Written evidence submitted by Dr John Mulligan (Clinical Psychologist/Unite Rip & National Applied Psychologists Organising Professional Committee member at Unite the Union, Unison & the Manchester Safer Staffing Strikers & Early Intervention in Psychosis Service); Miss Gemma Feeney (Peer Mental & Lived Experience Trainer at Manchester Safer Staffing Strikers & Early Intervention in Psychosis Service); Miss Claire Miller (Care Coordinator/Social Worker/Unison Assistant Branch Secretary at Unison, Manchester Safer Staffing Strikers & Early Intervention in Psychosis Service) (CMH0229)

 

Health Select Committee submission

 

Introduction

We submit this report on behalf of the Unison and Unite members of the Manchester Early Intervention in Psychosis Service (EIP).

 

We have developed this submission in collaboration with or support from allies within Community Works (Manchester based support group for people with lived experience), Retired Members of Unison and the national Unite Applied Psychologists Organising Professional Committee. 

 

Our secondary care EIP service has been engaged in industrial action for the past five months in an effort to draw attention to the very challenges and opportunities within secondary care services that the Health Select Committee are now investigating.

 

Keen for cross party solutions, we also submitted a petition prior to the HSC’s call for evidence, in the hope of securing a debate in parliament on the matters now under investigation.

 

https://petition.parliament.uk/petitions/702031

 

Since 2016, EIP secondary care services have been ‘piloting’ many of the improvements that the Community Mental Health Framework and related ‘Community Transformation’ documentation outline. For example, we have a two-week Referral to Treatment target, lower staff to patient ratios to facilitate fast access to bio-psycho-social interventions, consistent use of outcome measures, annual physical health checks and 70% success rates in getting patients into employment using Individual Placement and Support (IPS) staff embedded in Multi-Disciplinary Teams (MDT). We are extensively audited both by ourselves and via the annual National Clinical Audit of Psychosis (NCAP).

 

There is strong local and international evidence demonstrating EIP increase recovery and reduce suicide, hospital bed days and long-term use of secondary care and crisis services. We share many similarities and problems that the ‘Living Well services’ either currently or will soon experience. EIP were once considered the ‘community embedded, public health innovators’ that now seems to be the purview of or hope for the Voluntary, Community, Social Enterprises (VCSEs) sector. Finally, despite chronic under-funding, for years, our EIP team has the lowest staff turnover and sickness rates in our NHS Trust. 

 

We thank you for your efforts to investigate this crucial and neglected part of our NHS.

 

Resulting from our current industrial action, we have also had contact with staff and services users from across the country who expressed support regarding our objectives and shared their stories about the difficult state of secondary care services within their localities. 

 

We also thank those individuals for their support and for sharing their own challenges. 

 

It is rare for secondary care mental health staff to forgo much needed wages and strike in the cold winter months, for the sole purpose of improving secondary care community mental health services. 

 

We spent the last four years before this industrial action, trying to innovate and make the best possible use of the limited resources and staffing at our disposal. We also completed a large number of audits and used that data to highlight concerns, opportunities and advocate for more staff. Our strike action has involved us speaking with and visiting groups and individuals around the country, so whilst Manchester secondary care services are amongst the most problematic, we do not believe we are distant outliers with regards to our local difficulties. 

 

We have extensive experience of the challenges we face as a country and would like to share our perspectives and discuss possible solutions in more detail.  We ask that the committee consider giving us an opportunity to provide a more detailed oral contribution in addition to this written submission.

 

Below are some links to local news coverage of our strike action for information. Those interviewed are all supporters who have contributed in some way to this submission.

 

https://www.bbc.com/news/articles/cvgd833mpw0o

 

https://www.itv.com/news/granada/2024-11-15/the-public-should-be-alarmed-psychologist-slams-mental-health-provision

 

https://www.itv.com/news/granada/2024-11-15/patients-feel-abandoned-by-broken-greater-manchester-mental-health-care

 

https://www.bbc.co.uk/news/articles/cwyxjmmr3njo

 

This report has been completed by:

Dr John Mulligan 

(Clinical Psychologist/Unite Representative & Unite Applied Psychologists National Organising Professional Committee Member),

 

 

 

Gemma Feeney 

(Employed NHS Peer Mentor and Trainer with 20 years of lived experience using community and inpatient services) &

Claire Miller 

(Care Coordinator, Social Worker & Unison Assistant Branch Secretary).

