Future demand pressures on mental health services in England

The Health Foundation is an independent charity working to improve health and the quality of health care in the United Kingdom. The Health Foundation is requesting access to Mental Health Services data set (MHSDS) to analyse trends in mental health activity at a detailed level. In 2010/11 Mental Health was responsible for 10% of spending by the NHS (1). From then to 2014/15 there was an increase in average referrals to community mental health teams of 19 per cent, for crisis and home treatment teams the increase was 18 per cent(2).

There were 145 fewer psychiatrists across all grades (full time equivalent) in March 2017 than March 2010 (1.64% decrease). Over the same period there has been a decline in the number of mental health nurses of 5,161 (12.63%)(3).

In March 2015, research by Community Care and BBC News found that the funding for NHS trusts to provide mental health services had fallen by 8.25%, £600 million, in real terms over the course of the last parliament (from 2010/11 to 2014/15) (4). The data, based on 43 Freedom of Information (FOI) requests to 56 mental health trusts in England, showed that total funding for the trusts͛ mental health services fell in cash terms from £6.7 billion in 2010/11 to an expected £6.6 billion in 2014/15.

Figures from NHS Digital suggest that over a five-year period from 2008/09 to 2013/14 social care expenditure on adults with mental health needs aged between 18 and 64 reduced in cash terms from £1.2 billion to £1.1 billion(5).

This increase in referrals has been coupled with a reduction in real terms funding and staff for mental health services. The Health Foundation seek to analyse how this budgetary change has affected trends in activity. The project will inform policymakers and the NHS about the variability in quality and costs of mental health care in England, and thus help to identify priority areas for improving health. The aim of the project is to create an economic model of the person level factors that determine use of mental health services to i) estimate of how spending pressures on these services will grow in the future, and ii) estimate the potential impact of policies to reduce these pressures.

This work, as well as being its own piece of research on the determinants of mental health activity, will also feed into the current project (NIC-15411-C9Z9L): ͞The funding pressures facing health care in England for the next 15-20 years, and how service transformation can lead to greater sustainability. This is a wider projection model for healthcare activity and spending that is designed to inform public policy on healthcare finance and to improve the quality of health care in the United Kingdom.

The Health Foundation have been developing a model of projection for spending on health care. This has been used previously by the Nuffield trust in a decade of austerity, by the Health Foundation in Transformation Fund and in Wales on Path to Sustainability. Currently mental health activity is not modelled, with the assumption put in place that spending on mental health services holds its share of total spending.

Aggregate results from the MHSDS data used for this work will inform the design of this part of the projection model, as well as digging deeper into trends and activity levels in secondary mental health services. This will help to improve greatly the quality of the spending projections model, as well as enabling organisations to project the likely demand pressures on mental health services themselves. Note that no patient level data between the two projects will be shared or combined.

Finally, mental health services are suffering from restricting budgets and growing demand and it is clear that significant efficiency savings are being made. The Health Foundation would like to learn more about how these savings are being achieved, where they can be duplicated elsewhere in the healthcare service.

It is also possible that these savings are gained through reduced service or quality of mental health service, as recent increases in delayed discharges may indicate (6). If this is the case then the Health Foundation would like to learn about where these reductions are occurring. The quality and extent of mental health services will have clear knock on implications for use of the rest of the service and incorporate them into the wider projection model.

References

(1) Nuffield Trust, 2012. A decade of austerity? The funding pressures facing the NHS from 2010/11 to 2021/22. https://www.nuffieldtrust.org.uk/research/a-decade-of-austerity-the-funding-pressures-facing-the-nhs-from-2010-11-to-2021-22

(2) NHS Confederation, 2016. Key facts and trends in mental health 2016 update.

http://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/MHN-key-facts-and-trends-factsheet_Fs1356_3_WEB.pdf

(3) NHS Digital, 2017. NHS Workforce Statistics - March 2017, Provisional statistics. https://digital.nhs.uk/catalogue/PUB30003

(4) Community Care, 2015. Mental health trust funding down 8% from 2010 despite coalitions’ drive for parity of esteem. http://www.communitycare.co.uk/2015/03/20/mental-health-trust-funding-8-since-2010-despite-coalitions-drive-parity-esteem/

