Closing the gaps in mental health care
C
losing the Gap: Priorities for essential change in mental health was published in January 2014 by the Department of Health (DH), with the specific intention of accelerating the mandate for improving the ways in which people with mental ill health are treated and supported in our society. This latest policy document has been published to augment the Government’s existing mental health strategy, No health without mental health (DH, 2012). The strategy was built around six unambiguous objectives: ■■ More people will have good mental health ■■ More people with mental health problems will recover ■■ More people with mental health problems will have good physical health ■■ More people will have a positive experience of care and support ■■ Fewer people will suffer avoidable harm ■■ Fewer people will experience stigma and discrimination. Fundamentally, what the pledges ask is that everyone who needs mental health care should get the right support, at the right time. Additionally, one of the priorities the strategy identified was tackling the premature mortality of people with mental health problems across all age groups and, importantly, that more must be done to prevent mental ill health and promote mental wellbeing. Since publication, there have been positive and tangible changes to the way in which mental ill health is addressed in society. For example, third-sector initiatives such as the ‘Time to change’, led by Mind and Rethink Mental Illness, is reducing discrimination against people with mental health problems.
Background The Closing the Gap (DH, 2014) proposals reveal that, all too often, poor mental health precipitates such events as premature job loss, which the Government believes to be detrimental to the individual sufferer and to the economy. It is known that unemployment is linked to the onset or recurrence of mental
230
ill health, and being out of or absent from work can prolong or exacerbate it. This is why the various strategies to alleviate the burden of mental ill health rely on effective corporate support from health and employment services, and supportive action from employers too. Despite the rhetoric, people who use mental health services and those who care for them continue to report gaps in provision and long waits for services. There is still insufficient support within communities for people with mental ill health and, in some areas, there have been reports of people of all ages being transferred hundreds of miles to access an appropriate service, including tier 3 child and adolescent mental-health services. Worryingly, Closing the Gap confirms that there has been little impact on the enormous gap in physical health outcomes for those with mental health problems. In a review of the literature, De Hert et al (2011) found that the lifespan of people with severe mental illness is shorter than that of the general population, and that this excess mortality is mainly due to physical illness being two or three times higher than in the general population. Furthermore, the Department of Health believes that much more could be done to promote good mental health and to prevent mental ill health. To address these deficiencies, Closing the Gap encourages the public health community, through local government, to help give mental-health and wellbeing promotion and prevention the long-overdue attention they need and deserve.
25 steps to closing the gaps Closing the Gap identifies 25 aspects of mental health care and support where Government, social-care leaders and academics, among others, expect to see tangible changes in the near future that will positively change the life outcomes for people with mental ill health. The document gives details of how to bridge the gap between the long-term ambitions of the Government and the shorter-term action it wants implemented to illuminate
how changes in local service planning and delivery will make a difference, in the next 2 or 3 years, to the lives of people with mental health problems. It is beyond the scope of this paper to consider in detail all 25 steps, but I will consider the most important. ■■ High-quality mental health services with an emphasis on recovery should be commissioned in all areas. The Government wants to ensure that there is a hospital bed available locally for every adult who needs one, but also that there is high-quality, safe care in the community that reflects what patients want and need, and which focuses on recovery. This aspiration is supported by the National Institute for Health and Care Excellence (NICE), which published quality standards for adult mental health (NICE, 2011). These standards give detailed information about the expected direction of the care pathway and are designed to augment the information available to commissioners. Additionally, NHS England recently launched its mental health leadership programme for Clinical Commissioning Groups (CCGs) and is working with expert bodies to develop best-practice specifications for commissioning specialist mental health services (NHS England, 2013). It is also helping to develop resources that will support local authorities and CCGs in commissioning services to meet the needs of those in mental health crisis. ■■ Leading an information revolution around mental health and wellbeing. The Government believes that the country needs a truer, more up-to-date and more detailed picture of mental health and wellbeing. This is essential for delivering measurable improvements in community and population mental health, service improvements, evidencebased commissioning and changed attitudes to mental wellbeing. The Government has developed a new national Mental Health Intelligence Network (MHIN) that draws together comprehensive information about mental health and wellbeing. The aim is to