 

N.B. Many terms used to refer to people who use mental health services are problematic for various reasons. Both ‘Serious Mental Illness’ and ‘severe and enduring mental health difficulties’ are terms that sit amongst such terminology. 

 

Although never used in day-to-day practice, our group has regularly referenced ‘patients with severe and enduring’ in recent publications. National efforts to assimilate secondary care services into the primary care system and prioritise shorter term interventions and those with mild to moderate mental health difficulties, is, we believe, neglecting the majority of secondary care service users/patients.

 

Many such patients, who even with the most effective evidence-based interventions that are immersed in an optimistic, recovery focused approach, will require long term intensive support. So, when we reference ‘patients’ or ‘service users’ in the enclosed document, please assume we are talking about people involved with secondary care service who experience more ‘severe and enduring’ mental health problems.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Select Committee Submission

 

 

What Does High-Quality Care Look Like for Adults and their Families/Carers?

High-quality care involves swift access to compassionate, evidence-based interventions, facilitated by knowledgeable and professional, well-supported staff within a collaborative, adequately staffed multi-disciplinary team (MDT). 

 

With most having experienced abuse or trauma, usually resulting from the actions or inaction of others, secondary care patients need consistency. They need dedicated, capable, and compassionate staff to build and sustain positive working relationships. 

 

A consistent, compassionate, and competent Care Coordinator should have a manageable weekly schedule that allows sufficient time for each patient and family. While relationship-building is crucial, it must be accompanied by evidence-based interventions, particularly during the early ‘critical period’ when people first become unwell.

 

Beyond Care Coordinator-facilitated psycho-social interventions for anxiety, low mood, auditory hallucinations, paranoia, substance misuse, risk, trauma, etc. patients and families will want swift access to well supported Peer Mentors, Support Workers, Occupational Therapists, Housing, Welfare and Employment staff, Psychologists, Family Therapists, Psychiatrists, Pharmacists, etc. Families also want staff supported by good managers and enough administration staff to answer phone calls and ensure clinical staff have as much time for home visits as possible.

 

Care Coordinator caseload size is a benchmark for how comfortable or overstretched MDTs are. Despite NICE guidelines recommending a maximum of 12-15 patients per Care Coordinator within secondary care Early Intervention in Psychosis Services (EIP), we have spent years supporting 20-25 patients per Care Coordinator.  Community Mental Health Team (CMHT) colleagues have for many years struggled with caseload sizes of between 30-50 plus.

 

Families should never need to know or notice all the additional pressures staff are under. They should not suffer due to the time-consuming burden of important paperwork (care plans, clinical notes, benefits forms, tribunal reports, housing applications, care act assessments, safeguarding referrals, outcome measures, care package funding requests, referral and discharge documentation, etc.) or attendance at important meetings (team risk and referrals meetings, police liaison or MAPPA meetings, ward rounds, professionals or safeguarding meetings, funding panel attendance, clinical supervision, mandatory training, etc.).

 

Families and patients want an accessible, proactive Care Coordinator who can see them daily in a crisis and weekly thereafter. When time is limited, care can become overly focused on medication and ‘doing for’ rather than ‘doing with’, undermining patient autonomy. Patients and families deserve the benefits of involvement with services without the iatrogenic harm that involvement with services causes all too often these days.

 

Unfortunately, chronic understaffing in secondary care means that monthly contact is often the reality or even the ambition in many services.  Patients need consistency and security in their relationships with staff, yet NHS vacancies (12%), annual staff resignations (11%), and a £10 billion reliance on agency and temporary staffing each year, exacerbate the crisis. Ineffective and unsafe ratios of staff to patients facilitates distress, inconsistency and fragmented service provision, leading to a cycle of responding in crisis and withdrawing once risk reduces. Families want care that is preventative, not just reactive.

 

How could the service user journey be improved?

To enhance the patient journey, we need sufficient staff to help individuals map out their unique recovery path and ensure support is available at every necessary step of the way. Every ‘journey’ requires enough ‘boots on the ground’—every initiative, reform, procurement decision or Health Select Committee investigation should repeatedly ask: “What is the ratio of frontline staff to patients?"

