Mental health: on our minds?

Parity of esteem in mental health is something we hear a lot about: it essentially means putting mental health on a par with physical health.

Underneath this, though, it feels to me that there isn’t a parity of attention when it comes to mental health – it doesn’t feel to be discussed or debated anywhere near as much as other topics.

This feeling is borne out by two excellent reports published on the topic of Joint Strategic Needs Assessments (JSNAs) and Joint Health & Wellbeing Strategies (JHSWs) by the Children & Young People’s Mental Health Coalition and the Centre for Mental Health respectively.

The Children & Young People’s Mental Health Coalition found two-thirds of JSNAs didn’t have a section specifically on children and young people’s mental health. They also found that risk factors were highlighted which put children and young people at greater likelihood of having mental health problems, but the links between these factors and mental health weren’t made.

The Centre for Mental Health found 91% of JHSWs aimed to tackle at least one mental health issue, or 9% didn’t mention mental health at all. They too found that the majority of JHSWs highlighted health risk factors (such as drinking or smoking) but didn’t make the relevant links between these factors and mental health.

More encouragingly, though, where mental health was a priority in JHSWs that priority tended to be children and young people’s mental health – somewhere between 55-67% of JHSWs made it a priority.

Nevertheless, we have a situation where around one-third of JHSWs make no reference to children and young people’s mental health, and 10% make no reference to mental health in general.

Is mental health on our minds? These figures would suggest it isn’t as much as it should be. We also need parity of attention on mental health.


Highlights from CQC’s State of Care Technical Annex and King’s Fund’s money-fest!

A Technical Annex (pdf) to go with CQC’s State of Care 2012/13 report, you say? How could I possibly resist?!

Below are some highlights from the annex looking specifically at the funding of adult social care. (These figures will be familiar to folks who pore over the HSCIC releases every quarter, but I take the view you can never get enough of info like this.)

Total and type of spend on adult social care:

  • Spend on adult social care has risen in cash terms – from £16.8bn in 2009/10 to £17.2bn in 2012/13, but there has been a real terms decline. Adults under 65 with a learning disability where the only major user group to see a real terms rise in expenditure from 2009/10 to 2011/12.
  • The following proportions were spent on the following client groups in 2011/12(figures include Supporting People monies, which was presumably found down the back of the sofa in the last year or so
  • 53% of spend was on older people
  • 31% on adults under 65 with learning disabilities
  • 9% on adults under 65 with physical/sensory impairments
  • 7% on adults under 65 with mental health problems

Direct Payments expenditure:

  • Expenditure on direct payments for adults increased in both cash and real terms. £360m was spend on Direct Payments in 2006/07 and reached £1.1bn in 2011/12
  • This is a real terms increase of 175% and is 6% of all gross adult social care spend.

Unit costs of different types of social care are fascinating. Really.

  • The average cost per adult supported in residential care, nursing care or intensively in their own home was £608 per person per week in 2011/12 – a 5% real terms cut
  • The average cost of providing day care for adults (including older people) was £213 per person per week
  • The cost of home care per person per week for all adults was £206.


  • This one surprised me: the overall proportion of people who indicated that they (or their family) ‘top up’ their care has increased from 38.1% in 2010/11 to 38.8% in 2012/13. This probably isn’t as much as I thought it would be.

To summarise, there’s less money in real terms, no matter what anyone else tells you.

For those folks who want extra geek points – and, frankly, who doesn’t? – it’s well worth reading CQC’s technical funding annex in conjunction with the King’s Fund’s submission (pdf) to the Health Select Committee’s Inquiry into public expenditure on health on social care. In social care, it notes:

The number of older people receiving publicly funded services has fallen by 26 per cent since 2009/10, with an equivalent reduction of 21 per cent among working age adults over the same period. Given the overriding imperative to provide care closer to home and reduce the need for residential care and hospital admissions, it is particularly worrying that the largest reduction has been in the use of community-based services such as home care (down 25 per cent) compared to nursing home care (down 4 per cent) and residential care (down 1.7 per cent).

Their numbers on the NHS are just as frightening.