© 2014 MA Healthcare Ltd
Professor Alan Glasper discusses a new Government policy initiative to accelerate the process of making fundamental changes to the way in which people with mental ill health are treated and supported in society
British Journal of Nursing, 2014, Vol 23, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2014 MA Healthcare Ltd
healthcare policy provide a greater insight into mental health problems, how they vary with age and in different parts of the country, and what the most pressing needs are in each area. Its main purpose will be to help providers decide what types of health and social care services are needed in their area, and how they can improve the mix of services and support available. The Department of Health has also developed a ‘mental health dashboard’ (DH, 2013a) through which the key measures that already exist can be tracked and the priority outcomes from the outcome highlighted. ■■ Establishing clear waiting time limits for mental health services and addressing inequalities around access to these services. Closing the Gap shows that people with mental health illnesses wait for unacceptable periods before getting an appointment. NHS England is currently gathering information about access to, and waiting times for, adult mental health services around the country, and whether any particular groups of people experience longer waits or poorer access than others. It is a specific intention to develop new national standards that focus on improving access to adult mental health services. These will be introduced in 2015, but the Department of Health expects waiting times to fall substantially before the new standards are put in place. ■■ Improving access to psychological therapies. The Department of Health is confident about the veracity of the evidence-base that underpins the efficacy of psychological therapies. Many GPs want to be able to direct patients (including children and young people) to relevant psychological therapies at an early stage, as a way of preventing a deterioration in mental health. Additional investment from the Government will enable an extra 300 000 people to benefit from psychological therapies such as cognitive behavioural therapy (CBT). Service interventions that deliver the most successful outcomes, such as higher recovery rates, will attract more Government funding. Importantly, as with care for long-term physical conditions, this new policy initiative envisions that adults with mental health problems will be able to exercise choice about the care they receive and how they receive it. Anyone eligible to receive social care services will be enabled to choose and receive a personal health budget. ■■ Reducing the use of restrictive practices and ending the use of high-risk restraint. The Serious Case Review into the events at Winterbourne View Hospital (DH, 2013b) has made it clear that restraint and restrictive
British Journal of Nursing, 2014, Vol 23, No 4
practices, such as medication and seclusion, have been over-used in the care of people with challenging behaviour in health settings and are now unacceptable. But it is acknowledged that dealing with patients who are aggressive, threatening or refuse treatment, is difficult. This new policy seeks to encourage the use of positive behaviour support to minimise the use of restrictive interventions, and new guidance is being developed on the use of restrictive practices as a last resort. ■■ Poor quality services will be identified sooner and action taken to improve care and where necessary, protect patients. The Care Quality Commission (CQC) is currently developing a new model for monitoring, inspecting and regulating mental health providers that will ensure poor-quality services or gaps in provision are identified sooner. The CQC will carry out more visits to service providers, and talk to people who use those services, as well as their families and carers. Carers will be better supported and more closely involved in decisions about mental health service provision. Also, the Friends and Family Test will be used to identify poorquality services and, by the end of December 2014, it will be routinely used in all mental health care settings. (NHS Choices, 2013). ■■ Mental health care and physical health care will be better integrated at every level. This new policy reveals that as much as 80% of all mental health care takes place in GP surgeries and hospitals. It shows that the whole healthcare system has to improve integration of physical and mental healthcare. It is therefore essential that staff working in these settings understand the symptoms of mental illness and the physical health needs of people with mental health problems. This will help guide treatment decisions and lead to better dayto-day care. Importantly, physical illnesses must be diagnosed earlier and treatment plans adapted to reflect mental health needs to accelerate recovery. Health Education England will develop training programmes to ensure
that all healthcare employees have a greater awareness of mental health problems and how they can affect their patients. For example, selfharming may be a sign of a mental health crisis ■■ Promote mental wellbeing and prevent mental health problems. Mental health issues affect around 10% of women either during or after pregnancy, which the new policy highlights to support new mothers. Similarly, schools will be supported in identifying mental health problems among children sooner. The Department of Health is funding an interactive e-Portal (to be launched this year) that will bring together the latest evidence and guidance on mental health problems in children and young people. The goal is ensure that people with mental health problems live healthier, longer lives.