(5) NHS Digital, 2014. Personal Social Services: Expenditure and Unit Costs, England - 2013-14, Final release. https://digital.nhs.uk/catalogue/PUB16111

(6) Mind, 2017. Mind comments on delayed discharge in mental health trusts. https://www.mind.org.uk/news-campaigns/news/mind-comments-on-delayed-discharge-in-mental-health-trusts/#.Wmnvn65l-Ul

Data will be processed only by approved users within the Health Foundation’s secure environment. All analysts with access to the data will have completed an accreditation course on data protection legislation and statistical disclosure control, completed an information security training specific to the Health Foundation’s infrastructure, and signed a non-disclosure agreement and the terms of use of the secure environment. All analysts with access to the data are substantive employees of the Health Foundation.

MHSDS Data will only be processed on the Health Foundation’s premises and any publication derived from the data will be subjected to best practice guidelines on Statistical Disclosure Control (SDC) including the Code of Practice on Confidential Information, the Anonymisation Standard for Publishing Health and Social Care Data and the code of practice published by the ICO, Anonymisation: managing data protection risk code of practice before being released form the environment.

For this project, person level data for mental health services is required. The project aims to project cost pressures over the next 15-20 years; therefore, The Health Foundation need to track historic trends over a similar period for the whole population. The minimum data required within this project are Mental health (MHSDS) data for the latest two financial years (2016/17 and 2017/18).

Since this involves modelling the evolution of health care utilisation for people with various specific health conditions in the different government office regions, it will need comprehensive data coverage for these two years on community services (1.c), inpatients records (2.a) and service users (3).

The Health Foundation will explore whether mental health service use is affected by factors including age, sex, residence (government office regions), diagnosis and procedure codes, treatment function, admission method, the presence of other long-term conditions and time.

The primary models will be independent service-specific linear, or log-linear person-level models of the trends in the level of activity for mental health services. The results of the models will be used to create projections for future use at a national level, and by government office regions (or other similar sized areas as appropriate). The Health Foundation will therefore apply the results of the analysis of historic trends to publicly available population and mortality projections produced by the Office of National Statistics.

The Health Foundation will explore the trend over time for mental health patients from the latest two financial years of MHDMS. These will be done using a linear regression, with transformations applied where appropriate to ensure the best fit for each condition. By producing trends in this way, The Health Foundation are able to explore the trends for certain co-morbidities, instead of using single condition prevalence projections. However, The Health Foundation will compare their estimates to national data on prevalence of these conditions where possible for assurance.

The projections for costs on these services will be combined with projections for other NHS services, such as GP attendances and community pharmacies, produced using publicly available data. The combining of projection results in this way will primarily be done at a national level, and will not be done at a level lower than government office region. Therefore, there are no privacy or confidentiality concerns when combining the results.

Having established the models and projections, the results will be used to test the impact of a series of assumptions around future changes in NHS delivery. This will take the form of modelling assumptions on how service delivery might change at a national level. For example, The Health Foundation will test the potential impact on total NHS spending of a substantial investment in GP practices, which might be expected to lead to a reduction in mental health activity. Again, these results will only be published at a level no lower than government office regions.

The Health Foundation will also explore the impact of likely productivity growth on the projected growth. This will be based on evidence of recent and longer-term levels of productivity growth by running random effects, fixed effects and stochastic frontier analysis on weighted activity of different types of providers. As with other analysis, results will be used at a national or large regional level.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

There will be no data linkage undertaken with NHS digital data provided under this agreement.

Data provided under this agreement are also stored in a private secure data centre facility “UK Cloud” based in England. UK Cloud is ISO27001 and IG toolkit certified, and it is used by a number of UK Public Sector Organisations.

The Health Foundation is aware that they will not be able to estimate trends with only the latest two years of MHMDS data (2016/17 & 2017/18). Unfortunately, the only other financial year available (2015/16) from the MHMDS series is incomplete while the data series before 2015/16 is not compatible.

In order to address this limitation, it is proposed that the Health Foundation use aggregate public information from the Adult Psychiatric Morbidity Survey (APMS). This survey is carried out every 7 years and reports the treated prevalence of common mental disorders which has grown from 24.4% in 2007 to 39.4% in 2014. The APMS also gives a breakdown of data by age and sex, to which they can apply age and sex specific population estimates and projections.

