A growing, ageing population

The UK population continues to grow, with a predicted additional 4 million people by 2035 and, crucially, a doubling of those over the age of 65 (Kingston 2018). Life expectancy has been rising since first recorded in the mid-19th century. Initial gains were through reduced child mortality and improvements in basic sanitation, hygiene and housing conditions. This continued in the 20th century through the introduction of childhood vaccination programmes and universal healthcare coverage – what Deaton called the ‘great escape’ (Deaton 2013) – and more recently through modifying lifestyle risk factors of diet, exercise, cigarette smoking and alcohol consumption. Gains have slowed during the second decade of the 21st century, but by 2016–2017 half of new-born females could expect to be alive at 85.8 years of age, half of males at 82.3 (Office for National Statistics 2018). Most recent data suggest that life expectancy has reduced slightly (Institute and Faculty of Actuaries 2019). The reasons for this remain heavily debated, although it has been argued that austerity and cuts to health and social care are key drivers and the UK has some of the lowest investment in public sector infrastructure in the OECD (Marmot Reference Holt-Lunstad, Smith and Baker2010; Raleigh 2018).

To capture quality of life as well as longevity, the concepts of ‘healthy life expectancy’ (HLE) and ‘disability-free life expectancy’ (DFLE) are increasingly used. HLE is the number of years individuals perceive that they live in ‘good’ or ‘very good’ general health; DFLE is an estimate of the number of years lived without a long-lasting physical or mental health condition. Currently, UK HLE at birth is 63.1 years for men, 63.7 for women: as men have lower life expectancy, this is a greater percentage (79.6%) of men in good health than women (76.9%); indeed, the figures have worsened for women over the past 5 or so years.

An increasingly multi-morbid population

The UK population is growing clinically more complex, with more risk factors for ill health, and rising rates of comorbid conditions; this is significantly affecting the populations seen in mental health services. High body mass index (BMI), smoking, excess alcohol consumption, limited exercise and poor diet remain the leading morbidity risk factors (Public Health England 2018a), and all are higher on average in populations with mental illness. Smoking and alcohol consumption have fallen in recent years, but obesity rates have increased. Data from England in 2008 show that only 6% of individuals had none of these risk factors, whereas 5% had at least four and 70% of the population did not adhere to government guidelines on at least two (Buck Reference Buck and Frosini2012). Obesity in particular is seen as a key driver for many illnesses and rates are increasing in all age groups (Stevens Reference Prince, Knapp and Guerchet2012).

Multi-morbidity is a growing health challenge: the number living with four or more illnesses has been forecast to quadruple in England by 2035 (Kingston 2018). In a report on the healthcare needs of people with multiple conditions the Health Foundation estimated that 30% of those currently living with four or more conditions are under 65 years of age (Stafford Reference Patel, Caddy and Tracy2018), so this challenge of multi-morbidity is not limited to older populations. Figure 1 shows the most common comorbidities of those with a mental health condition. The report also noted that those with two or more conditions accounted for over half of primary and secondary care costs, and three-quarters of primary care prescription costs. Over a 2-year evaluation period, those with more than four conditions had a mean of 8.9 out-patient visits, once-monthly general practitioner (GP) visits and 20.6 prescribed medications.

FIG 1 The most common additional conditions for people with a mental illness and the proportion of people affected. Adapted from Stafford et al (Reference Patel, Caddy and Tracy2018).

Those with greatest need are often least able to manage their multiple appointments and medications, leading to fragmented care, exacerbation of their conditions and higher use of emergency care; they also suffer higher rates of social isolation, loss of work and financial hardship. Their numbers, and the demands on services, are increasing, and at present they commonly move across multiple services in an inefficient and costly manner.

Mental health morbidity, prevalence and societal impact

The Adult Psychiatric Morbidity Survey of 2014 (McManus 2016) reported that 17% of surveyed UK adults met the criteria for a common mental disorder. This has been increasing across the four survey periods since 1993, largely driven by an increase in rates in women. Notably, only 39% of those in need were accessing treatment, although this was up from 24% in 2007: already pressured services are seeing only a minority of need.

The Royal College of Psychiatrist's projections are that there will be an increase in demand across all mental health clusters in the coming decade (Royal College of Psychiatrists Reference Oung, Curry and Schlepper2019) (Fig. 2). The utility of these clusters remains heavily debated, but the underpinning message is clear. Demand growth is most notable in cognitive impairment and dementia, with modelling studies estimating that an additional 312 000 people in England will be living with dementia by 2029, at a societal cost of an additional £10 billion a year (Prince 2014). However, the other end of the lifespan is equally critical, particularly for prevention, with about half of mental health problems estimated to begin by the age of 14 and three-quarters by age 24 (Kessler Reference Kessler, Berglund, Demler, Jin, Merikangas and Walters2005).

