Written evidence from the Mental Health
Foundation (COM 98)
Thank you for the opportunity to provide written
evidence to your inquiry into NHS commissioning. Our evidence
looks at the challenges involved in commissioning mental health
services, in light of the Coalition Government's plans to move
responsibility for NHS commissioning from Primary Care Trusts
(PCTs) to GP-led consortia and a new NHS Commissioning Board.
The Mental Health Foundation is the leading
UK charity working in mental health and learning disabilities,
bringing together research, service development and policy. It
incorporates the Foundation for People with Learning Disabilities
(FPLD). This submission has been written jointly with Dr Alan
Cohen, GP and Director of Primary Care at West London Mental Health
NHS Trust.
SUMMARY
GP-led commissioning does have the potential
to improve both physical and mental healthcare for people with
mental health problems—but only if certain conditions are
met.
These conditions include:
— the implementation of a national tariff
for mental health care;
— GP-led consortia management allowances
that allow for the hiring of high quality mental health commissioning
expertise;
— effective commissioning partnerships
between local GP-led consortia and the NHS Commissioning Board,
which may be responsible for commissioning a range of services
for people with more severe mental health problems;
— an acknowledgement from GPs that mental
health commissioning needs to reflect a social model of recovery,
not just clinical care, and must include whole population mental
health promotion work; and
— the outcomes against which GP-led consortia
are measured must be designed in partnership with mental health
service users and their families.
There are a number of specific issues that current
and future mental health commissioners need to address, including
commissioning for outcomes, the impact of personalisation, Payment
by Results (the national tariff), the creation of integrated care
pathways and improving public mental health.
We recommend the development of a toolkit for
mental health commissioning specifically aimed at GP-led consortia
and the NHS Commissioning Board, using as its starting point existing
recent guidance on commissioning mental health services on the
basis of best evidence.
BACKGROUND
One in four people will experience a diagnosable
mental health problem in any year. One adult in six experiences
a mental health problem at any one time—mainly mixed anxiety
and depressive disorders but including schizophrenia and bipolar
disorder. One child in 10 aged 5-15 has a mental health problem.
A 2008 report from the King's Fund (Paying the Price, 2008)
estimated that in 2007 there were in England some 8.65 million
adults with mental disorders including 2.28 million with anxiety
disorders, 1.24 million with depression, 1.14 million with bipolar
and related disorders, 210,000 with schizophrenic disorders and
580,000 with dementia.
A recent analysis of the social and economic
costs of mental health problems in England estimated the annual
cost is £105.2 billion, of which £21.3 billion is the
direct costs of health and social care (The economic and social
costs of mental health problems in 2009-10, Centre for Mental
Health, 2010).
For the NHS, mental health is the biggest item
in PCTs' shopping baskets.
Primary care and mental health
90% of all mental health care is undertaken
in primary care. However primary care still remains underskilled
in its treatment of mental illness, with many GPs acknowledging
a lack of expertise in the area and many people failing to get
optimum care (for example, not everyone gets the best evidenced
interventions as set out in NICE guidance). The Foundation's 2009
survey of GPs undertaken for its report on Mindfulness indicated
that 75% of GPs have prescribed antidepressants to people with
recurrent depression even though they believed that an alternative
approach might have been more appropriate.
The fundamental failure of primary mental health
care is due to the following factors:
— inadequate training of primary care workers
in mental health. Many GPs have limited mental health training
despite around a third of their time being spent with patients
with mental health needs;
— despite recent welcome improvements there
remains inadequate access to effective treatments such as psychological
therapies and exercise therapy, and an over-reliance on medication
with a level of inappropriate prescribing;
— GPs remain the gatekeepers to the vast
majority of mental health care, with too few opportunities for
people to self-refer to support services;
— poorly defined care pathways through
primary care services and into more specialist services (and vice
versa); and
— poor information systems not linked to
secondary care.
PCT commissioning
Widespread concerns about the quality of PCT
commissioning underpin the Coalition Government's White Paper
proposals. Certainly within PCTs mental health commissioning remains
underdeveloped in many areas, often with those responsible not
having a background in mental health, or doing it only as part
of their job, or being relatively inexperienced. Most expertise
continues to reside within secondary care providers, so local
mental health trusts dominate local service provision. This is
not to say that there are not some expert mental health commissioners
within PCTs—but it is a patchy picture across the country.
