Written evidence from the Royal College
of Psychiatrists (CFI 13)
The Royal College of Psychiatrists is the leading
medical authority on mental health in the United Kingdom and is
the professional and educational organisation for doctors specialising
in psychiatry.
We are pleased to respond to this consultation. This
consultation was prepared by: Dr Neil Deuchar and Chris Fitch.
This consultation was approved by: Dr Neil Deuchar (Associate
Registrar).
SUMMARY
— While
the Government has stated that all clinicians will need to work
collaboratively to share expertise in the commissioning of services,
they have not stated how this will work in practice.
— Consequently,
the Royal College of Psychiatrists believe that basic steps should
be taken to ensure that mental health is assured equal parity
with physical health, and that care is effectively commissioned
across primary and secondary boundaries. These are:
Each GP consortia should appoint a psychiatrist
to sit on, or have a formal role, in advising its board
— The
psychiatrist or specialist clinician can strike a balance between
providing (a) expert knowledge about resident population need
and local mental health service provision, while (b) drawing on
wider knowledge about the most effective evidence-based practice
and interventions.
— The
psychiatrist can also help GP Consortia ensure meet the complex
needs of people with serious mental illnesses by commissioning
co-ordinated primary and secondary care, as well as integrated
local authority services.
Each GP consortia should also appoint a Mental
Health Lead (which should be a GP) to directly work with local
Medical Directors and other clinicians (JSNA)
— This
formal relationship should have two aims: (a) ensure that a "gap"
does not exist between those commissioning and providing services;
and (b) ensure that co-ordinated commissioning occurs across the
primary and secondary care levels, including integrated local
authority services, to meet the needs of people with mental illness.
— It
should be supported by the formation of a national network that
links and brings together (physically or virtually) GP Mental
Health Leads and local Medical Directors. This could promote and
share local innovation, while underlining adherence to standardised
care pathways.
Each GP consortia should ensure that psychiatrists
are centrally and fully involved in any Joint Strategic Needs
Assessment
— This
should happen because concerns already exist - acknowledged by
a number of local authorities - about the ability of local authorities
to ensure the JSNAs reflect the true prevalence of mental health
problems and the needs of their populations.
— There
is a danger that simply expecting GP consortia (with no prior
expertise in this area) to undertake these JSNAs will replicate
the problems which local authorities have encountered.
The NHS Commissioning Board should establish a
national advisory group on commissioning for mental health and
wellbeing
— A national
advisory group formed from specialist clinicians, providers, commissioners,
patients and carers would help the NHSCB establish the type and
form of specialised services that need to be commissioned at the
national and regional level, and help ensure co-ordination between
local GP Consortia commissioning and this level.
— The
College have serious concerns about barriers to the scope for
clinical involvement.
— It
will be critical in the new system that clinicians (both GPs and
psychiatrists) feel able to work closely to improve local services.
Reassurances are needed that clinicians will not be accused of
breaking Competition Law by working closely on commissioning and
service delivery issues with GP Consortia or the NHSCB.
— The
College are already working to help improve clinical involvement
in commissioning
— In
helping to achieve the above aims, we draw attention to a new
initiative the Joint Commissioning Panel for Mental Health. A
collaboration between the RCGP, RCPsych, NHS Confederation,
ADASS, NMHDU, Rethink, Mind, and the National Survivor and User
Network this will publish a series of practical frameworks for
mental health commissioning from April 2011.
INTRODUCTION
1. Following the publication on 18 January 2011
of the Health Committee's second Report on commissioning, it was
announced that the Committee would be considering a number of
issues in more detail. A call for further evidence was made.
2. This document is the response of the Royal
College of Psychiatrists to three of these issues:
(a) what should the arrangements
be for integrating the full range of clinical expertise into the
commissioning process?
(b) what should the arrangements
be for ensuring that the separation of commissioner and provider
functions does not obstruct high quality and cost effective services?
and
(c) what should the arrangements
be in terms of the NHS Commissioning Board performance managing
GP consortia, and also ensure that service commissioned centrally
by the NHS Commissioning Board link in with decisions taken by
local consortia?
3. In this response we adopt a primary focus
on clinical involvement. When dealing with issues (b) and (c)
we do so in the context of our discussion on such involvement.
