Written evidence from the Royal College
of Psychiatrists (COM 42)
SUMMARY
— The Royal College of Psychiatrists welcomes
increased involvement of clinicians in commissioning but believes
that there should be co-commissioning between specialists and
GPs and not GPs alone. Psychiatrists have considerable expertise
in mental health service delivery and need to be key players in
developing innovative and cost effective services. — Mental
health services should be commissioned based on care pathways
which set out a framework of:
(i) assessment standards;
(ii) evidence-based interventions;
(iii) outcomes to be assessed;
(iv) the timeliness of assessment and intervention.
Guidance needs to be provided as to the skills
and competencies required of the professionals who undertake the
assessment and interventions. The Royal College of Psychiatrists
and the Royal College of General Practitioners welcome the opportunity
to lead the development of such pathways and make them available
as templates upon which commissioners could plan local services.
— Commissioners have to ensure that they
retain a focus on:
— patients with complex mental health problems
who would not be subject to national commissioning but require
often expensive care and may be overlooked in favour of high volume,
low cost case.
— Commissioning needs to ensure that research
and teaching are protected.
— The College welcomes the focus on outcomes.
Commissioners must ensure that outcomes are for the whole population
on GP lists and not just those identified on chronic disease registers.
SPECIALIST SERVICES
What arrangements are proposed for commissioning
of specialist services?
1. The Royal College of Psychiatrists believes
that the NHS Commissioning Board will need to work with GP consortia
to produce a description of:
(i) the nature and extent of population health
needs and patient presentations that are currently being made
to primary care in their consortia area;
(ii) the clinical strategies that are currently
being employed to address these at a consortia level; and
(iii) the clinical strategies and organisational
arrangements that could be employed at a regional and national
level.
2. All services should be commissioned based
on care pathways which set out a framework of: (a) assessment
standards; (b) evidence-based interventions; (c) outcomes to be
assessed; (d) the timeliness of assessment and intervention. Guidance
needs to be provided as to the skills and competencies required
of the professionals who undertake the assessment and interventions.
The Royal College of Psychiatrists and the Royal College of General
Practitioners welcome the opportunity to lead the development
of such pathways and make them available as templates upon which
commissioners could plan local services.
3. Two considerations need to be made with
regard to mental health. Firstly, many patients with serious mental
illnesses have complex health and social care needs. Meeting these
needs often requires intervention not only from specialist mental
health services but also from local social care agencies, primary
care services, voluntary sector organisations, and networks of
peers, friends and family. Consequently, a risk may exist for
some patients that specialist mental health services (which are
often of low volume and high cost) are commissioned at regional
and national level, while other services (of higher volume and
lower cost) are commissioned at the level of the GP consortia.
This could mean:
(i) mental health patients with complex needs
may `fall between' GP consortia and the NHS Commissioning Board;
(ii) local GP consortia may not fully understand
or consider the needs of such patients when commissioning services
in their area (including joint commissioning with local authorities);
and
(iii) patients could receive uncoordinated or
fragmented care, or inappropriate "out of area treatments"
(with sizeable financial and social inclusion implications).
4. We therefore recommend that attention
needs to be given to whether local specialised services need to
be commissioned for some groups of patients with complex needs
(eg patients with schizophrenia who need key rehabilitation/recovery
services). Where properly implemented, such services could introduce
cost-savings, as individuals with complex needs often engage with
multiple services but with minimal co-ordination between them,
leading to inefficiency and ineffectiveness. Offender health and
special hospital services should continue to be commissioned at
the regional and national level.
5. Importantly, any decision to commission
specialised services at a local level will need to be decided
by GP consortia and the NHS commissioning Board based on (a) prevalence
of the condition in the local population (which could span several
GP consortia); (b) the extent to which meeting complex patient
needs requires a physical service base (eg therapeutic communities,
mother and baby units, eating disorder units or residential adolescent
units); and (c) whether the strategic overview and development
of such service types across England could be maintained in a
localised organisational arrangement.
6. Furthermore (as described in more detail
in 11 and 12), the commissioning of low volume specialised services
should be based on care pathways which set out a framework of:
(a) assessment standards; (b) evidence-based interventions; (c)
outcomes to be assessed; and (d) the timeliness of assessment
and intervention. Guidance needs to be provided as to the skills
and competencies required of the professionals who undertake the
assessment and interventions. The Royal College of Psychiatrists
and the Royal College of General Practitioners welcome the opportunity
to lead the development of such pathways and make them available
as templates upon which commissioners could plan local services.
