Monday, 27 October 2014

Waiting for mental health care: what does the public think?

Waiting for mental health care: what does the public think? Nick Clegg used his party conference speech earlier this month to highlight ‘the second class status given to mental health in the NHS’. On the same day, the government and NHS England announced new waiting times standards as part of the drive to put mental health care on an equal footing with the rest of the system. This is the first time mental health providers have been subject to explicit expectations around waiting times – something they may find is a mixed blessing.


Access to care is a longstanding problem in mental health, and the emphasis that is being placed on improving this is certainly welcome. Recently, for example, the work of the ‘We need to talk’ coalition has highlighted both the extent of geographical variation in waiting times for psychological therapy and the very real impact that this has on people’s lives.

It’s useful to know what the public think of the issue of waiting for mental health care. As part of the 2013 British Social Attitudes Survey, a nationally representative sample of more than a thousand people were asked how long they thought it would be reasonable to wait for treatment of depression after being referred by a GP.

The answers to this question are revealing and suggest that public expectations exceed current policy ambitions. 69 per cent answered that they would expect to be seen within two weeks, and 93 per cent thought a maximum wait of 30 days would be reasonable – considerably shorter than the 6 and 18 week standards being introduced for psychological therapies. Comparing this to other conditions, most people were prepared to accept a slightly longer wait for a referral for a ‘serious back problem that was stopping you from doing the things you normally do’, and longer still for a hip operation (see figure 1).
Figure 1: How long is it reasonable to have to wait?



How long is it reasonable to have to wait? BSA data



Source: 2013 British Social Attitudes Survey data

These results illustrate the value we place on our mental wellbeing and show that the public does care about waiting times in mental health. The question is whether waiting times standards will be effective in tackling the problem.

The new standards do not apply universally across the mental health system, but focus on waits for two specific types of service:
psychological therapies provided through the ‘Improved Access to Psychological Therapies’ (IAPT) programme – a primary care service aimed mainly at people with depression or anxiety disorders
early intervention in psychosis services for people aged 16-35 experiencing their first episode of psychosis (such as schizophrenia).

As a place to start, this focus makes sense. These two services represent areas where the evidence is strong, and where there has already been a focus on improving access. However, we need to know much more about waiting times in the rest of the system before going further. Poor-quality data is the rock on which efforts to improve mental health care often run aground. The fact is that we do not currently know enough about how long people are waiting for different forms of care, and where the biggest bottlenecks in the system are. Are there still greater access issues elsewhere, for example, in community mental health teams, or in the form of delays between first assessment and treatment? And does the selective focus on waits in two parts of the system risk skewing priorities and letting waits rise elsewhere?

The introduction of waiting times targets for hospital care in the rest of the NHS was the culmination of an enormous amount of analysis, which involved strengthening data systems, mapping patient pathways, establishing a detailed set of measurement rules, and identifying where along the patient journey the longest and most problematic waits were taking place. The same will be needed in mental health if the ambition is to introduce more comprehensive standards in future.

For mental health providers, the new standards are significant in that they introduce a form of accountability that is now common practice in the rest of the NHS, but which has not previously been applied to mental health. This is an important step on the way towards having comparable accountability mechanisms across mental and physical health.

The history of the ‘war on waiting’ in the NHS shows that impressive achievements can be made with sustained effort, but also that targets can have unintended effects and can drive perverse behaviours among those being measured. As standards are introduced in mental health, it will be important to keep their effects under review to understand what impact they are having, and whether they are achieving what we desperately need them to. The King's Fund

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