4. It should be noted that the College supports
the involvement of the full range of clinical staff working in
mental health into the commissioning process. In this response,
however, we do describe the specific benefits of centrally
involving psychiatrists in commissioning. Psychiatrists are:
— specialist
doctors with key expertise in caring for patients with conditions
such as depression, anxiety, personality disorders, learning disabilities
and schizophrenia;
— who
work with other mental health professionals as part of a team,
will also often have a management or leadership role within secondary
care, and will often have links with primary care;
— who
work with the patient to manage their mental disorder using measures
such as drugs, psychological counselling, improving home environments
and social networks, and physical health care; and
— who
hold roles managing and leading organisations, individual or groups
of services, or demonstrating leadership in their frontline clinical
work with patients and their carers.
CLINICAL INVOLVEMENT
5. In general, the College welcomes the emphasis
in the Health and Social Care Bill on putting the patient at the
centre of care, the increased involvement of clinicians in commissioning
(with a corresponding reduction in management costs), and the
provision of care across health and social care boundaries.
6. The College remains concerned though about
how the scale and the pace of change may impact on the
care and, in particular, the continuity of care that can be given
to patients with mental health problems.
7. We are, however, particularly concerned that
in some areas the new GP consortia will not have developed
the skills or expertise to support mental health commissioning
and believe that there needs to be engagement of specialist clinicians
from the outset.
8. However, while the Government has stated that
all clinicians will need to work collaboratively to share expertise
in the commissioning of services, they have not stated on record
how this will work in practice.
INVOLVING SPECIALIST
CLINICIANS
9. Although the Government intend to give GP
Consortia, Local Authorities and the NHS Commissioning Board the
autonomy to develop their own forms of involvement, this should
be balanced with the fact that these are statutory bodies funded
by public money and with the physical and mental health
outcomes of local people at stake. Consequently, we believe that
some basic mandatory steps should be taken to both ensure that
mental health is assured equal parity with physical health, and
that care is effectively commissioned across primary and secondary
boundaries. These are:
9.1 Each GP consortia should appoint a psychiatrist
to sit on, or have a formal role, in advising its board
WHY?
— The
population prevalence of mental health problems and disorders
requires the perspective of a psychiatrist or specialist clinician
who can strike a balance between providing GP consortia both with
(a) expert knowledge about resident population need and local
mental health service provision, while also being (b) able to
draw on wider knowledge about the most effective evidence-based
practice and interventions.
— This
central involvement is critical. And need exists to ensure that
(a) GP Consortia are aware (and put into practice) guidance from
NICE and other credible sources on evidence-based, standardised
pathways which consistently provide high-quality care and health
outcomes for patients; and (b) ensuring that local contextual
factors are taken into account in developing and delivering such
care, including the often highly variable access of different
population groups to such high-quality services.
— Striking
this balance between reducing variance in making available high-quality
and more standardised care, while taking into account (and reducing)
high levels of variance in access to these pathways, represents
a challenge that psychiatrists will be able to assist the GP consortia
in meeting.
— International
research by the Nuffield Trust indicates that specialist clinical
involvement is key in both planning and delivering care in close
cooperation with primary care.[33]
Research within the UK has also found that involving specialist
clinicians within commissioning was perceived as key due to their
local and clinical knowledge, and their role in driving subsequent
changes in service structure and delivery.[34]
— In
addition to addressing the established links between patients'
physical and mental health, there is also a responsibility for
consortia to ensure that they meet the complex needs of people
with serious mental illnesses by commissioning co-ordinated
primary and secondary care, as well as integrated local authority
services. The presence or involvement of a psychiatrist in the
consortia board will help ensure this is achieved
— Finally,
we believe that without the specialist clinical expertise of psychiatrists
in commissioning a danger exists that people with mental illness
(many of whom have specific diagnoses and needs which are not
always well understood, and where the cost of treatment is often
higher) will be a lower priority for GP consortia. As the new
English mental health strategy reminds us, there must be a parity
between physical and mental health conditions.
REQUIRED CHANGES
TO THE
BILL (CLAUSE
21 (14O) AND CLAUSE
21 (14Z))
— For
GP consortia (Clause 21 (14O)), the duty to "obtain appropriate
advice" is described as:
"obtain appropriate advice from people with
professional expertise in relation to physical and mental health.
This could involve, for example, a consortium employing or otherwise
retaining healthcare professionals to advise the consortium on
commissioning decisions for certain services, or appointing professionals
to any committee that the consortium may set up to support commissioning
decisions."