7. Secondly, descriptions of the nature
and extent of population health needs should take into account
the likelihood that people with serious mental illnesses are often
not on a GP practice register. For example, in some areas, we
know that over half the people with serious mental illness in
a GP registrant population do not appear on the GP register and
consequently do not receive physical health care services. This
inequality in access to services can contribute to the premature
mortality of people with serious mental illnesses (ranging from
10-25 years depending on locality). Commissioning incentives which
narrow this gap are therefore required both to improve the information
to commission services at a local, regional and national level,
as well as bringing people with the most complex needs into primary
care. Practical ways in which this could be achieved include the
NHS Commissioning Board and GP consortia working to create clinical
networks of primary and social care professionals. These networks
could link with public health bodies and users and carers, who
can draw on existing knowledge (such as that in a Joint Strategic
Needs Assessment) to scope and describe the local health and social
care requirement.
CLINICAL ENGAGEMENT
IN COMMISSIONING
How will commissioners access the information
and clinical expertise required to make high quality decisions
about the shape of clinical services?
8. There are at least four ways:
(i) through promoting and sustaining multi-professional
involvement;
(ii) ensuring that commissioners have the skills
and confidence to make decisions about services providing mental
health care;
(iii) providing information to allow commissioners
to implement care pathways; and
(iv) developing an overall suite of outcome measures.
9. Firstly, multi-professional involvement
in commissioning can be most effectively promoted and sustained
through joint-working by the relevant Colleges, national or regional
bodies and allied social care professions. Practice staff other
than doctors will bring vital insight and expertise to the table—not
only in terms of mental health issues but also, importantly, with
regard to proper arrangements for the physical healthcare of mentally
unwell patients. Foundation Trusts should also consider placing
staff within consortia. Although this may present certain conflicts
of interest, anecdotal evidence suggests that integrated approaches
to commissioning work rather better than combative ones, so agreements
at source between commissioners and providers would be an important
pursuit. A joint team of mental health specialists and commissioning
consortia should evaluate and inform the strategic development
of integrated care pathways for psychological therapies. This
should be underpinned by patient and carer participation and development.
It will also be important for the Boards of GP consortia to consult
or, if necessary, include other professionals groups, such as
Directors of Nursing and Chief Pharmacists as well as representatives
from the Local Authorities, to ensure multi-professional and multi-agency
leadership of decision-making.
10. Secondly, there is an opportunity to
improve GP skills in mental health. People presenting with mental
health conditions constitute 25% of the daily workload of every
GP. We believe that (a) at least one member from every GP practice
team should have had mental health training; (b) each consortium
should have a Mental Health Lead which could oversee this and
other training needs; (c) GP mental health specialist leadership
could be strengthened through existing structures (such as the
National Leadership Council); (d) post-graduate qualification
in mental health should be made available to GPs.
11. Thirdly, information on care pathways
needs to be provided to all commissioners. Primary mental healthcare
is largely related to persons suffering mild, moderate or (in
some cases) severe depression, anxiety and other conditions historically
referred to as common mental health problems. GP consortia should
ensure that (a) care is being provided in line with commissioned
pathways including NICE guidance for the relevant conditions into
clinical practice (including NICE guidance on physical health
problems where a mental health condition is associated with this);
(b) outcomes are evaluated using indices and instruments that
have been established (for instance as part of the Improving Access
to Psychological Therapies programme); (c) incentives and levers
to existing measures of quality improvement such as the Quality
Outcomes Framework (QOF) are used to shape pathway implementation,
and Commissioning for Quality and Innovation (CQIN) is used to
drive upstream interventions, primary prevention and public wellbeing.
Consortia must ensure that there are sufficient mental health
clinicians including psychiatrists, therapists and support workers
to deliver the pathway. The consortia should use aggregated data
on, for example, employment, to demonstrate the public health
and economic impact of their constituent practices' activity.
12. To provide the information needed to
meet this goal, a "Commissioning Pack" for mental health
needs to be produced for GP commissioning consortia. This should:
(a) outline and explain all types of services; (b) clarify for
GP commissioners the pathways of care; (c) contribute to methodology
for clinical quality review by commissioners of providers; (d)
capture the effectiveness of alternative solutions and interventions
chosen by patients exercising individual budgets; (e) help establish
demonstrable improvements in health and wellbeing of mentally
unwell and other populations through the use of outcome measures;
(f) help undertake clinical and economic analysis on behalf of
GP consortia of the operational reconfiguration of inpatient populations
and hospital structures required to achieve the objectives of
Quality Innovation Productivity and Prevention (QIPP); (g) help
design primary prevention strategies for specific conditions (eg
postnatal depression); (h) assist the design, in consultation
with public health colleagues, of community interventions for
health and wellbeing, and (i) assist with evaluation of the impact
on communities of primary preventative and wellbeing initiatives.
