Further supplementary memorandum by the
Department of Health (MH 1B)
GP COMMISSIONING PILOTS AND TOTAL PURCHASING
PILOTS AND MENTAL HEALTH—QQ 15-16
During the period that Total Purchasing Pilots
and GP Commissioning Pilots were operational, the Department of
Health commissioned a range of reports on the structure and effectiveness
of their commissioning, including that of mental health services.
These include:
TOTAL PURCHASING
AND EXTENDED
FUNDHOLDING OF
MENTAL HEALTH
SERVICES—THE
KING'S
FUND, 1998
This report studied 27 of the 53 "first
wave" Total Purchasing Pilots, 35 "second wave"
pilots and 13 extended fundholding sites (ie looked at a total
of 40 pilots).
Thirty of the 40 sites had sought to identify
individuals with mental health problems by developing a case register
from patient notes, drug records, Community Psychiatric Nurse
caseloads etc. Nineteen of the 40 had not undertaken a formalised
needs assessment, drawing on GPs' personal experience of service
use, unmet need, etc.
Many sites sought to improve communications
between primary care and specialist mental health services, including
27 of the 40 increasing the level of face-to-face contact, 11
having a practice attachment of mental health staff and five having
practice based mental health staff. This improved continuity of
care to patients and helped to ensure consistency of referrals
to secondary care.
Some pilots set up practice based mental health
teams with Community Psychiatric Nurses, care assistants, counsellors
and administrative support.
The potential benefits of these initiatives
for people with a severe mental illness include improving access
to services such as dentistry, chiropody, cervical screening,
etc. In addition, early interventions may help to cut the number
of acute admissions, reducing costs and improving patient care.
THE BERKSHIRE
INTEGRATED PURCHASING
PROJECT—THE
LONG AND
WINDING ROAD—UNIVERSITY
OF MANCHESTER
HEALTH SERVICES
MANAGEMENT CENTRE,
MAY 1999
This is the report of a three year study of
a single Total Purchasing Pilot site in Berkshire "measuring
the impact when a group of GPs was delegated the entire health
care budget for their population." The Total Purchasing Pilot
started in April 1994.
The report noted that improvements to services
for people with mental illness included reduced lengths of inpatient
stay and suggested that "the introduction of extra community
based staff in two of the practices to manage and co-ordinate
the care of this group of patients may have contributed to this
reduction".
The GPs were able to become involved in the
strategic discussions to rationalise acute services and close
a long-stay institution for mentally ill people.
The report states that "the relationship
with the local community and mental health Trust improved with
every year of the project . . . lessons from the project were
beginning to be applied by the Trust to the emerging PCGs".
However, GPs remained concerned about the level of liaison between
the community mental health teams and the primary care teams.
The impact of the Berkshire Integrated Purchasing
Project on mental health services from 1996-97 to 1997-98 was
significant. There was a 20 per cent reduction in Finished Consultant
Episodes (15 per cent reduction in the control group), a 34 per
cent reduction in number of bed days (18 per cent reduction in
the control group) and a 17 per cent reduction in length of stay
(3 per cent reduction in the control group— at the local
Trust. The report states that "in summary, lengths of stay
for mentally ill patients reduced more quickly in the Berkshire
Integrated Purchasing Project than for the comparison practices;
the introduction of extra community based staff in two of the
practices to manage and co-ordinate care for the mentally ill
may be linked to this".
THE TRANSITION
FROM TOTAL
PURCHASING PILOTS
TO PRIMARY
CARE GROUPS:
LESSONS FOR
PRIMARY CARE
GROUP DEVELOPMENT—THE
KING'S
FUND, 1999
This report draws conclusions from earlier research
about the lessons that Primary Care Groups could learn from Total
Purchasing Pilots. A number of Total Purchasing Pilots identified
mental health services as a priority. Among the wide variety of
action Total Purchasing Pilots took to tackle this identified
priority were:
— Community Psychiatric Nurses taking
direct referrals from the Primary Health Care Team;
— The appointment of more Community
Psychiatric Nurses;
— Community Psychiatric Nurses working
proactively with seriously mentally ill people;
— A more collaborative approach between
GPs and Community Psychiatric Nurses;
— Direct negotiation with the mental
health service provider;
— Contract pricing based on estimated
reduction in acute admissions.
This resulted in reduced occupied bed days,
reduced length of stay in hospital, prevention of admissions (especially
acute admissions of under 65s) and improved mental health liaison
services after discharge from hospital.