Conclusion Closing the Gap is a laudable mental health policy, which ultimately seeks to reduce the stigma and discrimination associated with mental health problems. The Government believes the policy will help millions of people affected by mental ill health to fulfil their potential as active and equal citizens. Nurses, especially those working in frontline services, are crucial to the policy’s success. Mental BJN health is everybody’s business. De Hert M, Correll CU, Bobes J, et al (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1): 52–77 DH (2012) No health without mental health: implementation framework. DH, London DH (2013a) Mental health dashboard. https://www.gov. uk/government/publications/mental-health-dashboard (accessed 10 February 2014) DH (2013b) Transforming care: a national response to Winterbourne View hospital. DH, London DH (2014) Closing the Gap: priorities for essential change in mental health. DH, London NHS Choices (2013) Friends and family test. http:// tinyurl.com/cxb2uoc (accessed 10 February 2014) NHS England (2013) Esteem for people with mental health issues—Dr Geraldine Strathdee. http://www. england.nhs.uk/2013/10/10/geraldine-strathdee/ (accessed 10 February 2014) NICE (2011) QS14: Quality standard for service user experience in adult mental health. http://guidance. nice.org.uk/QS14 (accessed 10 February 2014)
Key points n Closing the Gap is a new Government policy initiative to accelerate changes to the way people with mental ill health are treated and supported in society n There is still an enormous gap in physical health outcomes for those with mental health problems n Closing the Gap identifies 25 aspects of mental health care and support that will change the life outcomes of people with mental ill health n The initiative seeks to encourage the use of positive behaviour support to minimise the use of restrictive interventions, such as medication and seclusion
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
C
losing the Gap: Priorities for essential change in mental health was published in January 2014 by the Department of Health (DH), with the specific intention of accelerating the mandate for improving the ways in which people with mental ill health are treated and supported in our society. This latest policy document has been published to augment the Government’s existing mental health strategy, No health without mental health (DH, 2012). The strategy was built around six unambiguous objectives: ■■ More people will have good mental health ■■ More people with mental health problems will recover ■■ More people with mental health problems will have good physical health ■■ More people will have a positive experience of care and support ■■ Fewer people will suffer avoidable harm ■■ Fewer people will experience stigma and discrimination. Fundamentally, what the pledges ask is that everyone who needs mental health care should get the right support, at the right time. Additionally, one of the priorities the strategy identified was tackling the premature mortality of people with mental health problems across all age groups and, importantly, that more must be done to prevent mental ill health and promote mental wellbeing. Since publication, there have been positive and tangible changes to the way in which mental ill health is addressed in society. For example, third-sector initiatives such as the ‘Time to change’, led by Mind and Rethink Mental Illness, is reducing discrimination against people with mental health problems.
Background The Closing the Gap (DH, 2014) proposals reveal that, all too often, poor mental health precipitates such events as premature job loss, which the Government believes to be detrimental to the individual sufferer and to the economy. It is known that unemployment is linked to the onset or recurrence of mental
230
ill health, and being out of or absent from work can prolong or exacerbate it. This is why the various strategies to alleviate the burden of mental ill health rely on effective corporate support from health and employment services, and supportive action from employers too. Despite the rhetoric, people who use mental health services and those who care for them continue to report gaps in provision and long waits for services. There is still insufficient support within communities for people with mental ill health and, in some areas, there have been reports of people of all ages being transferred hundreds of miles to access an appropriate service, including tier 3 child and adolescent mental-health services. Worryingly, Closing the Gap confirms that there has been little impact on the enormous gap in physical health outcomes for those with mental health problems. In a review of the literature, De Hert et al (2011) found that the lifespan of people with severe mental illness is shorter than that of the general population, and that this excess mortality is mainly due to physical illness being two or three times higher than in the general population. Furthermore, the Department of Health believes that much more could be done to promote good mental health and to prevent mental ill health. To address these deficiencies, Closing the Gap encourages the public health community, through local government, to help give mental-health and wellbeing promotion and prevention the long-overdue attention they need and deserve.