— We
believe that a responsibility should be placed on GP consortia
to appoint a psychiatrist to sit on, or have a formal role, in
advising its board
— We
also believe that the responsibility placed by the Bill on the
GP consortia (Clause 21 (14Z)) to publish annual reports should
include a duty to report how they obtained such appropriate
advice from specialist clinicians.
— This
will help ensure that there is a check on meaningful involvement
from secondary care specialists - who, after all, are the health
professionals with the most experience of, and knowledge about,
particular groups of patients - in the commissioning of services.
9.2 Each GP consortia should also appoint
a Mental Health Lead (which should be a GP) to directly work with
local Medical Directors and other clinicians
WHY?
— A GP
Mental Health Lead should be appointed by the consortia to directly
work with Medical Directors based in the local Trust (or Trusts
depending on GP consortia size). This formal working relationship
should have two aims: (a) ensure that a "gap" does not
exist between those commissioning and providing services; and
(b) ensure that co-ordinated commissioning occurs across the primary
and secondary care levels, including integrated local authority
services, to meet the needs of people with mental illness.
— Having
both a GP Mental Health Lead working in an ongoing, daily manner
with Medical Directors, and the appointment of a psychiatrist
to sit on the GP consortia, provides a mechanism for both strategically
directing the commissioning of mental health care (often in line
with standardised, evidence based care pathways or guidance),
while taking into account more nuanced local and contextual issues.
— This
formal working relationship between the GP Mental Health Lead
and the local Medical Director(s) should be supported by the formation
of a national network that links and brings together (physically
or virtually) GP Mental Health Leads and local Medical Directors.
This could help promote and share local innovation, while underlining
the need for adherence to standardised evidence-based care pathways.
— Secondly,
the GP Consortia Mental Lead should develop contact with clinical
reference groups or managed clinical networks (where they exist),
or the MH Lead could help take steps towards the creation of these.
— Identifying
local clinical leaders will represent an important challenge for
GP consortia, so such points of contact are vital. Furthermore,
existing clinical reference groups or managed clinical networks
have made an appreciable impact in a number of specialty areas.
Although reported as comparatively rarer in mental health, they
can provide contact with professionals working across primary,
secondary and tertiary care (as well as trust, social services,
and professional lines), and this may be important particularly
in low population areas where there may be small numbers of specialist
clinicians.
9.3 Each GP consortia should ensure that
psychiatrists are centrally and fully involved in any Joint Strategic
Needs Assessment
WHY?
— This
should include the appointed psychiatrist (see 9.1 above) as well
specialist clinical experts or leaders identified by the Mental
Health Lead.
— This
should happen because concerns already exist - acknowledged by
a number of local authorities - about the ability of local authorities
to ensure the JSNAs reflect the true prevalence of mental health
problems and the needs of their populations.[35]
[36]
[37]
[38]
— There
is a danger that simply expecting GP consortia (with no prior
expertise in this area)to undertake these JSNAs will replicate
the problems which local authorities have encountered.
REQUIRED CHANGES
TO THE
BILL (PART
5, CLAUSE 176)
— In
Part 5, Clause 176 the Bill sets out the framework for "Joint
Strategic Needs Assessments"
— The
JSNA is the process that identifies current and future health
and wellbeing needs in light of existing services, and informs
future service planning taking into account evidence of effectiveness.
JSNAs are currently carried out by the local authority, but Clause
176 sets out a joint responsibility between local authorities
and GP consortia.
— Amendments
are needed to ensure that the NHS Commissioning Board is required
to produce guidance for consortia on how to conduct a Joint Strategic
Needs Assessment such that it best captures the current and
future needs of their population in its entirety; and to ensure
that GP consortia are required to demonstrate that they have taken
this guidance into account when conducting their JSNA.
— This
guidance should make recommendations about the central involvement
of psychiatrists and other specialist mental health clinicians
in line with 9.1, 9.2, and 9.3 above.
— 9.4 Foundation
Trusts can help by offering to place psychiatrists or other staff
within GP consortia - this will, again,
help integrate mental health expertise and leadership into the
heart of consortia.
9.5 The NHS Commissioning Board should establish
a national advisory group on commissioning for mental health and
wellbeing
WHY?
— The
same challenges - as outlined in 9.1 to 9.3 - confront the NHS
Commissioning Board as they do GP consortia.