It was suggested that Primary Care Groups should
build on these types of successes, focusing on the need for close
involvement with mental health Trusts.
FIRST OFF
THE STARTING
BLOCK: LESSONS
FROM GP COMMISSIONING
PILOTS FOR
PRIMARY CARE
GROUPS—UNIVERSITY
OF BIRMINGHAM
HEALTH SERVICES
MANAGEMENT CENTRE,
1999
This report noted that some commissioning groups
had identified objectives to "extend the provision of community
and practice based nursing, including mental health services"
(Blackburn with Darwen GP commissioning group) and "co-ordination
and support of established joint commissioning projects, elderly
care and mental health)" (Dartford, Swanley and Gravesham
Locality Healthcare Partnerships Project).
The Halesowen GP Commissioning Group included
"piloting of the Health Authority strategy for primary, community
and secondary care mental health services across the locality"
in their work programme. A sub-group on mental health worked with
local stakeholders to develop services.
The North Amber GP Commissioning Group aims
"to rationalise mental health services" in the area.
The commissioning group meets quarterly and includes a representative
from the local community and mental health trust, Community Health
Council, etc.
Finally, the Redbridge and Waltham Forest Whole
District Commissioning Pilot has an objective of "improving
mental health links to the mental health Trust and its teams,
including counselling, psychotherapy and liaison psychiatry".
GPs are reported to be working together more effectively for the
benefit of patients.
The Primary Care Groups that develop from such
commissioning groups will build on the successes of these earlier
organisations in meeting identified local objectives.
COSTS OF
SECURE SERVICES
AND NUMBERS
OF INAPPROPRIATELY
PLACED PEOPLE—QQ
82-83
The Committee asked what it costs when somebody
is in a high, medium or low security NHS establishment, or in
prison. The average cost of accommodating a patient in a high
security hospital in 1999-2000 is calculated to have been in the
region of £107,000. Detailed information about the costs
of accommodating patients in medium secure and low secure psychiatric
facilities is not available. The available information on medium
secure costs suggests that they can vary quite significantly from
one unit to another, and that the costs for different units range
from below to above high security hospital costs.
With effect from 1 April 2000, responsibility
for commissioning high and medium secure services has been devolved
to Regional Specialised Commissioning Groups. Regional Specialised
Commissioning Groups will want to ensure, as part of the contract
negotiation process with the providers of the services, that value
for money is being achieved in respect of the services they are
purchasing. Part of the contract negotiation process will include
the types and levels of services that should be provided, which
will affect the costs of the services and would need to be considered
together with other relevant factors in making comparisons between
different units.
An exercise to arrive at a national average
figure for the costs of accommodating patients in low secure accommodation
would be of dubious value because of the variety of services which
are covered by the low secure definition, and the differing local
factors which would need to be taken into account in deciding
whether or not costs are reasonable. This is a matter which is
more appropriately discussed locally between purchasers and providers
of services.
The figure provided by the Prison Service for
the average cost of a prison place is £25,000, or £22,600
if Prison Service Headquarters costs are excluded. It needs to
be borne in mind that these costs would largely cover only the
provision of a broadly primary healthcare service, and cost comparisons
with secure mental health service providers would be of little
validity. In 1998-99 the average cost of an uncrowded prison place,
ie calculated with reference to the total of the certified normal
accommodation across the prison estate, was £25,096. The
average cost per prisoner for the same year was £24,408.
The Committee also asked about numbers of people
placed in inappropriate facilities. Each Regional Specialised
Commissioning Group is in the process of developing secure service
strategies for its region based on updated regional needs assessments,
and this will inform ongoing plans for the provision of services.
In their first annual report, due later this year, each Regional
Specialised Commissioning Group will be required to provide waiting
time data from providers and Health Authorities on patients awaiting
transfer to and from all levels of secure psychiatric provision.
This will give us a clearer picture of the numbers of inappropriately
placed patients. From next year's annual report onwards, each
Regional Specialised Commissioning Group will also be required
to identify the numbers of prisoners waiting for transfer to secure
NHS facilities for whom they are the responsible commissioner.
It is expected that, in the interim, Health Authorities and prisons
will work closely together to ensure that a robust system of data
collection is in operation to identify the responsible commissioners
of services for prisoners requiring specialist treatment in secure
NHS facilities.
To further aid the process of moving inappropriately
placed patients out of the high security hospitals, the Health
Service Research Department at the Institute of Psychiatry, in
collaboration with the Universities of Manchester and Nottingham,
has been commissioned to undertake a comprehensive examination
of patients' needs. A full report will be available by March 2001.
