By Andy Bell
This week the Government published its long-awaited new health care legislation, the Health and Care Bill. The 232-page bill makes some significant changes to the way the NHS is organised and how it plans health services. It abolishes clinical commissioning groups, which since 2013 have had responsibility for planning health services in local areas, replacing them with sub-regional integrated care systems. It places stronger duties on these new organisations and the NHS trusts that provide most of our hospital and community health services to collaborate, both with one another and with local councils providing social care services. And, perhaps most controversially, it gives sweeping new powers to the secretary of state for health to intervene in NHS decision-making, for example in relation to closing or reconfiguring hospitals.
The bill’s implications for mental health services are profound and important
There is very little in the bill specifically about mental health services. Reforms to the Mental Health Act will come in a separate bill following the recent consultation on the Government’s plans to reform that legislation in line with Sir Simon Wessely’s 2018 Independent Review.
Nonetheless, the bill’s implications for mental health services are profound and important. Like all health and care services in England, mental health services will continue to be provided mostly by NHS trusts in conjunction with local authority social care and public health services. But decisions about how much money is spent on mental health care, what services are funded and who provides them will be made by newly created integrated care boards, which will govern integrated care systems.
The idea of integrated care has many potential benefits for both the public’s mental health and for mental health services
There will be about 50 of these new bodies across the country, with a population of about a million each, and they will will take responsibility for all health services in their areas from next year. They already exist in ‘shadow’ form – as ‘joint committees’ of existing organisations prior to being set up formally under the bill now in Parliament. And in that form they are already being given responsibility for implementing many aspects of the NHS Long Term Plan, including the expansion of community mental health services.
The idea of integrated care has many potential benefits for both the public’s mental health and for mental health services. Too often, people experience mental health care as dis-integrated, especially from physical health care. Fragmented services are especially commonly cited as a concern for people of all ages with ‘complex’ needs that require support from more than one agency at a time. Bringing support together and encouraging collaboration rather than competition between public services may help to reduce some of the fragmentation and gaps people face.
There is nothing in the bill that ensures mental health will be given equal precedence with physical health in integrated care systems
But the proposed new system has risks as well as possible benefits. By moving decision-making from more local clinical commissioning groups to much larger integrated care systems, local communities will be further away from the centres of power in the health care system. At present, there is nothing in the bill that ensures mental health will be given equal precedence with physical health in integrated care systems – and without such assurances, history suggests it is at risk of being marginalised. Finally, while the bill makes clear that integrated care boards are required to tackle health inequalities, there is little suggestion of how they will be held to account for how far or how well they do this.
Further, the bill provides little reassurance that local government services such as public health (including drug and alcohol treatment) and social care will have equal standing with health services in the new arrangements. While integrated care boards will include local government representation, they are not required to align with local government boundaries, and with local government funding falling further and further behind NHS spending, the inequality between the two grows year by year. Yet improving the public’s mental health and delivering modern mental health care depend on a well-functioning and equal partnership between the NHS, local councils, communities and a range of other agencies.
We will be scrutinising the bill closely and making recommendations to Parliament for how it may need to change to support mental health and tackle inequality and injustice.
