NHS long term plan consultation: NSUN’s response and template for members

In what ways, if any, do you think that delivering more care in the community could improve health and care?

More care in the community could help ensure that people are able to access care closer to home, and in terms of mental health care, less coercive and restrictive care than currently is provided in mental health hospitals. However, in order for more care to be delivered in the community, the decimation of the existing community mental health care must be addressed.

VCSE groups are losing NHS contracts and funding to provide services in the community, and simultaneously more grassroots by-and-for community groups that may not be recognised in the VCSE sector are excluded from trusts and foundations funding opportunities. These non-NHS groups and charities are vital to resource in tandem with NHS initiatives as they often offer care that the NHS cannot or will not provide (such as genuine and authentic peer support, but also other forms of support such as material, practical, and financial) – they provide care that is specific to community needs, is culturally competent, and takes a holistic, whole-person approach to mental health and wellbeing that seeks to alleviate the social conditions that drive distress.

Other forms of community care for people living with mental ill-health, distress and trauma must also be restored and resourced. For example, lots of people are prematurely offrolled from Community Mental Health Teams, and the Care Planning Approach is being abolished, removing peoples’ access to a care coordinator and care plan to help draw together complicated contact with numerous services or agencies into a single point of contact.

What, if anything, concerns you about the idea of delivering more care in the community in the future?

It concerns me that existing regional and local disparities – the ‘postcode lottery’ – around accessibility and quality of community care will continue to go unaddressed, or be worsened. There would need to be a commitment to a fair distribution of the funding and resourcing of place-based care initiatives that recognises that not everyone lives in, or has easy access to, cities and major towns. Easier access to care that is closer to home must be available to everyone, not just some people.

Another concern is that a focus on providing care in the community may de-prioritise the changes that need to be made to mental health hospitals. In recent years, there has been increasing evidence of poor care, such as abuse and neglect, within mental health settings. This is present in both statutory and private contexts. 

Some of these issues relate to issues of resourcing, notably understaffing and long waiting lists, which mean that many people often cannot get the care they need in the first place or are waiting many months for care, and some relate to a lack of training among mental health staff. However, improvements to mental healthcare must tackle the stigma and dangerous attitudes that exist within healthcare settings towards those living with mental ill-health, distress, and trauma, so that the “care” people wait so long to access does not cause more trauma and harm. 

Cultures of abuse, neglect and exclusion in mental health hospitals and the mental health system more broadly, where people are coerced and stripped of dignity, choice and agency, must be acknowledged and reckoned with as part of the 10-year Health Plan.

In what ways, if any, do you think that technology could be used to improve health and care?

In terms of mental health care, technological improvements such as better computer systems to improve efficient communication between multiple different services could help improve the coordination of care. Some people may benefit from patient notes being more easily accessible to different health professionals, so that they do not have to repeat e.g. past experiences of trauma and the diagnoses they have been given in each appointment with a new professional. The option of video appointments instead of face to face appointments could help improve the choice available to those who may struggle to attend in-person appointments due to accessibility barriers or experiencing anxiety around being in medical establishments. 

What, if anything, concerns you about the idea of increased use of technology in the future?

One concern is that an increased reliance on technology would exacerbate digital exclusion, restricting access to care for those who might struggle with technology, such as elderly people, people who have not had the chance to develop digital literacy skills, or Disabled people.

Another concern is about the ethics of the data-sharing that will occur through the increased use of technology and ‘improvement’ of computer systems, such as the sharing of mental health notes between healthcare practitioners working in different parts of the NHS (as well as potentially with external/third parties such as the DWP or the Home Office). There would need to be respect for patient consent regarding the sharing of information contained within peoples’ mental health notes. Mental health notes can contain biassed and stigmatising opinions that describe patients as being ‘difficult’ or ‘disengaged’, which can negatively affect the care they go on to receive. The sharing of such subjective notes obscure the fact that the reactions of patients often reflect problems with the care being offered, as well as structural problems like chronic underfunding and staff shortages.

I am also concerned about the increase in the rapid and large-scale rollout of technological solutions (often private, for-profit “innovations”) that promise to save time and money, but that may compromise peoples’ privacy and dignity, as well as exacerbating distress relating to surveillance. One example of this is Oxehealth’s Oxevision surveillance system, which uses infrared cameras to film and remotely monitor the pulse and breathing rate of inpatients, which is used across multiple NHS Trusts in England. The Stop Oxevision campaign raised concerns about the use of video-based patient monitoring systems as a blanket restrictive practice without regard for individual risk assessments or adequate consent policies in place. As a result of the campaign, NHS England wrote to all Trusts asking them to ensure that their use of Oxevision is lawful, but it is imperative that more is done to ensure the proper regulation of new technology used in mental health settings, and that the rolling out of such technology does not come at the expense of patient consent, dignity or the proper staffing of health care facilities.

Overall, I am concerned that an increased reliance on technology in mental health care may disrupt or replace personalised, compassionate and human mental health care that prioritises the development of therapeutic relationships.

In what ways, if any, could an increased focus on prevention help people stay healthy and independent for longer?

An increased focus on prevention in terms of mental health could help reduce the numbers of people experiencing mental ill-health, distress or trauma, but only if it acknowledges that the causes of mental-ill health are often social, material, and political. Efforts to ‘prevent’ mental ill-health must include a mental health focus in governmental policy-making, and this should be addressed in the long-term health plan. Some of the enablers to tackling the causes or exacerbating factors of mental ill-health include reforming the hostile and punitive social security system (including but not limited to rolling back on cuts to social security support, such as scrapping reforms to Work Capability Assessments and protecting Personal Independence Payments), recognising and challenging the impact of austerity and the Cost of Living Crisis (including improving housing security), improving education and employment conditions, and taking a clear stance on inequalities and injustice, including (but not limited to) tackling transphobia, xenophobia, classism, racism, ableism, as well as ‘hostile environment’ policies and practices that operate both within healthcare and more broadly in society.

What, if anything, concerns you about the idea of an increased focus on prevention in the future?

It concerns me that a focus on prevention of mental ill-health, distress, and trauma – which is often harmfully framed as a measure to decrease economic inactivity and/or the ‘social security bill’ – may risk abandoning those people who are already living with mental ill-health, distress, and trauma, and may experience these issues as chronic conditions where ‘recovery’ is not possible. Care must be longer-term, and people should not be viewed as a ‘drain’ on resources, or labelled too ‘complex’ for some services or ‘too ill’ for some and ‘not ill enough’ for others. 

A focus on prevention may also risk de-prioritising much-needed reform to the Mental Health Act, which is employed when people are well past the point of ‘prevention’. The latest update on the modernisation of the Mental Health Act confirmed that a Mental Health Bill will be introduced in phases, over a number of years. While the planned reforms present a step in the right direction, they do not go far enough in taking a rights-based approach to change, backed by significant funding. Efforts fail to address the scale of institutional and structural racism in the mental health system and use of the MHA, and the lack of community support and choice in what care looks like both for people experiencing crisis and for those living with long-term distress. There needs to be an urgent solidification and strengthening of reforms to the MHA in tandem with the development of the 10-year Health Plan.