Written evidence from Rethink (CFI 41)
A. SUMMARY
A.1 General Practitioners have inconsistent
expertise and competence in the area of mental health. The Bill
should provide a duty on commissioning consortia to involve specialist
health and social care professionals meaningfully, and extend
this duty top involving expert patient and carer groups. This
would also provide a stronger foundation for integrated working.
A.2 The wording of the Bill should reflect that
the duty to promote integrated working is for the purpose
of providing integrated services.
A.3 NHS reforms must distinguish between, and
strengthen, patient and public involvement to ensure that mental
health services meet local need. There are many opportunities
within the Bill to address this.
1. The Committee therefore intends to review
the arrangements proposed for integrating the full range of clinical
expertise into the commissioning process. (Paragraph 96)
1.1 The introduction of GP consortia-led commissioning
provides an opportunity to draw on a wider range of expertise
across health and social care expertise. We agree that the full
range of clinical expertise must be integrated into the commissioning
process. However, we believe that this should be extended to the
involvement of expertise from a wider range of professional expertise
(such as public health, social care, education etc) and also to
special interest expert patient and carer groups.
1.2 Mental health recovery is dependent on specialist
treatment and support from a range of disciplines, such as primary
care, psychiatry, psychology, nursing, pharmacy etc. The recovery
needs of the population experiencing mental ill health reach into
other domains, and opportunities for integrated working must be
indentified wherever possible for a truly joined up approach.
This approach will be dependent on those areas of expertise being
drawn up during commissioning from an early stage.
1.3 General Practitioners cannot realistically
develop the level of knowledge and expertise needed to develop
good quality commissioning plans for a full care pathway. Rethink
is not averse to the change in commissioning responsibilities
in principle; despite pockets of good practice, commissioning
through Primary Care Trusts has failed to deliver adequate mental
health provision across the board. However, we have significant
concerns about the ability of GP consortia to commission effectively
for mental health when knowledge of and expertise in mental health
conditions is so inconsistent amongst General Practitioners. This
concern is echoed by GPs themselves. In an independent piece of
research we surveyed 251 GPs and found that just 31% felt 'well-equipped'
to commission mental health services, compared to 75% for diabetes
and asthma.[83]
A further survey of 500 GPs undertaken to probe these findings,
shows:
— 54%
find people with mental illness one of the top three most difficult
groups to engage with. This compares with 37% citing young people,
18% citing black and minority ethnic groups and 7% citing people
with mobility problems.
When we asked whether there were any aspects of commissioning
for patients with mental illness such as schizophrenia and bipolar
disorder that they were worried about:
— 42%
reported lack of knowledge about specialist services for people
with mental illness.
— 23%
cited a lack of knowledge about mental illness.
— 10%
said they did not see people with mental illness very often.[84]
It is evident that the concerns brought regularly
to Rethink by service users and carers are felt by GPs themselves,
many of whom have had little or no specific training in mental
illness or mental health awareness. In light of the Health and
Social Care Bill's publication, mental health service users, carers
and staff have been reporting concerns to Rethink. One mental
health worker based in Leicestershire noted:
"One example is of a Practice where one General
Practitioner was able to recognise a manic episode in a patient,
whilst another GP in the same practice felt the problem was just
'bad behaviour.' There seems to be so little consistency in mental
health training."
1.4 Previous attempts at GP fund holding ('total
purchasing pilots') failed to deliver for mental health. Only
39% of mental health purchasing objectives were met. The formal
evaluation noted: "That the lowest rate of achievement
was in mental health is scarcely surprising given the complexity
of purchasing and service development in this field."[85]
This highlights the importance of a concerted effort in this health
area to draw on all available expertise to inform quality commissioning.
1.5 Rethink, and other national voluntary sector
patient organisations, are calling for a strengthening of the
duty for commissioning consortia (and the National Commissioning
Board) to 'obtain advice' from professionals with specialist expertise.[86]
Currently the Bill states that the National Commissioning Board
"must make arrangements with a view to securing that it
obtains advice appropriate for enabling it effectively to discharge
its functions from persons with professional expertise relating
to the physical or mental health of individuals". To
'involve' is a much stronger duty which will lead to greater involvement
of professional and patient groups, which the Government has stated
as an aim of the Bill.
1.6 We also consider it essential that this duty
be extended to 'involving patients and carers' in addition to
expert professionals. This is one area within the Bill where 'No
decision about me without me' can really be delivered. There is
a considerable resource in expert patients and carers, many of
whom have been co-opted into local service design and planning
over the years in order to achieve the highest quality care pathways.
It would be right for this duty to extend to drawing on the expertise
of these individuals and groups.
2. The commissioning of services that either
work across [health and social care] boundaries, or are intimately
linked is therefore an issue to which the Committee attaches great
importance, and we intend to review the effectiveness of the structures
proposed in the Bill which are designed to safeguard co-operative
arrangements which already exist and promote the development of
new ones. (Paragraph 107)
2.1 As referenced under the previous section,
we have concerns around how the Bill will ensure multi-agency
commissioning and integrated working, which are essential if patients
are to get the care they need.
2.2 The Commissioning Board and the Health and
Wellbeing Boards are required to "encourage" integrated
working between health and social care, and GP Commissioning Consortia
and local authorities required to "work closely together".
Neither of these sets out a clear aim to ensure the provision
of integrated services, and we urge the Government to strengthen
this.