 

Most recovery-focused work is people-intensive. We must ask: how many patients are there, and how many staff are available right now to meet demand? Not counting maternity leave, frozen vacancies, or reallocated posts—just a simple, accurate ratio of how many staff are working today and how many patients require a service.  The answer may be inconvenient and initially expensive, but the calculation is straightforward. 

 

There are now approximately 1.9 million people getting in contact with secondary care services yearly and a Long-Term Plan target to ensure 370,000 extra people access our services annually. Leaving aside the 613,000 patients already in receipt of varying levels of support within secondary care services, how many more front-line staff are required to support 1.9 million contacts and 370,000 new patients each year? In secondary care, ‘the patient journey’ is often a very long, slow moving queue.

 

If the Care Coordinator role is to be disbanded as indicated in related documentation, how many unqualified, lower paid and transient staff will be required to take over ‘case management’ responsibilities?

 

Chronic resource challenges over decades mean that there is a large amount of unmet need within our communities. New Living Well services might divert many patients away from needing secondary care. Contrary to the dominant narrative amongst funders, Living Well will identify and refer many more new patients into secondary care services. How many additional staff will be needed to effectively support those patients? 

 

The community transformation has redirected limited community funding into primary care/Living Well and away from secondary care and patients with more severe difficulties. Many GPs increasingly feel obligated to refuse shared care protocols. They are unwilling or unable to take on prescribing responsibilities for mental health patients due to safety and resourcing concerns. Are resourcing solutions being considered for such challenges?

 

Peer mentor staff have been referenced regularly by ‘community transformation’ advocates, yet the majority of Peer Mentors are currently in voluntary roles within the NHS. How many more paid ‘expert by experience’ roles are needed and is there an intention to transition from predominantly voluntary to predominantly paid roles? If Peer Mentors assume ‘case manager’ responsibilities, will they remain amongst our most poorly paid or unpaid staff within the NHS?

 

If psychologists are compelled to ‘case manage’ patients engaged in or waiting on therapy, alongside their existing role, what impact will this have on the number of people who access therapy each year (one therapist will at best see a maximum of 30 patients for 6-9 month of therapy per year)?  ‘Community transformation’ plans boast about increasing access to five different psychological therapies. Given the shortage of senior Psychologists to clinically supervise people in these five therapeutic modalities, how many of our 613,000 patients can realistically receive a course of therapy beyond the less than 1% who access it currently?

 

What is the required ratio of psychologists to patients? Currently in parts of the country, the ratio of patients to psychologists is over 1,000 to 1. Will ‘access to therapy’ targets mean psychologists focus solely on therapy and reduce or end their contribution to MDT efforts (e.g. training and supervision, risk formulating, informing care and risk planning and management, etc.)?

 

With 120 people with severe mental health difficulties dying daily from preventable conditions and a 15–20-year life expectancy gap, how many staff are needed to conduct annual health checks? NHS England say, ‘don’t just screen, intervene. Will Care Coordinator caseloads be sufficiently reduced to allow for life-saving interventions? Will brief health advice as our physical health staff rush around completing bloods and measuring weights be the limit of our ambition for physical health interventions amongst our patients?

 

Measured/monitored locally and nationally?

 

Targets: A Double-Edged Sword

Norman Lamb and national targets saved EIP services at a time when Trusts were considering ‘reintegration’ into CMHTs. Targets are essential, but where staffing and funding shortages continue to be an issue, some targets are prioritised to the detriment of patients and services.

 

The risk of falsely inflating the perceived ‘good health’ of a service increases as targets are met but standards elsewhere deteriorate. Targets create ‘winners’ and ‘losers. One example of this is the drive to ensure that funding for Voluntary, Community and Social Enterprises (VCSEs) and private healthcare companies are prioritised over ‘core’ NHS services. Another is the prioritisation of Primary Care or ‘Living Well’ patients and ‘back to work’ interventions over severely unwell patients who will not benefit from such short interventions and the loss of the professional Care Coordinator role.