25 steps to closing the gaps Closing the Gap identifies 25 aspects of mental health care and support where Government, social-care leaders and academics, among others, expect to see tangible changes in the near future that will positively change the life outcomes for people with mental ill health. The document gives details of how to bridge the gap between the long-term ambitions of the Government and the shorter-term action it wants implemented to illuminate
how changes in local service planning and delivery will make a difference, in the next 2 or 3 years, to the lives of people with mental health problems. It is beyond the scope of this paper to consider in detail all 25 steps, but I will consider the most important. ■■ High-quality mental health services with an emphasis on recovery should be commissioned in all areas. The Government wants to ensure that there is a hospital bed available locally for every adult who needs one, but also that there is high-quality, safe care in the community that reflects what patients want and need, and which focuses on recovery. This aspiration is supported by the National Institute for Health and Care Excellence (NICE), which published quality standards for adult mental health (NICE, 2011). These standards give detailed information about the expected direction of the care pathway and are designed to augment the information available to commissioners. Additionally, NHS England recently launched its mental health leadership programme for Clinical Commissioning Groups (CCGs) and is working with expert bodies to develop best-practice specifications for commissioning specialist mental health services (NHS England, 2013). It is also helping to develop resources that will support local authorities and CCGs in commissioning services to meet the needs of those in mental health crisis. ■■ Leading an information revolution around mental health and wellbeing. The Government believes that the country needs a truer, more up-to-date and more detailed picture of mental health and wellbeing. This is essential for delivering measurable improvements in community and population mental health, service improvements, evidencebased commissioning and changed attitudes to mental wellbeing. The Government has developed a new national Mental Health Intelligence Network (MHIN) that draws together comprehensive information about mental health and wellbeing. The aim is to
© 2014 MA Healthcare Ltd
Professor Alan Glasper discusses a new Government policy initiative to accelerate the process of making fundamental changes to the way in which people with mental ill health are treated and supported in society
British Journal of Nursing, 2014, Vol 23, No 4
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2014 MA Healthcare Ltd
healthcare policy provide a greater insight into mental health problems, how they vary with age and in different parts of the country, and what the most pressing needs are in each area. Its main purpose will be to help providers decide what types of health and social care services are needed in their area, and how they can improve the mix of services and support available. The Department of Health has also developed a ‘mental health dashboard’ (DH, 2013a) through which the key measures that already exist can be tracked and the priority outcomes from the outcome highlighted. ■■ Establishing clear waiting time limits for mental health services and addressing inequalities around access to these services. Closing the Gap shows that people with mental health illnesses wait for unacceptable periods before getting an appointment. NHS England is currently gathering information about access to, and waiting times for, adult mental health services around the country, and whether any particular groups of people experience longer waits or poorer access than others. It is a specific intention to develop new national standards that focus on improving access to adult mental health services. These will be introduced in 2015, but the Department of Health expects waiting times to fall substantially before the new standards are put in place. ■■ Improving access to psychological therapies. The Department of Health is confident about the veracity of the evidence-base that underpins the efficacy of psychological therapies. Many GPs want to be able to direct patients (including children and young people) to relevant psychological therapies at an early stage, as a way of preventing a deterioration in mental health. Additional investment from the Government will enable an extra 300 000 people to benefit from psychological therapies such as cognitive behavioural therapy (CBT). Service interventions that deliver the most successful outcomes, such as higher recovery rates, will attract more Government funding. Importantly, as with care for long-term physical conditions, this new policy initiative envisions that adults with mental health problems will be able to exercise choice about the care they receive and how they receive it. Anyone eligible to receive social care services will be enabled to choose and receive a personal health budget. ■■ Reducing the use of restrictive practices and ending the use of high-risk restraint. The Serious Case Review into the events at Winterbourne View Hospital (DH, 2013b) has made it clear that restraint and restrictive