Existing guidance
It is important that existing guidance on commissioning
mental health services is not overlooked. Commissioners currently
have access, for example, to Commissioning for personalisation:
a framework for local authority commissioners (Department
of Health, 2008) and The Commissioning Friend for Mental Health
Services (National Mental Health Development Unit, 2009).
This latter guidance points out that in recent years:
"The focus of commissioning has broadened,
reflecting the need to view mental health as a whole population
issue. This includes moving towards a more holistic approach to
service delivery and through such an approach enabling service
users to experience positive mental health and wellbeing"
(p 6).
LIBERATING THE
NHS: COMMISSIONING FOR
PATIENTS (JULY
2010)
The Coalition Government's proposals include
moving most commissioning from PCTs to GP-led consortia, with
more specialist services commissioned by a new NHS Commissioning
Board.
GP-led consortia
There have been two previous waves of GP led
commissioning, starting with GP fundholding in the 1990s. So far
as mental health was concerned, two lessons came out: the commonest
service purchased was on-site counselling (now acknowledged as
an important area for development, as evidenced by the Coalition
Government's continuing commitment to the Improving Access to
Psychological Therapies (IAPT) programme). The second lesson was
that commissioning services for people with severe and enduring
mental illness was very difficult or unsuccessful.
More recently, practice-based commissioning
(PBC) has focused on areas where national Payment by Result tariffs
exist. This has effectively excluded mental health services where
no tariff has yet been implemented nationally.
GP-led commissioning does have the potential
to bring improvements to people with common mental health problems
(such as depression and anxiety disorders). First, if the IAPT
programme is maintained, it will help to highlight the links between
mental health and long term physical health conditions, and ensure
that the physical health needs of people with mental health problems
(which can be ignored) are better met. Second, it could help rigorously
to implement standardised, evidence based interventions.
The situation is less clear in respect of people
with serious and enduring mental illness. At present many services
such as early intervention teams, crisis intervention teams, child
psychology services and forensic services cover much large populations
than the 150,000 population it is suggested GP consortia will
cover. This could mean that quite a wide range of services for
people with more severe mental disorders would be commissioned
instead by either a lead commissioner within a "consortia
of consortia" or the NHS Commissioning Board. If that is
the case, there would be a challenge to ensure effective care
pathways, given that many individuals will over time move, in
stepped care, between a range of services of different types and
intensity.
GPs at present lack commissioning skills, and
it is likely that many GPs have no desire to learn those skills.
The proposals will therefore require a significant training input
allied to the hiring of expert commissioning staff to undertake
the nuts and bolts of commissioning. If the managerial allowance
is set too low then both the quantity and quality of commissioning
experience is likely to suffer, as will the cost benefits and
patient outcomes that good commissioning can yield.
GPs naturally have a primarily clinical approach
to their patients but many people with mental health problems
require a wider social model of care, and multidisciplinary interventions,
to help them recover. It is not easy to see how the new arrangements
will guarantee better joint working between the NHS, local authority
social services and the new local authority-led Public Health
Service than the current arrangements, despite the obligations
to involve local authorities and local health and wellbeing boards.
NHS Commissioning Board
The White Paper suggests that the NHS Commissioning
Board will commission national and regional specialised services.
We assume this will include the three high secure hospitals in
England (at Ashworth, Rampton and Broadmoor). However, as noted
above, it is possible that a range of services for people with
more severe mental illness may end up being commissioned by the
NHS Commissioning Board.
The Coalition Government's proposals suggest
that "it makes sense" for the NHS Commissioning Board
to have responsibility for commissioning health services for,
among others, those in prison or custody. We are not so sure.
It is estimated that approximately 70% of prisoners have either
a psychosis, a neurosis, a personality disorder, or a substance
misuse problem. Many will move in and out of prison on a regular
basis, in the same way that some patients will move between hospital
care and care in the community on a regular basis, and from medium
secure to low secure facilities, or vice versa. In these circumstances
it is essential that a clear care pathway is commissioned and
this may be more difficult if some services are commissioned locally
and some by the NHS Commissioning Board.
ISSUES FOR
CURRENT AND
FUTURE MENTAL
HEALTH COMMISSIONERS
There are a number of issues that current and
future mental health commissioners need to address, including:
— commissioning for outcomes;
— Payment by Results (the national tariff);
— integrated care pathways; and
A short note of each of these is set out below.
Commissioning for outcomes
GP-led consortia will need to work within the
national Outcomes Framework imposed by the Department of Health
(following consultation). The outcomes against which GP-led consortia
are measured must be designed in partnership with mental health
service users and their families.