FIG 2 Estimates of projected percentage growth in demand across mental health cluster caseloads in England between 2018 and 2024. There are slight differences in projections between men and women: these data take an average between them. CI, cognitive impairment; MHP, mental health problem. Adapted data from Royal College of Psychiatrists (Reference Oung, Curry and Schlepper2019: p. 8).

Mental health problems cost the UK about 4.1% of GDP through direct health and social care costs and indirect losses, matching the EU average (Organisation for Economic Co-operation and Development 2018). The Centre for Mental Health noted that in 2016–2017, the UK economy lost £34.9 billion owing to employee mental illness, equivalent to £1300 for every employee in the country (Parsonage 2018). An estimated £10.6 billion was from sickness absence, £21.2 billion from reduced productivity at work (so called presentee-ism) and £3.1 billion from replacing staff who left their jobs because of their mental ill health. This was 35% higher than the corresponding figure a decade earlier, although this change is in part due to a larger workforce receiving an (adjusted) higher average salary.

Mortality rates for those who use secondary mental health services have reduced slightly since the turn of the millennium, but on average men using these services die 19 years, and women 16 years, earlier than the rest of the population (Strategy Unit 2017). Many deaths are preventable through better support in lifestyle, preventive approaches, and better medical and medication reviews (Royal College of Psychiatrists Reference Oung, Curry and Schlepper2019). Of note, much of the literature on putative gains from preventive work has focused on physical health factors such as smoking, alcohol and obesity, with far less on potential gains from prevention or early treatment of mental illness (early intervention in psychosis is perhaps the notable exception). Some of this might be due to a lack of clear reliable evidence of ‘what works’: there is much interest in the impact of ‘early years’ programmes on outcomes of resilience and well-being, but much debate on their effectiveness and value for money.

Social determinants of health and social outcomes of poor health

A King's Fund report on population health noted six major social areas that affect health and use of public services (Buck Reference Buck, Baylis and Dougall2018): income, housing, the environment, transport, education and work. Note that healthcare is not among these predominantly socioeconomic and environmental factors.

The landmark 2010 Marmot review of health inequalities in England (Marmot Reference Holt-Lunstad, Smith and Baker2010) found that people in the poorest areas were dying an average of 7 years earlier than those in the richest areas, and further, that such individuals spent an average of 17 additional years living with disability. Those in the most deprived areas are twice as likely to die prematurely from cancer, and four times as likely to die prematurely from cardiovascular disease, than those in the least deprived areas; for cardiovascular disease this gap has increased since 2010 (Public Health England 2018a). In 2014–2016 the age-standardised mortality rate for suicide was twice as high in the most deprived decile compared with the least deprived. Low life satisfaction is four times higher among those who are unemployed (Public Health England 2018b). Loneliness is a growing problem: one in eight adults in the UK reports having no friends (Relate 2017), and feeling lonely has been estimated to have the same effect on health as a smoking habit of 15 cigarettes a day (Holt-Lunstad Reference Ham and Murray2015). The number of rough sleepers in England increased by 372% from 2010 to 2018 (Ministry of Housing, Communities & Local Government Reference Kingston, Robinson and Booth2017); there has been an almost 25% increase in deaths of homeless individuals since 2014 – at a mean age of just 44 – and over half of these were from drug poisoning, liver disease or suicide (Office for National Statistics 2019). The Social Metrics Commission (Reference Parsonage and Saini2018) identified that in the UK in 2018:

• • 14.2 million (22% of the population) were living in poverty: 8.4 m working-age adults, 4.5 m children, 1.4 m of pension age

• • 7.7 million (12.1%) were living in persistent poverty, that is in poverty for most or all the past 4 years

• • a ‘resilience gap’ existed between those in poverty and those who were not.

The costs of social inequities have been estimated at £36–40 billion a year through direct expenditure and lost taxation. York University's Centre for Health Economics has estimated the direct cost to the NHS for failing to provide preventive care to the poorest communities at £4.8 billion a year (Asaria Reference Asaria, Doran and Cookson2016).

