This week, the government’s much anticipated NHS long-term plan has finally seen the light of day after months of delay. It talks of investing more in primary, community and mental health care, creating a digital “front door” to the NHS, reducing the burden of many life-limiting conditions and improving the flow of patients through A&E. These are certainly areas that need a fresh focus, given rising demand and slipping waiting times and standards in recent years.
It’s great that the plan will see an extra £2.3bn for mental health. As a GP, around half my consultations are with patients who have mental health problems. Services are at breaking point – with thresholds to accept referrals so high that often only those in crisis (such as being potentially suicidal) are seen, with limited possibilities for GPs to refer for talking therapies. Around 90% of us GPs feel services for these young people with mental health problems are inadequate. Waiting times for adult talking therapies on the NHS can be as long as two years, leaving patients in limbo and in a revolving door system of GPs, A&E or emergency psychiatry services.
The NHS plan promises that 350,000 more children and young people will be treated and similar numbers of adults offered access to talking therapies. But it seems that much of this extra funding will go on services for those in crisis, not ongoing help and support. What patients really need are long-term interventions that the NHS does not have the staff to deliver quickly: one in 10 mental health posts remain unfilled – 2,000 mental health nurses quit every month, and plans to increase numbers have seen little success.
I would like concrete funding proposals for counselling, cognitive behavioural therapy and other talking therapies so that patients can be supported over years, not just months. The digitalisation of healthcare services through apps and online CBT has its place, but cannot be used alone.
My patients Tom, who has anxiety, and Doris, with borderline personality disorder, have tried various medications with little benefit. They attend the practice regularly, often call 111 or the Samaritans, and both have been waiting six months for dialectical behaviour therapy. But our local mental health service does not have the resources to see patients such as these on an ongoing basis – unless they become suicidal or develop acute psychotic conditions.
No one can quibble with the government’s commitment to new “support teams” in schools to identify and support children with mental health problems earlier. Many schools no longer have dedicated nurses, and health visitor numbers have plummeted, while caseloads rocket, due to cuts to public health. This has left many pupils with complex asthma, epilepsy and other health conditions without access to a school nurse, adding strain for parents and teachers, and leaving GPs like me and other community staff with limited or no access to school nurses.
Rather than new teams, I’d like the government to ringfence public health budgets, so that local authorities can’t use the money for something else. Health visitors are working beyond capacity with complex caseloads (children’s safeguarding, domestic violence and postnatal depression). In many parts of the country they look after many more under-5s than previously or the recommended number, which is a big concern. Sexual health budgets also need realistic scrutiny. Despite escalating demand, cash-strapped local authorities are cutting spending on promoting safe sex to those at risk of sexually transmitted infections.
But are we putting the cart before the horse? Where is the plan to recruit and retain our workforce? This is essential to any long-term plans. Many of us have been drawn to the NHS for its varied roles, sense of purpose and a chance to become experts in our fields. But over years of relentless work, with little personal development or pastoral support, we lose many excellent staff along the way.
Yes, I would like to see reduced waiting times in A&E and shorter hospital stays. But this should not be at the cost of “too soon” hospital discharges, which have become so common in recent years, with a backdrop of collapsing social care and no intermediate care provision whether in the form of beds or community geriatricians. General practice – already at capacity – then becomes the inevitable sponge, which is now saturated.
The NHS long-term plan has a lot to deliver, but we need to ensure we are focusing on where the real problems lie within the NHS and how we must resource the solutions. Without this, everything just becomes rhetoric.
• Zara Aziz is a GP in inner-city Bristol