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data).

For data from the Mental Health (MHSDS, MHLDDS, MHMDS) data sets, the following disclosure control rules must be applied:

• National-level figures only may be presented unrounded, without small number suppression

• Suppress all numbers between 0 and 5

• Round all other numbers to the nearest 5

• Percentages can be calculated based on unrounded values, but need to be rounded to the nearest integer in any outputs

• In addition for Learning Disability data in Mental Health (MHSDS, MHLDDS, MHMDS), the England-level data also must apply the suppression of all numbers between 0 and 5, and rounding of other numbers to the nearest 5.

The LIA was carried out by The Health Foundation using the ICO template and considered by NHS Digital. The Health Foundation concluded that they can rely on legitimate interests for this processing. A summary of the decision justification is provided below;

1. Purpose test: are you pursuing a legitimate interest? The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Their aim is a healthier population, supported by high quality health care that can be equitably accessed.

2. Necessity test: is the processing necessary for that purpose? Having access to pseudonymised patient records allows the Health Foundation to analyse the impact of new initiatives to drive learning and improvement. Given the complexity of the analyses, it is often not possible to rely on aggregate and/or less confidential data. An assessment is made for each use of data to ensure that no other means of aggregation can be used.

3. Balancing test: do the individual’s interests override the legitimate interest? The Health Foundation only process pseudonymised patient data (as anonymised with the ICO’s code of practice). There is no direct relationship and collection of information from the data subjects (e.g. patients).When possible, if the analysis involves potentially vulnerable groups the Heath Foundation seek the advice of external steering groups or advocacy patients groups to help us considering any further privacy implication and harm to data subjects. All data is held securely and all outputs are aggregated with small number suppressed.

***UPDATE 2018-11-30***

Following a phone call with DARS on 29th November 2018, The Health Foundation would like to request three additional packages to the data.

Package 1d (incorporating tables 202 'care activity', 603 'provisional diagnosis', 604 'primary diagnosis', 605 'secondary diagnosis'. These data are required in order to create estimates of spending on health care. Costs will be associated with different types of care and activity, which are associated with diagnoses. For each observation in the data, The Health Foundation will use the diagnosis codes and care activity to estimate costs, which will then enable them to project spending on health care in aggregate.

Package 4 (incorporating tables 801 'clustering tool assessment', 802 'coded scored assessment', 803 'care cluster'. As with the diagnosis information contained in package 1d, data from package 4 will allow The Health Foundation to associate costs with the assessments generated on a patient-level basis. The Health Foundation will use these data to more accurately predict costs and spending on health care.

Package 2c (incorporating table 804 'forensic pathways'). The Health Foundation require these data to enable them to work out the different treatment pathways that different patients travel. They will aggregate this data into a number of set pathways, and in turn, estimate the cost for the set pathways and create projections for spending on these pathways.

Outputs for all projects will be in line with best practice guidelines on statistical disclosure control and privacy protection.

The project will aim to investigate whether there are significant differences in mental health activity across regions in England. If the analysis does find differences by region, The Health Foundation will investigate the extent of these differences and present the findings in the final report. The study will also aim to find the key drivers of these differences in activity in order to explain why differences in mental health activity occur.

The analysis will project the expected funding pressures on mental health services. Based on this, The Health Foundation will comment on the future budget required to keep up with expected mental health activity under a variety of scenarios including:

- Expected changes in population using ONS population projections by age, sex and region

- Expected changes in NHS pay, under the recent pay deal and after accounting for drift, it is expected that NHS staff pay will increase at an average annual rate of 2% over the next 15 years. Pay accounts for around 65% of hospital operating costs, pay increases will increase spending pressures on the NHS and therefore a larger budget will be required to keep up with expected mental health activity assuming all other factors are held constant.

- Efficiency savings from increased productivity. Using data from the OBR economic fiscal outlook , it is expected that efficiency gains of an average of 0.8% over the next 5 years. Higher productivity will increase efficiency and reduce the spending pressures on the NHS and mental health.