13. Fourthly, all practices should use care
pathway determined outcome measurements. The RCPsych should be
consulted to ascertain whether it could play a role in terms of
data collection and analysis. For example, an outcomes quality
network for mental health could enable consortia to compare their
performance with one another in the context of robust and fair
outcomes data. The Royal College of Psychiatrists already undertakes
benchmarking with mental health services across the country. Data
could be used to populate data-packs for individual GP and psychiatrist
appraisals. This would align the goals of the local and wider
NHS to the aims and objectives of individual practitioners, and
also further integrate outcomes data into quality systems in both
GP practices and Mental Health Foundation Trusts.
How will commissioners address issues of clinical
practice variation?
14. Firstly, variability in experience,
knowledge, skill and focus is likely to exist both within GP practices
and across GP consortia. Since the mechanics of commissioning
for mental health are in their infancy, the potential exists for
GP commissioners to adopt a path of least resistance—procuring
by block contract, for example. This would represent a missed
opportunity. We believe the risk of this is can be mitigated by
a commissioning framework. This should be set and quality assured
by the NHS Board with regional or other local coordination.
15. Secondly, GP Consortia will need guidance
to ensure their quality assurance parameters and mechanisms are
consistent with those of colleagues (as set out by Care Quality
Commission and Monitor). It is likely that systems to enable this
in mental health are not as developed as in other areas of clinical
commissioning activity. Consequently, the expertise of organisations
such as RCPsych and the NMHDU will be essential, as will a commissioning
pack in which to make, sustain and extend these connections.
16. Thirdly, in addition, Accountable Officers
in each of the GP consortium should be encouraged to identify
a Mental Health Lead for that GP consortium (or share one a lead
with another consortium). This Mental Health Lead will need to
work with consortium or regional commissioning support to ensure
the principles of best practice mental health commissioning are
embedded into behaviours and processes in consortia. Mental Health
Leads should be encouraged to form a network, whether regionally
or nationally, to share and develop best practice, and organisations
such as the RCPsych and RCGP can assist with their coordination.
GP consortia must ensure that they have access to a specialist
advice and ensure that primary and secondary care develop a pathway
rather than an artificial commissioner/provider split.
17. Fourthly, the use of regularly published
and agreed pathways and outcome data would help drive-up clinical
quality, consistency, and equity. If sufficiently detailed information
were available, this could be used to enable patient choice. It
would be advantageous to develop clinical dashboards for clinicians,
practices, and mental health teams. If adequately developed and
deployed, the use of the Mental Health Clustering Tool (MHCT)
can provide a core tool for monitoring and assuring primary (and
secondary) care performance. This becomes stronger and more meaningful
if aligned to a suite of outcome indicators for different broad
areas of mental healthcare. Using Payment by Results Mental Health
Clusters commissioners can identify what should happen for whom.
Procuring mental healthcare consequently becomes: (i) much more
business-like (and therefore attractive to stewards of public
funds); and (ii) a basic minimum standard exists of what a patient
can expect from being placed on a certain pathway is achieved
(which aids patient empowerment through the passage of reproducible
information). Primary care performance may also need aligned incentives,
for instance shared audits with secondary care.
How will GPs engage with their colleagues within
a consortium and how will consortia engage with the wider clinical
community?
18. See above.
ACCOUNTABILITY FOR
COMMISSIONING DECISIONS
How will patients make their voice heard or their
choice effective?
19. Commissioning must actively and meaningfully
consult and involve representatives from the population it wishes
to serve. For urban settings, this must include hard-to-reach
groups such as asylum seekers, the homeless, the chronically severely
unwell and offenders. Having heard from these groups, commissioning
should encourage processes and systems that enable balances of
legitimately differing perspectives to be resolved between users,
carers and providers in everyday clinical practice.
20. The litmus tests of success in this
endeavour is not so much engagement with services (although this
is important at the outset). Instead it is the acquisition of
recovery and citizenship on the part of patients who become emancipated
from being defined solely as "service users". Commissioning
must therefore also ensure that (i) employment, education and/or
voluntary activities exist for all; and (ii) that patient expertise
and peer mentorship is used where appropriate to provide interventions.
