19 The LGA strongly supports the principle for increased choice and autonomy for service users. However, to enable genuine choice and autonomy, there will need to be a broader range of appropriate specialised mental health support in the community. Mental health support services in the community are often commissioned by councils, a key commissioning partner is the NHS. This will require increased investment in evidence-based community mental health services co designed and co-commissioned with the NHS. Some of these services already exist, but some will need to be established to meet specific needs or communities.
20 Not being able to access the right care at the right time can lead to people reaching crisis point and ending up in hospital. In the annual CQC State of Care 2020 report (The state of health care and adult social care in England 2020/21) on the care for people with mental health needs in acute hospitals, they identify that, once in hospital, people are not receiving the care that they need, with poor co-ordination and joint working between acute and mental health services and delays in assessments and securing beds. These delays can then be made worse if there is a lack of availability of mental health beds, with people in distress having to stay in inappropriate and sometimes unsafe environments.
21 A lack of access to local community services can also lead to people being placed in hospital far from home. Such placements can isolate people from friends and families. The CQC in 2020 found that this also increases the risk of closed cultures developing (The state of health care and adult social care in England 2020/21). A closed culture is a poor culture in a health or care service that increases the risk of harm. This includes abuse and human rights breaches. They expressed concerns that the risk of closed cultures has increased during the pandemic, with restrictions on people’s movements and services having to restrict or stop families from visiting their loved ones.
22 We support the changes to the current act to increase choice, such as Advanced Choice Documents and input into Care and Treatment Plans, and improved autonomy, such as enhanced opportunities to challenge decisions. These changes must be supported through investment in the AMHP workforce, where there are increasing problems of recruitment and retention (Briefing: Mental Health Act – Approved Mental Health Professional services), and in services that are able to provide appropriate alternative support.
23 We welcome the opportunity for the new Act to support councils to grow the capacity and capability of voluntary sector providers, such as Independent Mental Health Advocacy (IMHA) services. We recognise that these are operating in an increasingly fragile market. We are concerned that the White Paper Impact Assessment does not reflect the increase in use of advocacy services which will occur with an ‘opt-out’ model. The Impact assessment assumes a 40 per cent uptake, however it may be that where contracts currently provide for an opt-out model, referrals are likely to be higher.
24 The White Paper recommends that as a minimum an annual report should be prepared by advocacy service providers, with the opportunity for quarterly exception reporting as required. Many advocacy providers already report to local authorities and CQC inspects access to advocacy as part of its emphasis on ensuring the rights of detained patients. Any further reporting requirements should be proportionate to the provider organisation capacity and should be person centred and not unduly bureaucratic.
25 An additional complexity is advocacy for people who are detained or assessed outside of their normal area of residence. Advocacy costs may need to be borne by the council in which a mental health or detention facility is located. It may also require additional funding to ensure that the person receives an advocacy service familiar with their local originating community or needs. Furthermore, a person may decide to stay in the local area after discharge from hospital, which may have an additional demand on advocacy services where the hospital is based.
26 The current White Paper Impact Assessment does not address the costs or benefits of additional community services. Councils have a lead role in commissioning a range of specific services for adults, such as supported housing, home care and enablement, employment, and day/activity services, including specific services for young people and those with autism. Social work services are also responsible for the effective preparation for adulthood for young people moving to adult services and joint working with children’s services and Child and Adolescent Mental Health Services.
27 The White Paper recommends that commissioning by councils should be strengthened. We would welcome further discussions on this point. Local government works according to sector led improvement principles (What is sector-led improvement?) ; an approach agreed with MHCLG. Local health and council partners are best placed to identify service needs and responses in consultation with local communities and voluntary providers. We want to ensure that any future commissioning arrangements reflect local needs and knowledge and the process is not overly prescribed by central government.
28 The White Paper outlines a Quality Improvement (QI) programme – it identifies specific reforms to the act which are most likely to benefit from a QI approach; improved care planning, reducing inequalities, improved partnership working, improved assessment processes, greater levels of safety, and the dignity and respect experienced by service users. We support improved quality in service delivery, but it is important that the QI programme makes links to councils’ mental health role and importantly reflects sector led improvement principles.
29 The White Paper also proposes to look at how any expansion of the CQC monitoring role could make a positive impact and aid the quality and safety of care. It proposes working with Local Authorities and others to consider how best to extend these powers, and then publish proposals for consultation at a later stage. The LGA would be keen to be kept informed of this work prior to the consultation. 30 However, our is that improvement is first and foremost a local endeavour. It is local councils, working alongside commissioner partners in health, as well as other partners from the provider sector, the voluntary and community sector, people with lived experience and others, who lead and support an area’s local improvement journey. Sector-led improvement is the sector’s national programme of activity to support and enhance that journey.
31 A constant pursuit of improvement should underpin what drives all parts of the health and social care sectors so that people of all ages are able to live their best lives. We support the emphasis on collaboration, action, encouraging innovation, and the importance of sound evidence. As the regulator for health and care services, CQC is clearly an important agent of improvement. However, we believe CQC’s regulatory role may be compromised if it steps into the role of convenor of local improvement.
32 The NHS and councils working in partnership is a key theme that needs to be reflected in the new Act. The LGA see integration as a means to deliver better health and wellbeing outcomes through effective, streamlined and coordinated care and support. Whether working at national, regional, system, place or neighbourhood level, effective partnership working on health, care and wellbeing should have the following elements:
32.1 collaborative leadership
32.2 subsidiarity - decision-making as close to communities as possible
32.3 building on existing, successful local arrangements
32.4 a person-centred and co-productive approach
32.5 a preventative, assets-based and population-health management approach
32.6 achieving best value (Six principles to achieve integrated care).