 

Some observations from our EIP targets since 2016:

The two-week Referral to Treatment Target (RTT): We used two Care Coordinator posts to create ‘assessment practitioners. Positively, more patients are seen within two weeks. Less positive is that converting two Care Coordinator into assessor posts meant 40-50 patients were re-distributed amongst the remaining Care Coordinators, resulting in significantly longer delays for appointments and crisis support over early, preventative interventions.

 

Physical Health Intervention and Treatment: We currently have a 70% success rate on our annual PHIT target according to national audit statistics. The reality is that many of our patients are putting on 2.7 stone/17kg in weight in one year. Our physical health staff covering 550 patients do not have time to ‘intervene’ as well as ‘screen’. Despite their outstanding efforts, this 70% success rate masks the fact that 1,678 NICE recommended PHIT appointments per year are not taking place (e.g. new arrivals and those on antipsychotics should have more frequent PHIT appointments). 97% of our mostly young population are on antipsychotic medication. Without enough staff, we remain dominated by a medical model of ‘mental Illness' that leaves limited time or peoplepower for the life extending and enhancing physical and mental health interventions that are desperately needed.

 

Cognitive Behavioral Therapy (CBT) and Family Therapy (FT): Ambition and innovation can be constrained, as Trusts focus more on achieving targets rather than quantifying and satisfying actual need within our communities. For example, ensuring 36% of our patients receive CBT and 25% of families receive FT will achieve ‘top performing’ within EIP NCAP targets.

 

How targets are measured is also important. Engaging in an initial assessment with EIP assessors is not patients meeting their Care Coordinator and starting interventions, yet contrary to NICE guidelines, NHS England count the initial assessment as the RTT ‘clock stop’. Recording when the assessment takes place instead of when the Care Coordinator starts evidence-based intervention work with the patient are two very different things. NHS England have permitted EIP services to divert from the NICE guideline ‘in the small print’ to such a degree that most EIP services appear to be achieving the two-week target when they are not.

 

Also, NHS England support the idea that if a patient has two sessions of CBT or FI, they are recorded within the national audit as having had a course of CBT or FT. Again, the severe shortage of applied psychologists and Care Coordinators can be concealed by what targets are selected and how they are measured.

 

Suggestions:

Target ‘ratio of staff to patients. Work out how many staff we need to provide a good service and invite Trusts, VCSEs and private healthcare companies to regularly report on related targets.

 

Target number staff to patient face-to-face contacts per year. Meaningful work takes place when people meet. A target related to the number and quality of clinical interventions that take place is important.

 

Target retention, turnover and sickness.

We need to turn secondary care services into places that staff want to work in.

 

Target what matters in physical health.  We have significant problems with nutrition, metabolic, cardiovascular, respiratory illnesses, etc. We've known about all these for decades and only now are we considering measuring this within secondary care.

 

PHITs provide results for blood glucose/HbA1c, Cholesterol, weight and waist circumference, blood pressure, etc. so why not target the interventions rather than just the measuring? Why not target the number of people transitioning from healthy to prediabetic to diabetic each year? Target ‘intervene’ related results as well as the numbers we ‘screen’.

 

We know that antipsychotic medication cause or contribute to many short and long-term physical health difficulties. The only current targets for antipsychotics involves repeatedly trying alternatives until the patient is prescribed clozapine. What about targets for responsible prescribing, judicious use of medications and supportive withdrawal from such medications before discharge from services where possible?

 

Dialog plus: The new dialog plus will help us understand the patient perspective on service provision as well as their recovery. Targeting the content scores and not just dialog plus completion could be beneficial. This measure will aid goal setting, so it will be useful. Avoid adding in other measures. Staff often discuss their suffering on the front line as ‘death by a thousand cuts’. One more small task could be the final straw for one of the 11% of staff resigning each year.

 

Other targets:  Use of hospital bed days and crisis services, waiting times for mental health act assessment and subsequent admission, numbers of patients on antipsychotic medication or on medication prescribed outside of recommended guidelines, outcome on discharge (e.g. numbers discharged back to GP or onwards to other services). Also, although complicated, shared targets with councils would be worth considering (e.g. to address patient homelessness, hunger, employment, etc.).

 

What is the current state of access for adults with severe mental illness?

Secondary services have been in crisis for decades. We need more staff, likely numbering in the tens of thousands. Successive governments, NHS England and senior Trust executives have avoided coordinating and then funding an accurate staffing capacity and demand assessment. There has never been enough staff and despite many positive words and costly reorganisations, we still avoid the difficult reality of this staffing crisis.

