Investigation: Child mental health cuts to pile pressure on GPs
Young people with psychological problems are being ‘bounced’ around the system and cutbacks this year could make this worse, reports Caroline Price
The crisis unfolding in mental health services for children and teenagers in England is about to get worse. GPs complain of ‘horrendous’ waiting times for specialist services for the growing number of young people with emotional and behavioural problems encountered in primary care. But instead of investment to tackle the problem, new figures obtained by Pulse reveal that many CCGs are planning to implement a mental health tariff cut of 1.8% to child and adolescent mental health services (CAMHS) over the next year, as recommended by NHS England. This comes on top of a 1.3% cut last year.
GPs warn the cuts will exacerbate the problems they are having, and even a health minister has described the disproportionate level of cuts to mental health as ‘flawed’.National ‘tariff deflator’ guidance outlined by NHS England and Monitor earlier this year advised CCGs they should be aiming for a 1.8% cut in non-acute provider contracts in 2014/15, which include mental health services. This compares with 1.5% for acute sector contracts.
Information supplied to Pulse from 43 CCGs after a request under the Freedom of Information Act shows only one will not be seeking savings from their CAMHS budget. Three-quarters said they would be applying the recommended 1.8% cut in child mental health funding, in line with the NHS England guidance. NHS Bromley CCG, which is adhering to the 1.8% target, says: ‘This is a Government directive and not a locally driven reduction.’
CCGs say the cut will not affect front-line services. A spokesperson for NHS Barnsley CCG explains: ‘We are applying the tariff deflator for non-acute services of -1.8% as advised in the “Everyone Counts” planning guidance issued by NHS England. ‘The tariff deflator is applied to the total contract values for non-acute services with the expectation that providers maintain current service levels and standards within the reduced contract value.’
What is the ‘tariff deflator’?
• The ‘tariff deflator’ is a nationally determined reduction in the price paid for health services commissioned by the NHS, applied in order to achieve efficiency savings.
• For 2014/15, NHS England and Monitor agreed commissioners should apply a tariff deflator of 1.5% to contracts for acute services and of 1.8% for non-acute services, including mental health.
• NHS England says the acute sector needs the lower figure because it needs to invest money to meet the recommendations of the Francis and Keogh reports.
• But critics argue that already overstretched mental health services will be hit hard by the bigger cut, which, they say, runs counter to the Government’s stated aim to achieve parity of esteem between mental and physical health.
But GPs insist there will be an inevitable impact on services that are already over-stretched. Dr John Grenville, chair of Derbyshire LMC, says the planned cuts are short-sighted and will lead to a reduction in services for children and young people, which are already struggling to meet demand. He says: ‘We have so many people saying our children’s health is important, mental health is important and if we don’t invest now we will pay for it in the longer term. And then we have them saying “we’re going to make cuts”.
‘Unless someone can say up front that they are absolutely certain there are 1.8% efficiency savings to be made and identify them, then what’s going to happen is we are going to see cuts in services – and historically that is what happens.’
Dr Grenville adds that GPs are increasingly being expected to manage young people with mental health problems such as depression and anxiety, eating disorders, ADHD, self-harm or psychosis, even though they lack the time and the experience to do so.
‘The referrals tend to get bounced. Very often you just get the response, “We don’t think this falls within our remit”. This is just on paper; without speaking to the child or family, they decide it is not severe enough to require an assessment.’
3Dr Robert Morley, chief executive of Birmingham LMC, agrees this is an ongoing problem: ‘There have always been horrendous problems with waiting times and getting patients seen by psychiatrists – especially issues with 16- and 17-year-olds falling between child and adult care. We are often fobbed off by being told to send them to educational psychology and various other “noctor” services.’
A review by chief medical officer Dame Sally Davies, published last year, said there was evidence to suggest that young people’s mental health was a growing problem, with self-harm rates increasing sharply in the past decade in particular.
This, the report said, combined with cuts in local authority spending on CAMHS since 2008, has led to increasing pressure in some areas, with ‘frequent anecdotal reports of services having long waiting lists and of thresholds being too high in terms of referrals of children and young people with less severe problems not being accepted’.
Kent LMC chair Dr John Allingham says: ‘GPs face a very complicated system with lots of tiers and levels. What makes it more pressing is that it’s a growing area of demand, as you have more children being diagnosed with ADHD and so on.
‘This is an area that needs to be invested in rather than disinvested and I think we need a simplification of referrals. I often sit with a child in front of me, thinking: ‘Right, you’ve been here, you’ve been there, where next?’
Dr Allingham adds: ‘One of the best analogies I’ve heard came from a senior NHS England colleague, who said this area of care is like putting a ball into a pinball machine – the patient can bounce from buffer to buffer before finally reaching the right hole.’
But Pulse did find some CCGs that are taking a more enlightened approach. Nine of those that responded to Pulse’s request said they would make smaller cuts of between 1.0% and 1.6% in their CAMHS contracts.
NHS East Lancashire CCG says it has a block contract with its CAMHS provider and will be making a smaller 1.2% cut in 2014/15. A spokesperson says: ‘The 1.8% recommended by NHS England can be reduced to take account of additional cost pressures. The CCG has done this.’
NHS South Devon and Torbay CCG is in a similar position. A spokesperson says: ‘Both our CAMHS providers are part of block contracts that we hold with separate providers and as such, based on last year’s out turn, we have not applied any deflater.’
Even ministers have criticised the disproportionate cuts to mental health services, which goes against the Government’s stated aim to give mental health parity with physical health in the NHS.
Minister for care and support Norman Lamb says: ‘I believe the decision to cut the tariff for mental health and community providers more than for acute providers was flawed.’
He says NHS England and Monitor have made it clear that commissioners do have the flexibility to negotiate smaller cuts as the ‘tariff deflator’ is not a binding target, and that the Government would closely scrutinise the decisions made by CCGs.
We generalists have no option but to seek specialist help
Dr John Grenville
Dame Sally has called for general practice to take on greater management of young people’s mental health, with paediatrics and child health becoming a ‘core component’ of extended GP training.
The RCGP supports this approach and chair Dr Maureen Baker recently called for all GP trainees to spend time training alongside child health specialists and psychiatrists to improve their understanding of the specific mental health problems involved.
But with four-year training for general practice yet to get off the ground, GPs say they often have ‘no option’ but to seek specialist help.
Dr Grenville says: ‘We are now told there are an awful lot of children as young as four or five with clinical depression. As a GP, I do not have the skills to diagnose depression in a child as young as that. With the increasing number of diagnoses, such as ADHD and oppositional defiance disorder, we generalists have no option but to seek specialist help.’
He adds: ‘If a child presents with possible ADHD, it is certainly not good enough for the GP to say, “let’s try some atomoxetine or methylphenidate”. The patient should be getting a proper assessment.’