False Economy

We’ve been reading a lot recently about the impact of cuts and rationalisation of mental health services – the Health Select Committee of the UK parliament recently published a document which highlights a lack of parity for mental health and physical health care, having been dogged by difficulties in patients accessing services and the ineffectiveness of community treatment orders.

Public demand for services, like energy, goes somewhere if not down the intended route and we have seen several examples of disaster, arising from the inability of some services to match demand and the attempts by others to react to it when it is unmet.

We saw more about this today, in the publication of a BBC and Community Care investigation into NHS mental health bed provision.  The medical director of what is probably the UK’s most prestigious mental health trust has claimed the system is now inefficient and unsafe.  It was music to my ears to hear him say this morning that it was probably costing more to do it this badly.  A variation on my frequent proposition that it would be “cheaper to do it properly.”  I remain convinced that this is true.

We see hidden costs in many ways –

  1. We have seen the tragedy of exclusion – service users living increasingly desperate lives, unable to cope with poverty, financial restrictions and the stigmatisation of mental illness disappearing in to the background of our society and we see the links in police custody to poverty, mental illness and substance (ab)use.
  2. We have seen the tragedies of self-harm and suicide – service users and others with unmet needs who may well not be known to MH services who are at risk, unable to access support they require taking their lives.
  3. We have seen the tragedy of criminalisation – incidents of offending by people in crisis which may well have been preventable which then lead to the victim-cost as well as the costs of prosecution into the justice system.
  4. We have seen the tragedy of untoward events – we have seen incidents where someone in crisis (whether or not they have received adequate support) comes into contact with the police and for reasons covered by Lord ADEBOWALE, there is death or serious injury following contact.

Cost: human, economic and social – arising from problems of resourcing and from systemic issues (currently being reviewed by the Care Quality Commission) and all this against a backdrop of the overall mental health budget having risen by 59% in the decade to 2012; with a small drop last year.  It is rightly argued that this increase only brought funding to where it probably should have been, if it even did that, and therefore there should be absolutely no perception that mental health services are now cash-rich because of budget inflation.


But as we have seen restrictions and rationalisation of service (management-speak), we see the costs of failure demand and they often do come back against the NHS as a false economy.  The costs of a prison sentence are covered by the government budget for the Ministry of Justice who fund our prison system; but if prisoners are transferred from prison to hospital as patients, the costs transfer to the Department of Health whose budget funds our hospital system.

So for example, Phillip SIMELANE was recently convicted of killing Christina EDKINS and inquiries are ongoing about the contact that MH services had with him whilst he was previously in prison for an unrelated matter.  He managed to leave prison with inadequate housing support and the investigation is looking at whether he had adequate mental health care support, prior to killing Christina.  Mr SIMELANE’s mother has publicly claimed he was let down by “the system” and it is now the mental health system that is picking up the bill for his hospital order at around £300,000 a year, rather than the provision of appropriate outpatient or inpatient care after prison.  I’m sure the inquiry will reveal whether or not they feel the incident was “preventable.”

We also see mental health demand being deflected by mainstream services to 999 services: both the ambulance service and the police service are de facto front-line mental health professionals, only without the training or sometimes without the legal powers to cope.  This is why we see “Street Triage” emerging: paying a nurse to work even further and deeper into the crisis than ever before.  Incidentally, what ever happened to “Early Intervention”?  This is not a phrase I’ve heard for a while, as the commissioning focus shifts to other, baser priorities.


Of course, not all crisis events are predictable or preventable and many involve patients unknown to their mental health trust or even to their GP as having a mental disorder.  But we know in many areas, that up to half of s136 detainees – the people that Street Triage nurses will be seeing – are already known to services.  What’s going on there? – do we even ask?!

Data from a couple of years ago in one local authority outlined that 55% of their overall budget was being spent on the secure care of just 67 individuals in medium and high secure hospitals, each patient consuming around £300,000 – £400,000 of budget per annum.  This means that around 45% of budget being spent on just under 2,500 other patients and every time one of them becomes in need of secure admission, it creates more pressure as the forensic bill rises.

So you can reduce bed numbers if you want and continue to do so beyond the point at which available beds only just match demand.  We can conceive this as saving money because we are paying for fewer beds which cost about £125,000 a year.  But by the time you’ve then paid for an out-of-area or private bed for the patients who couldn’t access your service, by the time we’ve measured the costs in other ways and by the time crisis has become such as to mean the justice system has sentenced someone to a hospital order and detention in a bed which costs £300,000 to £400,000 a year, how much money have we saved?

It takes just one patient to be placed in medium or high secure hospital system to blow our the budget for decommissioning three beds.  And the number of restricted patients in hospital has been rising steadily over the last eighteen years.

  • In 1995, there were 2,478 restricted hospital patients.
  • In 2004, there were 3,282
  • In 2010, there were 4,404.
  • I’m very interested in being quite unable to find statstics since 2010 – all help gratefully received!

And this is just about the money, mainly because that’s what all too many people are focussed on – what about human and social costs?  They extend way beyond vulnerable people and degrade us all.

Unmet need is unmet need: if we do not respond to it when first identified, then we will see this “demand” go elsewhere.  We will see suicide, unemployment and ever greater social exclusion and discrimination than we’ve seen before.  And when we sit down at the end to decide whether the books have balanced, we will have to factor in the cost in human life and human disadvantage.  It’s not just about money.  It’s not even about money.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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