The study's aims are:
— To assess the treatment and placement
needs of all patients currently in the high security hospitals;
— To establish from these data a profile
of patients rated for high, medium and low secure provision;
— To make recommendations for the types
of care and treatment needed by these patients at each level of
care in the foreseeable future.
This study is the first which addresses the
needs of patients using multiple standardised instruments. It
will dovetail with the work being done by the Regional Specialised
Commissioning Groups in informing future service provision and
identifying gaps in current service provision. It will also lead
to the freeing up of beds in the high security hospitals for people
currently placed in other facilities, particularly prisons, who
require care and treatment in a high security setting.
SOCIAL SERVICES
INSPECTION OF
COMPULSORY MENTAL
HEALTH ADMISSIONS—Q
98
This inspection, which was carried out in 10
councils between June 1999 and March 2000, examined the way social
services undertook their responsibilities under the Mental Health
Act 1983. It focused particularly on the role of Approved Social
Workers and on the experience of black and other minority ethnic
groups who were the subject of assessments under the Mental Health
Act. On most of the Social Services Inspectorate teams there was
a black inspector.
The inspection was designed to explore evidence
and explanations for:
— Over- or under-representation of
ethnic minority groups amongst those assessed under the Mental
Health Act;
— Over- or under-representation of
ethnic minority groups amongst those compulsorily detained as
a result of assessment;
— The varying experiences of different
ethnic groups of statutory mental health service users;
— The availability of appropriate alternative
mental health services for ethnic minority groups.
Information was collected on the characteristics
of persons recently assessed under the Mental Health Act in each
of the social services areas. This has provided data on the age,
gender and ethnic group of over 1,000 assessed persons, and shows
the outcome of the assessments and the legal status of the service
user. This data has not yet been analysed and interpreted.
Detailed examination of a sample of around 200
case records enabled inspectors to explore with both service users
and professionals the varying provision of services for ethnic
minority groups and the extent to which ethnicity and cultural
issues were taken into account by mental health service professionals
and providers. The findings are not yet finally collated.
The national overview report of the inspection,
which will include an analysis of the collated inspection data,
is currently being prepared. Publication is expected in November
2000, and a draft report is expected in September.
EXAMPLES OF
GOOD PRACTICE
AND PROGRESS
ON BLACK
AND MINORITY
ETHNIC ISSUES—QQ
99-100
Social Services Inspections
The Inspection Division of the Social Services
Inspectorate has carried out three inspections with a black and
minority ethnic focus—on older people, on families and children
and on those detained under the Mental Health Act (see p 6). Through
these three inspections, they have developed expertise in addressing
the issues that concern black and minority ethnic service users.
Each inspection team included a black inspector (there are five
in permanent posts, out of 45 inspectors) and additional secondees
were recruited. All staff involved in these inspections have been
given additional training in cultural awareness.
Oxleas NHS Trust
In 1997, Oxleas NHS Trust started to do some
work in the area of culturally appropriate services when a group
of clinicians and managers came together to identify what work
needed to be done in order to ensure that the Trust was a culturally
competent organisation.
This work has resulted in the Culture in Practice
initiative which has four elements:
The initiative has the active support of the
Trust Board sponsored by the Medical and Nursing Directors. It
is administered by a Culture in Practice management team and includes
a network of trained Cultural Advisers.
To help implement the initiative, the Trust
has developed a Culture in Practice Resource Pack, drawn up by
a wide variety of disciplines to include service users and local
voluntary sector groups.
The initiative provides for:
— Staff training—on cultural
competency; on the importance of effective ethnic monitoring;
in getting staff to ask patients what they see as their cultural
needs;
— The Trust being able to—identify
the ethnic origin of its own staff; identify gaps in service and
advocacy;
— A corporate approach to include—information
on an equal opportunities policy; procedures on recruitment and
selection; complaints procedures; guidelines on confidentiality;
core care plans for patients and a database of national and local
contacts.
Ealing, Hammersmith and Fulham Mental Health NHS
Trust
This Trust has set up a Focus Group to provide
for effective user expression; to share a variety of experiences;
to act as a resource for patients; to provide a means of dialogue
and engagement; to promote dignity, self care, self worth and
respect; and to promote staff training.
The Group has introduced:
— A range of ethnic minority magazines
and newspapers into the wards;
— A dictionary of common phrases and
questions in 29 languages to help both staff and patients;
— A multi-faith worship area;
— The re-naming of a forensic ward
to that of a local "champion" of mental health rights
for people from an ethnic background.