It is not yet clear what these mental health
outcomes will look like, but in any case we believe that commissioners
will need to ensure that the services they commission are NICE-concordant;
that adequate funding must be made available to allow the widespread
implementation of such services; and that there must be a wide
range of service providers available to allow genuine patient
choice in meeting their own desired and agreed outcomes.
Payment by Results
The diverse and fluctuating nature of mental
health problems means that accurately predicting costs of treatment
and support is hard. However it is now expected that a set of
Payment by Results "currencies" for adult mental health
services will be introduced from 2012-13. There are also plans
to develop currencies for child and adolescent services.
It is important that this work continues to
be prioritised. Once agreed and implemented, the national tariff
(covering a number of mental health patient "clusters")
should significantly help GP-led consortia and the NHS Commissioning
Board in making equitable commissioning decisions.
Integrated care pathways
GP-led consortia and the NHS Commissioning Board
will need to adopt a whole systems approach involving integrated
care pathways and stepped care.
Integrated care pathways provide the opportunity
for effective multidisciplinary support for individuals, based
on guidelines and evidence for specific groups of patients, while
at the same time ensuring close service user involvement including
service-user reported outcome measures. The stepped care model
involves matching individuals to the lowest appropriate level
of service, only stepping up to more specialist services when
and if clinically required—or stepping down if that level
of intervention is no longer needed. All interventions at all
levels need to be evidence-based and effective, but stepped care
means that individuals are not inappropriately treated by overqualified
professionals in more expensive settings that required. NICE has
lent its support to this model in its guidance, for example on
stepped care in anxiety (CG22), depression (CG23) and obsessive
compulsive disorder (CG31).
Personalisation
As the personalisation agenda is rolled out
and an increasing number of people become able to commission not
only their own social care support but also their health care
through personal health budgets, commissioners will need to shape
the local health and social care provider market to ensure patients
have a genuine choice about their treatment and care provider.
The White Paper is unclear about the interface between GP-led
consortia and the personalisation agenda, and further clarification
is needed.
Public mental health
We welcome the White Paper's emphasis on GP-led
consortia having to ensure that they draw on the advice and support
of the local health and wellbeing board in relation to population
health and identify ways of achieving more integrated health and
adult social care.
The creation of a new Public Health Service—to
be hosted by local authorities—creates an opportunity to
focus resources on areas of health promotion and illness prevention.
However the health promotion debate still tends to focus heavily
on trying to address physical health needs (through, for example,
smoking, diet and exercise). Less than 0.1% of the total NHS adult
spend on mental health is currently directed at mental health
promotion work. It is essential that GP-led consortia recognise
that this needs to change and, indeed, that good mental health
is a key resource underpinning the choice of healthier lifestyles.
Good mental health commissioning must start
with prevention and health promotion. As The Commissioning
Friend for Mental Health Services puts it (p 11):
"Services will need to be based more around
models of recovery [rather than traditional mental health services]
and seek to promote positive mental health and wellbeing in a
broader public health context."
CONCLUSION
In 2007 the Foundation published a report (Primary
Concerns: A better deal for mental health in primary care,
2007) that looked at, among other things, practice-based commissioning
(PBC), a precursor of GP-led consortia. The conclusions and recommendations
reached then remain valid today, namely:
— the introduction of a national tariff
for mental health services;
— a training agenda for GPs to reflect
the commissioning skills they would require;
— the rapid development of joint commissioning
by primary care practices; and
— commissioning for the mental health needs
of the whole population.
However the Coalition Government's proposals
are of course more radical than PBC, with all GP practices obliged
to become members of GP-led consortia.
We conclude that GP-led commissioning does have
the potential to improve both physical and mental healthcare for
people with mental health problems—but only if certain conditions
are met.
These conditions include:
— the implementation of a national tariff
for mental health care;
— GP-led consortia management allowances
that allow for the hiring of high quality mental health commissioning
expertise;
— effective commissioning partnerships
between local GP-led consortia and the NHS Commissioning Board,
which may be responsible for commissioning a range of services
for people with severe mental health problems;
— an acknowledgement from GPs that mental
health commissioning needs to reflect a social model of recovery,
not just clinical care, and must include whole population mental
health promotion work; and
— the outcomes against which GP-led consortia
are measured must be designed in partnership with mental health
service users and their families.
We recommend the development of a toolkit for
mental health commissioning specifically aimed at GP-led consortia
and the NHS Commissioning Board, using as its starting point existing
recent guidance on commissioning mental health services on the
basis of best evidence.
October 2010
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