Individuals with mental health problems face an increased range of social problems, from poverty and unemployment to greater rates of imprisonment. They are more likely to have difficulties with housing, including rent arrears, live in deprived neighbourhoods and have challenges independently managing daily needs. Over half with psychosis have no stable homes; there is good evidence to support sheltered housing, including as an actual intervention in helping individuals' mental health, but the funding is not always available for this (Centre for Mental Health 2016). Individuals with severe mental illness are more likely to suffer stigma, discrimination and social exclusion, and have more risky health behaviours such as higher rates of smoking – 40% compared with approximately 15% in the general population. They often find it harder to initially access services and, once in services, to receive appropriate preventive help, with the problem of ‘diagnostic overshadowing’, wherein physical health problems are misattributed to mental illness.

The relationship between mental ill health and social problems is bi-directional. Adverse childhood experiences are linked with a large range of subsequent physical and mental health problems (Herzog Reference Evans2018; Morris Reference Makurah2019) through direct neurobiological alteration (Morris Reference Makurah2019) and psychological distress from problems such as living alone, unemployment and poor physical health (McManus 2016). Over 50% of Employment Support Allowance claimants have a primary mental health problem (Makurah Reference Herzog and Schmahl2018). Only about 7% of those in contact with secondary mental health services are in paid employment (Public Health England 2018a). In one of the most disadvantaged of all healthcare conditions, people with psychoses form almost 60% of all mental health in-patients and 37–80% of those detained under the Mental Health Act 1983, and account for 80% of all experiences of restrictive practices of restraint, including prone restraint, seclusion and rapid tranquillisation. There are other critical intersectional issues, including gender and ethnicity, for example Black individuals are several times more likely to be detained under sections of the Mental Health Act as well as more likely to be on higher doses of antipsychotics and receive psychological interventions less often than their counterparts from other ethnic groups. The Commission for Equality in Mental Health has been drawing evidence from a wide range of sources on such issues and expects to publish its findings and recommendations in 2020 (Commission for Equality in Mental Health Reference Charlesworth, Gershlick and Firth2019).

Funding healthcare

The NHS accounts for about 7% of UK GDP (Stoye 2017), just below the EU-15 weighted average. Over the past decade, funding has increased at about 1% a year in real terms (above inflation), compared with a longer-term historical figure – and that recommended by the Office for Budget Responsibility to meet growing need – of about 4%. An important but complex factor within total spending is the efficiency of the money invested. The National Audit Office has estimated that £6 billion in potential savings could be realised by 2020–2021 through reduction in waste and variation in care quality and efficiency (Morse Reference Charlesworth2018). However, there have traditionally been few national levers to either reduce or measure efficiency improvement.

There has been an increase in the number of NHS trusts now reporting annual budgetary deficits, from fewer than 10% in 2009–2010 to over 40% since 2014–2015. Mental health trusts appear to perform relatively well, with ‘only' 19% reporting a deficit in December 2018 (Anandaciva Reference Anandaciva, Jabbal and Maguire2018). However, the Royal College of Psychiatrists has noted that the typical block contracts disincentivise increasing activity (unlike the more usual payment-by-results (PbR) contracts in the acute sector), and apparent surpluses may thus mask inadequate funding for true need (Royal College of Psychiatrists Reference Oung, Curry and Schlepper2019). There are also concerns that much of any additional funding is syphoned into the acute sector at the expense of mental health and community services (Charlesworth Reference Charlesworth, Gershlick and Firth2019a). PbR is not without its own problems, and there is a converse argument that the most appropriate way to provide mental health services is to do what one can for a given population within a resource envelope – in other words, a block contract. Parts 2 and 3 of our series address the concept of a capitated budget, where a single provider, or small group of providers, cover all healthcare needs of a defined population in an ICS; this, in principle at least, allows for better oversight of management of complex illnesses and preventive work.

Investment in NHS estates fell by 17% between 2010–2011 and 2017–2018, and there is an increased maintenance backlog. The Department of Health and Social Care's capital budget was 0.27% of GDP, in contrast to the OECD average of 0.51% (Charlesworth Reference Charlesworth, Gershlick and Firth2019a). Again, mental health trusts have suffered relatively greater reductions in capital spends: 39% below that planned for 2017–2018, compared with a shortfall of 29% in acute trusts.

The NHS Long Term Plan contained a commitment to an average increase in NHS England's budget of 3.4% for the 5 financial years commencing 2019–2020 (NHS England Reference Morris, Berk and Maes2019: para. 6.1) (Fig. 3). However, the plan does not cover non-NHS aspects such as public health, social care, education or training (Dunhill 2018); indeed, budgets for Public Health England and Health Education England have been cut by 15% and 24% respectively over the past 5 or so years. Further, funding is not evenly divided across the 5 years – the greatest spend will be in 2023–2024 – and is not front-loaded, meaning that services might need to be ‘double run’ as the new preventive interventions are being established while the excess acute demand is still being met (Charlesworth Reference Charlesworth, Gershlick and Firth2019a).

