The Unkindest Cut - Article in Public Health News (June 5)
The unkindest cut
Supporting people with mental health problems and helping people to resume as complete a life as possible is not just a matter of NHS finance but about how well the different parts of a complex network work together. Chris Reynolds reports on how funding cuts are threatening services in Hertfordshire
On 17 May, the Hertfordshire County Council health scrutiny committee decided that the mental health cuts proposed by the local primary care trusts were not in the interests of the people of Hertfordshire. A week earlier objections that the cuts were inappropriate, ineffective or put patients and carers at risk had been ignored by the joint commissioning partnership board which acts for the eight PCTs and the county council which funds the Hertfordshire Partnership Trust (PHN, 15 May, page 7). The scrutiny committee took a different view and the matter has been referred to the secretary of state for health.
So should those of us who opposed the cuts be celebrating? Of course we are very pleased that the scrutiny committee agreed the cuts were badly flawed. But celebrate? No. Not yet.
In 2005, the strategic health authority organised a major consultation, Investing in your mental health, in part to rationalise in-patient services and in part to speed up implementation of the national service framework across the county. By providing improved early diagnosis and strengthening the network of community support services, the plan was to maximise recovery and minimise the need for more expensive acute hospital beds. It was clear there were serious gaps in primary care services between the community mental health teams (provided by HPT) and GPs. It was also obvious that more voluntary sector services were needed, on a more reliable funding basis, particularly in some parts of the county.
The consultation was approved in December 2005. It was also agreed that new facilities should be available before old ones were withdrawn. Unfortunately the financial 'cancer' affecting the Hertfordshire acute hospitals spread to the PCTs and, in January, the secretary of state said the rot must be eliminated. The brakes were slammed on throughout Hertfordshire. The SHA responded by top slicing all trusts, including HPT. What has happened since is an example of 'more haste, less speed' with mentally ill patients being the losers all down the line.
The PCTs wanted £5m worth of cuts in place for April - about 10 weeks away - and asked HPT for suggestions. It was immediately clear that most of the money would have to come from cutting real services. Within days, HPT reluctantly came up with a provisional list of possible cuts for discussion, with an indication of the implications and estimated savings.
A hurried meeting of the JCPB froze this discussion list as if it was written in stone. It agreed consultation was needed on £3.2m significant service changes, but with no proper assessment of how one cut affected another if both were made. The effect on patients, carers and other parts of the mental health support network were not seriously considered. As a non-voting member of the board, I pointed out the danger of not properly evaluating the risks associated with the cuts.
At the JCPB's request, the scrutiny committee approved a truncated consultation period ending on 3 May. The consultation document contained no risk assessment table but asked separately about the possible risks associated with each cut. There was a very good response - nearly 400 questionnaires or written submissions were received. Many identified significant risks and more than 60 came from organisations with specialist knowledge of the areas being cut, ranging from patient groups through to clinicians in both primary and secondary care.
Eight days later, the JCPB considered the response document and, by a majority, approved all but one of the cuts. While the consultation document specifically asked for risks, this was skated over - with no analysis of those submitted. There had been some minor variations and some expansion in detail, and all the cuts would be expected to return the exact sum promised in the initial 'for discussion' list.
To most people this appears to be a whitewash. Detailed written submissions from knowledgeable organisations pointing out significant risks relating to specific cuts were summarised in a table - maximum circa 60 words per submission - but otherwise ignored. While the wording is obtuse, it gives the impression that risks to patients are not a matter for the planners but something to be sorted out after the cuts are made by clinicians. I could go on. A few days later the scrutiny committee was asked to accept a response document which failed to properly address patient safety and inadequately covered the consequences of the cuts on other organisations in the mental health support network. It also seemed at that at least some cuts will prove a false economy.
So what happens next? The cuts, coming so soon after the Investing in your mental health consultation, have been a public relations disaster. Mentally ill patients, their carers and support staff are left in limbo until a decision is made. If the NHS insists on extracting its pound of flesh from underprivileged people, the cuts and the associated betrayal will be devastating. Some of Hertfordshire's mentally ill will no longer go on long waiting lists for treatment - the service they need will have been withdrawn.
Chris Reynolds is vice chair of the "Herts Parts' PPI forum, a non-voting member of the JCPB, official PPI forum observer on Herts County Council health scrutiny committee and official PPI forum rep on the HPT board.He is writing in a personal capacity