British Journal of Nursing, 2014, Vol 23, No 4
practices, such as medication and seclusion, have been over-used in the care of people with challenging behaviour in health settings and are now unacceptable. But it is acknowledged that dealing with patients who are aggressive, threatening or refuse treatment, is difficult. This new policy seeks to encourage the use of positive behaviour support to minimise the use of restrictive interventions, and new guidance is being developed on the use of restrictive practices as a last resort. ■■ Poor quality services will be identified sooner and action taken to improve care and where necessary, protect patients. The Care Quality Commission (CQC) is currently developing a new model for monitoring, inspecting and regulating mental health providers that will ensure poor-quality services or gaps in provision are identified sooner. The CQC will carry out more visits to service providers, and talk to people who use those services, as well as their families and carers. Carers will be better supported and more closely involved in decisions about mental health service provision. Also, the Friends and Family Test will be used to identify poorquality services and, by the end of December 2014, it will be routinely used in all mental health care settings. (NHS Choices, 2013). ■■ Mental health care and physical health care will be better integrated at every level. This new policy reveals that as much as 80% of all mental health care takes place in GP surgeries and hospitals. It shows that the whole healthcare system has to improve integration of physical and mental healthcare. It is therefore essential that staff working in these settings understand the symptoms of mental illness and the physical health needs of people with mental health problems. This will help guide treatment decisions and lead to better dayto-day care. Importantly, physical illnesses must be diagnosed earlier and treatment plans adapted to reflect mental health needs to accelerate recovery. Health Education England will develop training programmes to ensure
that all healthcare employees have a greater awareness of mental health problems and how they can affect their patients. For example, selfharming may be a sign of a mental health crisis ■■ Promote mental wellbeing and prevent mental health problems. Mental health issues affect around 10% of women either during or after pregnancy, which the new policy highlights to support new mothers. Similarly, schools will be supported in identifying mental health problems among children sooner. The Department of Health is funding an interactive e-Portal (to be launched this year) that will bring together the latest evidence and guidance on mental health problems in children and young people. The goal is ensure that people with mental health problems live healthier, longer lives.
Conclusion Closing the Gap is a laudable mental health policy, which ultimately seeks to reduce the stigma and discrimination associated with mental health problems. The Government believes the policy will help millions of people affected by mental ill health to fulfil their potential as active and equal citizens. Nurses, especially those working in frontline services, are crucial to the policy’s success. Mental BJN health is everybody’s business. De Hert M, Correll CU, Bobes J, et al (2011) Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10(1): 52–77 DH (2012) No health without mental health: implementation framework. DH, London DH (2013a) Mental health dashboard. https://www.gov. uk/government/publications/mental-health-dashboard (accessed 10 February 2014) DH (2013b) Transforming care: a national response to Winterbourne View hospital. DH, London DH (2014) Closing the Gap: priorities for essential change in mental health. DH, London NHS Choices (2013) Friends and family test. http:// tinyurl.com/cxb2uoc (accessed 10 February 2014) NHS England (2013) Esteem for people with mental health issues—Dr Geraldine Strathdee. http://www. england.nhs.uk/2013/10/10/geraldine-strathdee/ (accessed 10 February 2014) NICE (2011) QS14: Quality standard for service user experience in adult mental health. http://guidance. nice.org.uk/QS14 (accessed 10 February 2014)
Key points n Closing the Gap is a new Government policy initiative to accelerate changes to the way people with mental ill health are treated and supported in society n There is still an enormous gap in physical health outcomes for those with mental health problems n Closing the Gap identifies 25 aspects of mental health care and support that will change the life outcomes of people with mental ill health n The initiative seeks to encourage the use of positive behaviour support to minimise the use of restrictive interventions, such as medication and seclusion
231
British Journal of Nursing. Downloaded from magonlinelibrary.com by 147.188.128.074 on November 12, 2015. For personal use only. No other uses without permission. . All rights reserved.