— A national
advisory group formed from specialist clinicians, providers, commissioners,
patients and carers would help the NHSCB establish the type and
form of specialised services that need to be commissioned at the
national and regional level.
— It
would also help the NHSCB in its additional role of contracting
and monitoring GP Consortia, to ensure the local, regional, and
national commissioning of services provides a coordinated and
coherent experience of care. As explained earlier, this is important
for patients with complex health and social care needs, as they
often require intervention not only from specialist mental health
services (at the regional or national level), but also from local
social care, primary care, voluntary organisations, and social
and family networks. There is a need to avoid such patients "falling
between" GP consortia and the NHS Commissioning Board, or
patients receiving uncoordinated, fragmented, or inappropriate
"out of area treatments" (with implications for health
and social outcomes).
REQUIRED CHANGES
TO THE
BILL (CLAUSE
19, (13G) AND (13P))
— Like
GP consortia (see 9.1), the NHSCB (Clause 19 (13G)) also has the
duty to 'obtain appropriate advice' in carrying out their functions
and to:
— "take
the view of other healthcare professionals, so it can effectively
discharge its functions."
— We
believe that a responsibility for establishing a national advisory
group on commissioning for mental health should be placed upon
the NHSCB.
— We
also believe that the responsibility placed by the Bill on the
NHSCB (Clause 19 (13P)) to publish annual reports should include
a duty to report how they obtained such appropriate advice
from specialist clinicians.
— This
will help ensure that there is a check on meaningful involvement
from secondary care specialists - who, after all, are the health
professionals with the most experience of, and knowledge about,
particular groups of patients - in the commissioning of services.
HELPING TO
ACHIEVE CLINICAL
INVOLVEMENT: AN
RXAMPLE
10. In helping to achieve both the aims outlined
above within mental health, we draw the Health Committee's attention
to a new initiative the Joint Commissioning Panel for Mental
Health:
— this
is a collaboration between the RCGP, RCPsych, NHS Confederation,
ADASS, NMHDU, Rethink, Mind, and the National Survivor and User
Network (other organisations to be confirmed);
— it
will publish a series of practical frameworks for mental health
commissioning from April 2011 aimed specifically at those commissioning
during the current transition from PCT to GP consortia;
— publish
briefings on the key values and principles for effective mental
health commissioning;
— support
commissioners in commissioning mental health care that delivers
the best possible outcomes for health and well being;
— offer
a means for GP consortia and the NHS Commissioning Board to "obtain
appropriate advice" from clinicians and other groups when
carrying out their functions.
11. Further details about this initiative are
available by contacting the Policy Unit of the Royal College of
Psychiatrists.
BARRIERS TO
CLINICAL INVOLVEMENT
12. We do, however, have concerns about barriers
to the scope for clinical involvement and the commissioning of
mental health services as described in the current Health and
Social Care Bill.
13. Clinical involvement, competition, and
conflict of interest
WHY?
— it
will be critical in the new system that clinicians (both GPs and
psychiatrists) feel able to work closely to improve local services.
— reassurances
are needed that clinicians will not be accused of breaking competition
law by working closely on commissioning and service delivery issues
with GP consortia or the NHSCB.
— we
are concerned about a situation where providers who have been
unsuccessful in bidding for services may cite the close working
between clinicians as a conflict of interest, and we feel that
clarification on what is acceptable and unacceptable behaviour
in terms of contact between GPs and other clinicians should be
given by the NHS Commissioning Board at the outset in order that
all clinicians know where they stand.
HOW DOES
THIS RELATE
TO THE
BILL?
— Section
51(1a) places a duty on Monitor to promote competition in health
and adult social care services, while Section 62 ensures that
healthcare services come under the aegis of the Office of Fair
Trading (under part 4 of the Enterprise Act 2002).
— the
College is seeking clarification on a potentially contentious
issue whereby clinicians may feel that they will be accused of
breaking competition law by working collaboratively over service
issues.
