Optimising adult mental health service configurations across health and social care

Introduction

Government policy for the care of working age adults with mental health problems has long been committed to the principle of community care. This is not to suggest that inpatient beds are not necessary. On the contrary, it is generally agreed that there will always be a significant minority of people who need hospital admission, with the intensive levels of assessment, monitoring and treatment this offers. Nevertheless, much still needs to change. Six-fold variations have been found in inpatient admission rates, while the development of specialist community care teams has delivered very good care in some areas, but fragmented, inefficient services in others. Indeed, it is commonly believed that if the ‘right’ services were available, significant gains could be made in quality of life and service efficiency.

Service planning is difficult in mental health care, however, as multiple organisations provide treatment and support for a heterogeneous population; outcomes are complex and difficult to measure; and little is known about the relative cost-effectiveness of institutional and non-institutional services. The allocation of resources has thus often been based on historical funding patterns and the piecemeal application of changing local and national priorities.

Objectives

The study addressed the broad question: can the needs of certain service users receiving inpatient and community mental health team services be met in alternative ways which maximise independence and safeguard service quality? In so doing it sought to identify the characteristics of these service users at care margins (for example age, diagnosis and living arrangements); the alternative services they would require; and their cost.

Methods

The study was conducted in partnership with a mental health Trust between June 2013 and December 2014 and employed a Balance of Care (BoC) approach. There were eight interlinked
activities:

1. A systematic literature review identified the utility of the approach to assist decision-makers plan mental health services for working age adults with mental health problems
2. Routinely collected health and social service data were used to benchmark local services against that in other areas
3. A profile of service users cared for by inpatient and community services was developed from service user records
4. The sample was categorised into subgroups on the basis of five characteristics deemed likely to be important in determining the setting and costs of their care: diagnosis, risk, psychotic symptoms, drug/alcohol problems and relationship difficulties
5. A series of anonymous case studies was formulated to represent the most prevalent subgroups
6. Separate groups of practitioners, service user representatives and carers identified those subgroups for whom alternative services would be preferable and specified the care they needed
7. The potential costs and consequences of the alternative options were explored using economic modelling
8. The likely impact of the suggested changes was identified through consultation with local interest groups.

Findings

• The Balance of Care approach has rarely been applied to the needs of working age adults with mental health problems; it appears to be useful for service commissioners and decision-makers
• Local staff identified ten subgroups of inpatients who could potentially be more appropriately supported in the community if enhanced community services were available
• Projected possible overall cost savings were considerable; the average community care plan costs less than half the cost of inpatient care
• Analysis suggested that while secondary mental health care costs would fall, social and general health costs would rise
• Joint-agency planning and integrated service provision are important to support more service users in the community.