FIG 3 (a) Growth in total NHS funding from 2018 to 2024, from £116.9 billion to 137.5 billion; (b) how the additional £20.6 billion will be spent. Note that there will be reduced funding for community prescribing and administrative costs. Adapted from Charlesworth et al (Reference Charlesworth, Gershlick and Firth2019a).

Funding social care

An ageing population with greater needs will need ever more support from social care. In England, contrasting with treatment – which is provided free by healthcare services – support and personal care required following illness, disability or in old age is either provided by the voluntary sector and unpaid caregivers, or funded privately or publicly. Local authorities have a legal duty of care to provide the publicly funded aspect. There are nationally agreed targets for ‘needs testing’ (the degree of impairment necessitating input) and ‘means testing’ (the financial thresholds beyond which individuals contribute to their own care). Most funding is local, coming from business rates and council tax, although central government contributes grants and can influence local authority borrowing and spending priorities. Nevertheless, inequities can arise, with different local authorities spending varying amounts on individuals with similar needs and means, depending on local funding levels and agreed priorities. It is worth noting that housing is not funded through adult social care, with central government spending on social housing falling from 0.7 to 0.4% of GDP between 2004 and 2012, to 0.2% in more recent years, while housing benefit spending on rented properties increased across the same time period from about £16 billion to over £25 billion a year (National Housing Federation Reference McManus, Bebbington and Jenkins2019).

Nationally, gross expenditure on adult social care has fallen (on a single occasion it remained level) every year since 2009. Local authorities have suffered a 7% decrease in national gross spending during this time, despite a growth in need (Nuffield Trust 2017). Public health services moved to local authorities in 2014 and have suffered a 23% reduction in spend per person between 2014–2015 and 2019–2020. Local authorities are now also responsible for alcohol and substance use services, and with spending no longer ring-fenced, cuts of about 30% have occurred nationally during a similar time frame and the UK has seen a considerable rise in drug-related deaths (Drummond 2017).

In the next 5 years local government income from local taxes is anticipated to grow by 1.4% a year (Charlesworth Reference Charlesworth and Johnson2019b), but the Institute for Fiscal Studies (IFS) estimates that an annual increase of 3.9% is required over the next 15 years to meet need (Charlesworth Reference Makurah2018). A Care and Support Commission's report (often referred to as the ‘Dilnot report’ after its lead author) supported introducing a cap to prevent people from extreme care costs, and a means test, below which individuals were eligible for local authority support towards care costs (Commission on Funding of Care and Support 2011). Notably, the IFS projection of funding needs is predicated on maintaining the uncapped means test that limits eligibility; clearly, if that were reformed, as has been debated, the cost would be considerably greater. The overarching figure also does not take regional variation into account: poorest areas will be disproportionately hit by austerity and have the highest social care needs, yet are also likely to have the lowest revenue from business rates. Further, if social care salaries were to rise at an equivalent rate to that promised to NHS staff under ‘Agenda for Change’ (see below), then an additional £1.7 billion a year would be required by 2023–2024 (Charlesworth Reference Charlesworth, Gershlick and Firth2019b).

To redress this funding gap, the 2014 Baker Commission called for a single budget and alignment of health and social care, paid for through taxation and national insurance (Commission on the Future of Health and Social Care in England 2014). A joint report by the House of Commons Health and Social Care Committee and the Housing, Communities and Local Government Committee called for similar charges in what was labelled a ‘social care premium’ (Health and Social Care Committee 2018). In both cases it was argued that it is important to target wealth as well as income, to avoid solely hitting working-age adults, and that additional responsibilities should be borne by those of state pension age.

The Nuffield Trust recently outlined several options available to better fund social care, including various permutations of increasing general, inheritance and local taxation, voluntary or mandatory insurance, and altering caps on lifetime spend or the means-testing threshold (Oung 2019). The various models highlight that there are no easy ways to generate the large funds required, and that each comes with unique costs and benefits. Further, although many people with mental illness clearly have significant social care needs (and vice versa), the largest growth in need is from a frail ageing population without mental (or acute physical) healthcare needs, and there are dangers that meeting their enormous and appropriate needs will overwhelm the resources to address those of mental health service patients.