OTHER BARRIERS
TO CLINICAL
INVOLVEMENT
14. There are a number of other barriers to specialist
clinicians becoming sufficiently involved in the commissioning
process:
— pressure
of existing work commitments - the benefits
to both of the health of patients at the population level,
and an individual patient in their respective service,
needs to be communicated and instilled in specialist clinicians;
— effectively
working across primary and secondary care service boundaries -
challenges in working (and effective commissioning) across primary
and secondary care boundaries are well recognised. There may be
a need to consider the benefits of psychiatrists having a greater
role in primary care commissioning and delivery. This could result,
for example, in GP registrants with serious mental illnesses and
long-term conditions receiving specialist input without the need
for referral to secondary care, as well as attendees with Medically
Unexplained Symptoms and co-morbidities benefiting from specialist
oversight of personalised care planning free from the stigmatisation
and potential iatrogenesis of referral to psychiatry in secondary
care settings;
— no
appropriate links or relationships for engagement
- research undertaken on US Physician Groups indicates that involving
clinicians requires a range of opportunities and channels.[39]
including informal and formal (paid) positions. These could include
associated networks, taking on governance functions, attendance
at general meetings, or specialist working groups. Doctors were
also compensated for their involvement;
— incomplete
understanding of the commissioning process - specialist
clinicians may perceive themselves as lacking the knowledge and
understanding about commissioning to participate. and
— lack
of support or incentive from employing organisation - there
may be benefits, for example, of Foundation Trusts placing specialist
clinicians within GP consortia.
OTHER ISSUES
15. ANY WILLING
PROVIDER: (CHAPTER
2, CLAUSE 61-63.)
— Chapter
2 of the Bill, in particular Clause 61 will further roll out the
Government's service provision model "Any Willing Provider".
The Government's aim in introducing "Any Willing Provider"
is to promote choice and competition in the NHS. The Royal College
of Psychiatrists support choice and competition where they can
stimulate innovation and, importantly, drive up the quality of
mental health care.
— However,
we are concerned about the potential use of the concept of "any
willing provider" and we have evidence from addictions services
to suggest that the current model has involved frequent retendering,
with decisions often made on price over quality and which has
led to service fragmentation, disruption to continuity
of care, and loss of integration of care pathways.[40]
— We
would like clarification as to whether Any Willing Provider will
apply fully to mental health. If this is the case, we have concerns
that patient continuity of care will suffer under such a system,
and would urge that the Government stipulates that mental health
will instead be subject to competitive tendering, with one main
provider being granted a contract for services rather than myriad
providers under the Any Willing Provider model.
— While
competition is to be welcomed in driving up the quality of care,
it needs to be undertaken in the context of cooperation, integration,
and with the optimum positive impact on the patient's health.
Consequently, we need to ensure that one of the defined criteria
that any "Any Willing Provider" would need to meet is
that despite any transfer of service provision, the patient would
not be aware that they were receiving care from a different provider
— We
would also urge the Government to ensure that competitive tendering
for mental health services should be done on the basis of a minimum
period contracts (whether that service be run by a statutory,
private or voluntary sector provider) in order that the lack of
stability which arises when services are re-tendered after only
two or three years, and which are already apparent in some sections
of the mental health service work, are not replicated across the
sector.
February 2011
33 The Nuffield Trust is one of the leading independent
health policy charitable trusts in the UK They report that: "The
US experience shows that holding risk-bearing budgets can motivate
doctors to deliver efficient, coordinated care that reduces avoidable
and repeated admissions to hospital. However, to achieve this,
the groups had to ensure that primary and specialist doctors cooperated
closely and were able to invest in a range of high quality and
innovative services that offer alternatives to hospital care,
particularly for older patients with chronic conditions.".
http://www.nuffieldtrust.org.uk/aboutus/index.aspx?id=37 Back
34
Cornish, Y, Why involve provider clinicians in commissioning?
Clinician in Management 1995; 4 (5): 5-7 (November 1995). Back
35
http://jsnaonline.org/2008-9/Hull%20Summary%20JSNA%20271008.pdf
(for example, p28) Back
36
www.ic.nhs.uk/webfiles/Services/in%20development/jsna/Calderdale2.ppt Back
37 http://www.cambridgeshire.nhs.uk/downloads/Your%20Health/JSNAs/Mental%20Health%20JSNA.pdf
(for example, p11) Back
38
http://www.northtynesidejsna.org.uk/wp-content/uploads/2010/11/Autism-Adults.pdf
(for example, p9) Back
39
Thorlby R, Rosen R, Smith J GP commissioning: insights from medical
groups in the United States. January 2011, Nuffield Trust. Back
40
http://www.scan.uk.net/docstore/scanBites20.pdf Back
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