The primary output of this project will be a Health Foundation report, similar in style to the report ‘The path to sustainability' available at http://www.health.org.uk/publication/path-sustainability. It will provide an update to the funding pressures that are expected over the next 15-20 years. Before publishing, The Health Foundation will approach contacts from budgeting and planning organisations such as NHS England for peer review. One benefit of this is to ensure the findings are consistent with the expectations of the NHS and involved bodies, and by involving them early in the reporting process The Health Foundation can raise awareness of the upcoming publication. The report will be targeted at a national audience, with a discussion around regional variation in mental health activity. This report will be made publicly available through the Health Foundation’s website by 2021.

The main report will be written with the interested public in mind. There will be an accompanying technical appendix designed for technical experts seeking to replicate the methods used in the model. The final report will be published and publicised by the Health Foundations dedicated communications team, who regularly generate a wide reach for The Health Foundation's work, Including media, stakeholders in the English and UK health system and the public.

Note that the Health Foundation meets regularly with representatives from the Department of Health, NHS England and NHS Improvement. The proposed work will inform ongoing conversations with these organisations and interim findings will be presented to their representatives in addition to the more formal outputs listed above.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide.

The Health Foundation has strong links with NHS teams, national policymakers (e.g., NHS England) and patient advocacy groups. The Health Foundation provide leadership and advice on quality improvement as well as commentary on health care policy. The analysis of MHSDS data will inform these activities. The Health Foundation assess the impact using objective measures (e.g., number of publication downloads, publication citations and attendances at events and seminars) as well as record specific instances where our work has informed decision making for the NHS and improved the quality of care ultimately delivered to patients.

Due to these strong links with the health service, the Health Foundation is well positioned to reach as many beneficiaries as possible for this project. The Health Foundation will engage with relevant national policy makers including the Department of Health, NHS England and NHS improvement during the design of the modelling, to ensure they are aware of the work, and create a level of early buy in. The results will be published with a launch event in late Autumn 2018 to ensure the Health Foundation properly explain them, and invite open discussion. Following the analysis, The Health Foundation will discuss the results of the scenarios of different models of delivery to further inform policy makers on the impact that different decisions would have. These will mostly be discussions of the national situation, with some regional analysis at a level similar to government office regions.

This work will also feed into the projection model (1) that has been used and quoted by NHS Confed (2), the IFS (3), King’s Fund (4), Nuffield Trust, OBR (5) and NHS England (specifically Simon Stevens).

It will predominantly shed light on the likely pressures facing mental health services, which will help commissioners and care providers to effectively allocate funding. Importantly this will help insure the right level of investment and, particularly, workforce are available to meet the needs of those with mental ill health over the next 15 years.

The Health Foundation will soon be publishing a report of how money moves throughout the NHS based on an analysis of the Department of Health accounts. Throughout this process The Health Foundation have been in contact with the team at NHS England behind the mental health dashboard. Their team has been helpful and engaged with the Health Foundation to ensure the analysis accurately reflects NHS mental health spending and activity data. The Health Foundation plan to present their findings from this analysis to the NHS mental health spending team for peer review. In the wake of the mental health five year forward view, it will help inform the national planning process for mental health.

The Health Foundation hope to work with the NHS England team again during the analysis and reporting stage of the current project. This will ensure consistency and raise awareness. The aim of the analysis is to explore regional variations in mental health activity as well as project expected mental health activity and associated cost. The analysis can be used to plan and allocate resources to those areas which are expected to need them most, both regionally and within mental health clusters.

In addition, the findings of this work will be shared with relevant patient groups via the Health Foundation comms team. For example, the Health Foundation regularly gets in touch with relevant patient groups through a plain English summary of the findings together with a copy of the original publication. The Health Foundation will invite patients to get in touch if they would like to further discuss the work. The Health Foundation would be happy to present their results to their regular meetings or to invite patient representatives to external events.

References

(1) https://www.health.org.uk/sites/health/files/FundingOverview_NHSFundingProjections.pdf

(2) http://www.nhsconfed.org/news/2018/01/nhs-confederation-teams-up-with-independent-experts-for-study-into-health-and-care-funding

(3) https://www.ifs.org.uk/uploads/publications/budgets/gb2017/gb2017ch5.pdf

(4) https://www.kingsfund.org.uk/publications/hospital-activity-funding-changes

(5) http://cdn.obr.uk/July_2017_Fiscal_risks.pdf

Not stated in the register.