The Focus Group has benefited different groups
in different ways:
— The service has a greater awareness
and sensitivity around this area;
— The patients have a feeling that
that they are being looked after by an organisation that cares,
one that values their needs both collectively and as individuals;
furthermore, recognition by psychiatrists of the Group's significance
has affected clinical practice, leading to greater patient satisfaction;
— The staff have recognised the importance
and benefits of cultural awareness training.
In addition, the Trust has drawn up a racial
harassment policy covering both staff and patients.
Like Oxleas, these changes have been driven
and fully supported by the Trust Chief Executive and the Trust
Board.
Wolverhampton African-Caribbean Community Initiative
This initiative, which has won Beacon status,
is a resource centre providing day care; outreach services and
supported housing for African-Caribbeans with a mental illness.
The resources centre is provided by the voluntary sector funded
through social services. This is underpinned by joint working
between health, social services and the voluntary sector which
substantially increases the effectiveness of services through
true partnership working.
The staff:
— Are assigned as link workers, working
between acute wards and community mental health teams to offer
support, guidance and practical help providing a bridge between
hospital and the community;
— Offer support to in-patient staff
on issues relating to specific social, cultural and spiritual
needs of each client group;
— Participate in ward-based patient
reviews; Care Programme Approach meetings and sittings of Mental
Health Review Tribunals;
— Offer advocacy and translation services;
— Offer support to carers and families;
— Provide ethnically sensitive day
care.
IMPROVING THE
COLLECTION OF
STATISTICAL DATA
ON CHILD
AND ADOLESCENT
MENTAL HEALTH
SERVICES—QQ 58-61
There is currently limited statistical data
collected within the NHS that is specific to child and adolescent
mental health services.
New central requirements for data need to be
incorporated into established collection systems and must produce
information that is also useful to service providers and planners
at local level. Care must be taken to ensure that the information
is both reliable and accurate and that its value for service monitoring
and planning also justifies any additional costs and practical
burdens that are incurred.
The statistical data collected for child and
adolescent mental health services is currently under review by
the Department of Health in order to assess future requirements.
In addition, improvements in child and adolescent mental health
services are being monitored by Regional Offices of the NHS Executive
in partnership with the Social Care Regional Offices within the
performance management framework.
The Department of Health, the Scottish Health
Executive and the National Assembly for Wales commissioned the
Office for National Statistics to conduct a survey of the Mental
Health of children and adolescents in Great Britain. The report
was published on 30 March 2000 and provides, for the first time,
information on prevalence of mental disorders in children and
young people, levels of impairment and service usage throughout
Great Britain. We intend to repeat this survey in five years'
time.
The Health Select Committee specifically asked
about the numbers of children and young people admitted to adult
psychiatric beds. This information is not currently collected
but admissions under the Child and Adolescent Psychiatric specialty
is. This includes young people cared for by a Child Psychiatrist
in adult settings. Information about the usage of adult psychiatric
facilities for the care of children and young people is of value
to the Department of Health and mechanisms for collecting this
information are being explored.
Information about the child and adolescent mental
health services workforce is limited at present to Child Psychiatry
and Child Psychotherapy. Numbers of Clinical Psychologists and
Nurses working within child and adolescent mental health services
cannot be disaggregated from the overall figures for Clinical
Psychology and Mental Health Nursing. NHS data on the workforce
is collected by use of occupational codes covering the main functional
groupings. The future requirements for monitoring of the NHS workforce
are currently under review and changes to the current data collection
are not envisaged until this review is complete. Given the mobility
of some of the child and adolescent mental health services workforce
and the varying settings in which they may be employed, in addition
to the variety of roles that may be undertaken, the accurate collection
of information about the child and adolescent mental health services
workforce is more complex than it may appear. Nonetheless future
requirements to assist in workforce planning will be fed into
this review. Decisions for changes in the census collection for
child and adolescent mental health services will be assessed in
relation to similar needs in several other specialist areas.
The Department for Education and Employment has
provided this information about the shortage of Educational Psychologists
The Department for Education and Employment's
Programme of Action: Meeting Special Educational Needs,
published in November 1998, acknowledged the important role that
educational psychologists play, and the Department has established
a working group to consider aspects of this and the related issues
of training and recruitment. The educational psychologists working
group includes serving educational psychologists, Local Education
Authority representatives, a special educational needs co-ordinator,
headteachers and Health and Social Services representatives. It
is envisaged that a report will be published in the summer.
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