So, to summarise again:

  • There’s less money in adult social care
  • There are less people getting adult social care
  • The number of people getting fewer services is rising quicker than the rate at which money is being taken out of the social care system
  • Money is being cut from services which cost less and people prefer quicker than it is being cut from services which cost more and people prefer less
  • The NHS is fairly buggered, or at least faces the biggest financial challenge it has ever faced.

What could possibly go wrong?

Demos’s report on pre-payment cards

I’ve just had a quick read of Demos’s report published today on pre-payment cards.

Recall that pre-payment cards (also called prepaid cards) are like debit cards, where funds are loaded into an account linked to the card and then spent by the card holder until the balance reaches zero. They can be used to make purchases, set up direct debits or standing orders, and sometimes withdraw cash at ATMs.

There has been an increased usage of pre-payment cards by local authorities, especially in the area of administering Direct Payments in social care, and the Demos report makes recommendations about them being considered for wider use, for example in benefits administration and other forms of public payments.

The topic of pre-payment cards is an emotive one, since it symbolises the concept of the state potentially or actually prescribing what Direct Payments or benefits can be spent on. This is fascinating in itself because, as the report highlights, pre-payment cards are essentially a question of the “nitty-gritty of implementation”.

Of course, I have views on pre-payment cards and whether they should be used. This comes from being pretty heavily involved in two areas of work – Direct Payments implementation and making the Right to Control a reality – and especially from the perspective of service users. I’m painfully familiar with the both the advantages and disadvantages that can arise in making payments to people or trying to integrate several types of payment. As I told the judge, I now know more about the appearances of money laundering than I probably should do.

For those interested in the issues, the Guardian has an article by Ally Fogg which covers a lot of the debate.

The wider point to make, though, is that Demos should be congratulated for at least bringing the topic out into the open. Pre-payments cards are a growing phenomenon and there is a need for an open debate on their merits and demerits, rather than their use growing in the absence of a debate.

It would be great if a space could be created in which this debate can take place that brings together users, public bodies, government and those providing pre-payment cards.

Big beasts versus social enterprises in health

The King’s Fund had a very interesting report out last week: Social Enterprise in Health Care.

Focusing on the health sector, the report explores the reasons why some social enterprises became social enterprises in the first place, and whether what they were hoping to achieve has happened in practice.

I think this is of interest because Disabled People’s User-Led Organisations operate in the same “space” as social enterprises.

Beyond the specifics of the challenges facing establishing social enterprises, there is a wider context. As the report’s author, Rachel Addicott, highlights in her summary post on the report, there is something of a paradox at the heart of the health reforms when it comes to social enterprises.

On the one hand, there is a desire for the NHS to become the largest social enterprise sector in the world.

On the other, there is the “any qualified provider” drive towards greater competition. Thus:

The question is whether these emergent organisations can really compete with the likes of private companies and large voluntary sector providers.

Of course, the issues that face emerging social enterprises are similar to those that face smaller voluntary sector providers, including disabled people’s user-led organisations – a virtually unheard of provider in the health sector.

But even here there is something of a hierarchy. As Addicott notes:

Many social enterprises have emerged from primary care trust (PCT) provider arms – some taking the entire provider service with them, and others breaking away into smaller enterprises that deliver distinct types of care.

As such, even these spin-out social enterprises have a head-start over smaller voluntary sector organisations, since they’ll have the contacts and the familiarity with health commissioning – issues of process – to compete when bidding for contracts – an issue of content.

The King’s Fund rightly, in my view, calls for creating conditions in which social enterprises can grow and flourish, and so contribute to a

future market containing a plurality of differently-sized, locally-based social enterprises growing and competing.

Creating such conditions would also have a beneficial impact on DPULOs, too.

The King’s Fund suggests that such conditions can be crated through both political commitment to a practical support programme and a commissioning strategy to nurture the development of the social enterprise model.

Such practical support was made available under the previous Right to Request programme (on which more here), and covered areas such as HR, finance, governance structures. It also made mentors widely available for other organisations – mentors being organisations already successfully operating as social enterprises and providers in the health sector.

Having something similar to the support programme for the Right to Request for emerging social enterprises in the current health reforms would be of great use. Making this support available for smaller voluntary sector providers as well would be a generous, and beneficial, extension of the support.