2.3 The health charities' joint briefing (ref.
4) recommends amendments to the Bill:
Section 19, (Clause 13J) Page 17, line 40
Insert "integrated" before final word of
paragraph "services"
Section 179 (Clause 2) Page 152, line 33
Insert "integrated" before the final word
of the paragraph "services"
The inclusion of the word "integrated"
will ensure that the duties to promote integrated working are
for the purpose of the provision of integrated services.
3. The Committee does not find the current
stance on patient and public engagement in commissioning persuasive.
The National Health Service uses taxpayers' resources to deliver
a service in which a high proportion of citizens take a close
interest both as taxpayers and actual or potential patients. While
the Department may be right to point out that there is no special
virtue in uniformity of structure, the Committee regards the principle
that there should be greater accountability by commissioners for
their commissioning decisions as important. We therefore intend
to review the arrangements for local accountability proposed in
the Bill. (Paragraph 118)
3.1 The current provisions for patient and public
involvement within the Bill must be strengthened for "No
decision about me without me" to become a reality. We are
very pleased to see that this has been identified as an area for
further inquiry by the Committee, as this is a priority concern
for Rethink and the health charities working together on these
issues.
3.2 The Health and Social Care Bill offers an
opportunity to improve scrutiny structures and ensure that patient
voice across England is listened to and understood. This issue
is particularly pertinent for people affected by mental illness,
a traditionally marginalised group who often struggle to get their
voices heard in existing structures. Rethink is keen to ensure
that changes to the way scrutiny takes place are wholly positive,
and that mechanisms are consistent whilst retaining the flexibility
to react to the local landscape.
3.3 Rethink believes that the heavy emphasis
of the Bill on "patient involvement" for the delivery
of democratic legitimacy is misguided. We would welcome a clear
definition of "patient involvement" in the Bill, and
believe that this is an essential element of effective treatment
and support. However, "patient involvement" and "public
involvement" are different. "Patient involvement"
alone will not deliver the extent of involvement and scrutiny
anticipated by local populations. This is particularly important
for groups which have historically been inconsistently understood
and supported by GPs, including people with mental illness.
3.4 With regard to public involvement in service
design and planning, the Bill is focused on HealthWatch. Rethink's
primary concern, based on previous experience of LINks, is that
HealthWatch is unlikely to be representative of all health areas,
those patient groups who are most vulnerable, and those who may
be unable to commit to such a formal involvement role. We would
therefore like to see stronger duties on GP and local authority
commissioners to involve local communities, including "hard
to reach" groups, in local decisions about the services they
use. The increased funding for HealthWatch is unlikely, in our
view, to be used for this function at local level given pressures
on local authority budgets.
3.5 There are many opportunities presented in
the Bill to strengthen public involvement. We are working alongside
the aforementioned health charities to highlight these. Most important
perhaps, is the need for a definition of "public involvement",
which should set out the typical opportunities throughout the
commissioning process. We are particularly concerned with regards
to the wording of the duty on the Board and on commissioning consortia
to ensure that people using services are involved, "whether
by being consulted or provided with information or in other ways".
It is essential to achieve the aspirations of the Bill that patients
and the public are meaningfully involved, which is seriously undermined
by the freedom for commissioning bodies to "provide with
information".
3.6 Rethink is regularly contacted by local mental
health service users and families who feel that poor decisions
are being taken, without meaningful consultation, about which
they are offered information at a late stage with no opportunity
to influence. We cannot emphasise strongly enough the importance
of taken this opportunity to deliver true involvement in local
decision making.
3.7 Similarly, we believe that the inclusion
of lay members within GP consortia constitutions would be line
with the aspirations of the Government to draw on resource and
expertise within communities. The Big Society approach has given
greater opportunities to the public in the areas of education
and public services, and we do not see how Health can justifiably
be excluded from this.
3.8 Opportunities for local scrutiny should also
be strengthened within the Bill. Local authorities will be responsible
for the scrutiny of local health service provision, including
those services provided by the local council. However, they will
have flexibility to do this as they see fit. There is no requirement
for the council to have an "Overview and Scrutiny Committee"
made up of elected representatives. Whilst the policy landscape
has shifted in terms of commissioning responsibility, there is
no reason why the principle of local accountability should not
remain the same. Whilst we do not propose a requirement for local
authorities to maintain Overview and Scrutiny Committees per
se, there must be clarity around the expectations in terms
of resource and independence provided by leadership by elected
representatives. If provision is not made to remedy this on the
face of the Bill, Rethink believes that the proposed approach
to scrutiny will not be adequately independent, or accessible
to the public.
4. RETHINK MENTAL
ILLNESS - WHO
ARE WE?
4.1 Rethink is the leading national mental health
charity, helping everyone affected by mental illness recover a
better quality of life. We are the largest voluntary sector provider
of mental health services in England, and have a 10,000 strong
membership.
February 2011
83 Rethink, Fair Treatment Now, 2010 Back
84
Rethink, NHS Reforms, 2010 Back
85
Nicholas Goodwin, Nicholas Mays, Hugh McLeod, Gill Malbon, and
James Raftery, on behalf of the Total Purchasing National Evaluation
Team (1998) Evaluation of total purchasing pilots in England and
Scotland and implications for primary care groups in England:
personal interviews and analysis of routine data, British Medical
Journal 25; 317(7153): 256-259. Back
86
Age UK, Alzheimer's Society, Asthma UK, Breakthrough Breast Cancer,
British Heart Foundation, Diabetes UK, National Voices, Rethink
and the Stroke Association: The Health and Social Care Bill
- Health charities respond (briefing) Back
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