 

Positively however, a large investment of several billion more in mental health staffing will save the NHS budget and economy a significant portion of £153 billion yearly cost of mental health difficulties. Consider that for every additional Care Coordinator funded within our EIP service, we save 197 hospital bed days per year (that's £85,000 in NHS cost or up to £250,000 for private beds). Or consider a situation where Care Coordinators were doing intensive preventative work with 12 patients instead of primarily crisis interventions with 25. Aside from the benefit to individuals and putting a stop to the revolving door short-sightedness of early and inappropriate discharges from hospitals, think about the vast reduction in the £1.45 billion emergency inpatient costs or the £14 billion we spend annually on type two diabetes?

 

Has the Community Mental Health Framework been an effective tool?

Within the Community Transformation related documentation are instructions for local commissioners to spend between 25% and “the vast majority” of our limited NHS community mental health budget on VCSEs and private healthcare companies. Redirecting half of figures like ‘£2.3 billion per year by 2023/2024’ to VCSEs and private companies, acknowledged by NHS England as being currently ‘at an early developmental stage', is concerning.  With the new Procurement act increasing the ability of commissioners to award more contracts without competitive tendering, the prospects for patients with the most complex difficulties and services like ours are not good.

 

Operationalisation of the Community Mental Health Framework and Community Transformation has done nothing for patients with more ‘severe and enduring’ mental health problems. Worse, the syphoning of limited funding away from people who cannot benefit from shorter term or employment interventions has disadvantaged and possibly discriminated against our patients.

 

Expectation has turned to hope for many CMHTs regarding their ability to start seeing patients within a month of a referral arriving. Hope that each patient will have an annual PHIT to update us on how unwell many are. Hope that we will somehow support patients to access five different types of therapy and hope that an enhanced primary care and Living Well offer will reduce the numbers of secondary care patients competing for resources.

 

A lot of hope balanced against the certainty around plans to remove the professional Care Coordinator role and replace that with an unqualified, lower paid and transient workforce.

 

Rather than investing in our greatest strength, which is MDT working, hubs are being created in what appears to be a ‘make do and mend’ approach to the secondary care staffing crisis. These profession specific hubs, separate the different professions from each other, degrade rather than enhance MDT working and are likely the antithesis of the seamless service provision described in related NHS England documentation.

 

The Royal College of Psychiatrists revealed that between 2020 and 2022, 120 people with mental health challenges died daily from preventable illnesses in England—a stark increase from 73 per day in 2018-2020. That's 43,800 premature deaths annually, from a population of 613,000 patients. We have known for decades that people with significant mental health problems die 15-20 years early. It's 2025 and only now are we planning to start measuring people’s decline in physical wellbeing? What a shame.

Table 1. Year on year increase in rates of preventable deaths across England.

How could the funding system be reformed?

NHS England have a workforce calculator tool that can be used to inform each service on how many staff from each discipline/job role are needed to provide a certain standard of service for whatever number of patients require a service each year.

In our petition for a parliamentary debate, we suggest that every Care Coordinator should have a maximum of 12 patients to support within the community. We suggest that there should be one applied practitioner psychologist available for every 40 patients.

To keep the equation simple and much cheaper, we will ignore the fact that removing the Care Coordinator role and the evidence-based psycho-social interventions they facilitate will necessitate the need for far more therapists. Also ignore the fact that MDT applied psychologists have many more roles, opportunities and obligations than solely focusing on facilitating one-to-one therapy.

The sums tell us that 51,083 Care Coordinators and 15,325 Clinical Psychologists/Psychological Therapists will be needed to support our 613,000 patients with ‘severe and enduring’ mental difficulties. If anyone disagrees with these numbers then great – lets debate and decide together?

Significant additional investment in staffing would not just be good news for patients, families, existing staff and those who value evidence based and economically sound decision making. Thousands more young people who are being denied an opportunity to train and enjoy a career in the NHS will benefit.  Spending enough on staff will significantly improve the health and happiness of the nation.

Examples of good or innovative practice in community mental health services?

We have many examples and ideas. We would appreciate an opportunity to discuss these and other related matters further with committee members.

February 2025