaps in provision, and to monitor progress or deterioration in services. At the same time it needs to be acknowledged that within this context of overall disinvestment in mental health care, some services are being expanded, particularly the remit of the Improving Access to Psychological Therapies (IAPT) services. Taken as a whole, these findings are far from reassuring for everyone dedicated to better mental health care in England.

Authors contributions

MD is an Academic Clinical Fellow at King s College London, Institute of Psychiatry, Psychology and Neuroscience, and is a Specialty Registrar at the South London and Maudsley NHS Foundation Trust.

She was formerly a Medical Advisor to the Director of Research and Development at the National Institute for Clinical and Health Excellence. She undertook the primary data retrieval, and wrote the first draft of this paper. GT is Professor of Community Psychiatry at King s College London, Institute of Psychiatry, Psychology and Neuroscience, and is Consultant Psychiatrist at the South London and Maudsley NHS Foundation Trust.

He has published extensively on mental health services, and their evaluation, on stigma and discrimination, and on global mental health. He supervised the design, conduct and writing up of this paper, which is based upon a chapter on Service Gaps in the UK Chief Medical Officer 2014 Annual Public Health Report on Public Mental Health. GT is the guarantor of the paper.

Both authors read and approved the final manuscript.


The authors are pleased to acknowledge the important contributions of the following organisations and individuals to this paper: Centre for Mental Health, MIND, Rethink Mental Illness, Royal College of Psychiatrists, and other members of the Mental Health Policy Group, Martin Baggaley, Andy Bell, Gyles Glover, Gus Heafield, Martin Knapp, David McDaid, Nisha Mehta, and Helen Undy. GT is supported by the NIHR CLAHRC South London and the NIHR BRC at the South London and Maudsley NHS Foundation Trust. MD is an NIHR Academic Clinical Fellow.

Compliance with ethical guidelines

Competing interests Both authors declare that they have no competing interests.

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.07), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.08) applies to the data made available in this article, unless otherwise stated.


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