21. The significance of this approach is
that it is drives prevention and partnerships. Involving Health
Watch and Patient Participation Groups becomes an essential condition
to the commissioning process, links with Local Authorities, and
forms the bedrock of an approach which is as concerned with the
antecedents of mental ill health as treatment itself.
22. Mental health is well-placed to champion
multi-professionalism in mental health commissioning. This is
because practitioners tend to operate in a culture of multidisciplinary
teams in which consultants often have leadership roles.
23. Both Health Watch and Patient Participation
Groups must ensure input for individuals with mental health experience,
including both those with ongoing illnesses and those who have
recovered.
What will be the role of the NHS Commissioning
Board?
24. See above.
How will commissioning interface with the Public
Health Service?
25. The setting up of health and well-being
boards—underpinned by statutory powers—is an effective
structure to achieve joint working across health, social care
and public health. These boards should include Directors of Public
Health as this would provide a mechanism whereby commissioning
will interface with the public health service at the local level.
Members of GP consortia will require sufficient training in mental
health to ensure they are able to influence debates and discussions
about appropriate public health interventions. This will help
ensure that public mental health is adequately addressed in the
joined up commissioning plans devised by health and well-being
boards.
How will commissioning interface with Health Watch?
26. GP consortia will be held to account
by local HealthWatch groups. HealthWatch should takeover the complaints
advocacy services currently run by the NHS, resulting in GP consortia/commissioners
being held to some account for the quality of the services they
provide, while supporting service users and carers in their healthcare
choices.
INTEGRATION OF
HEALTH AND
SOCIAL CARE
How will any new structures promote the integration
of health and social care?
27. Firstly, there is also considerable
research on joint working and partnership, and it would be very
helpful for the Department of Health to summarise this to inform
better integrated working.
28. Secondly, GP practices can make stronger
links with local authorities by: (i) solutions based on the needs
of "citizens" as well as "patients"; (ii)
programmatic approaches to commissioning with unified GP and Local
Authority leadership; (iii) single commissioning strategies for
Brighter Futures; (iv) full engagement with personalisation and
self-directed support; (v) Total Place-based models of public
sector commissioning; (vi) evaluation against outcomes and decommissioning
where there is no evidence of impact; (vii) shared financial and
operational risk; (viii) working with social enterprises to build
resilience across populations; and (ix) single, lean governance
mechanisms.
29. Thirdly, Joint Strategic Needs Assessment
is poorly supported by public health professionals and agencies
in some areas. This is because proficiency is lacking in the need
to prioritise mental health and specialist learning disability
commissioning. Some mental health-specific JSNAs have been developed
by a joint Primary Care Trust/Local Authority Health and Wellbeing
Teams, and these are examples of good practice. In other areas,
local Mental Health and Learning Disability Partnership Boards
(established between PCTs and Mental Health Trusts with multiagency
representation) have been part of informing and scrutinising the
findings of specific population health needs assessments and these
partnerships and working models should similarly be preserved.
What arrangements are proposed for shared health
and social care budgets?
30. No comment.
What will be the role of local authorities in
public health and commissioning decisions?
31. Local authorities will play a major
role in this through the role set out for them in the proposed
health and well-being boards. As regards public health, money
ring-fenced for local public health budgets (under the Directors
of Public Health) should be further ring-fenced for public mental
health strategies and interventions. In terms of commissioning,
only if members of GP consortia are given both sufficient training
in mental health and the requisite training in the needs assessment
functions currently carried out by PCTs, will those commissioning
mental health care be able to adequately contribute to the joined
up commissioning plans across the NHS, social care and public
health which the newly-created health and well-being boards will
be responsible for.
OTHER ISSUES
32. The Commissioning Board must also ensure
that universities and NHS training structures will interface with
the proposed new system so that teaching and training of undergraduate
and post-graduate professionals can be fully supported with minimal
disruption during any transitional periods. Thought will also
need to be given to how professionals in training can move between
jurisdictions in the UK and how revenue flows from consortia to
universities and teaching hospitals (in respect of Service Improvement
for Training and funding for original research, for instance).
Many academic posts are currently supported by NHS Trusts and
if they are uncertain of their revenues they will be loathe to
continue their investment in these posts, meaning checks and balances
may need to be introduced into the system to prevent destabilisation
of innovation.
October 2010
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