Are GPs up for commissioning mental health?
CCGs are at different stages in different parts of the country.
Some 35 are just completing authorisation while others are waiting to begin the process.
Levels of engagement and cohesion between GP commissioners, local authorities, public health, community services and patient groups varies from CCG to CCG.
What is consistent though is the message from GPs that they want to ensure the delivery of services to their patients that are of good quality, fairly distributed, cost effective and needs-led. This has always been the case, regardless of a new health act being introduced.
So what of mental health commissioning? It is a complex and multifaceted area steeped in risk, variety and sheer scale. But mental health and wellbeing threads its way through everything. It makes the commissioning of diabetes, cardiovascular or hypertensive care look like a walk in the park. There are layers to mental health delivery and care pathways meander and intertwine. It is often difficult to disengage mental health from physical health, social care, housing, benefits, employment, carers’ needs and so the list goes on. The level of expertise that is required to commission mental health services, end-to-end is daunting. It is also the sheer scale and numbers of people suffering with mental health problems. A staggering 1 in 4 people in the UK suffer depression and/or anxiety alone at some point in their lifetime. And these are the ones who come to the NHS. Big White Wall has identified that 73% of people using its anonymous online interface service are presenting a significant new problem for the very first time. And as well as a huge body of unmet need there are also issues of ethnicity and culture, community variability and involvement and the language of mental health which simply does not translate into some languages. In Somali, for example, there are very few words which relate to mental health so depression and anxiety as words simply do not exist. Understanding the needs of veterans and armed forces personnel and their families or those that have come from countries at war is also critical.
I think there are four ‘types’ of CCGs in relation to commissioning mental health. The first are those saying ‘no thanks’ to commissioning mental health and allowing it to be commissioned on a larger scale with centralised expertise. The larger commissioning organisations can then deal with the all complexities of multiple mental health trusts, deliver the ranges of services required at scale and oversee the performance and ensure the maintenance of standards. The second ‘type’ of CCG are saying that the commissioning should be centralised but at a sector level with local GP (CCG) clinical representation. In this model perhaps a local CCG would be the host commissioner with the main responsibility of delivery sitting within a CSU. The third type is a confident CCG that wants to take this on but with care that a range of expertise is bought in and on site. The fourth is the sector approach aligned with a single big mental health trust where the provider performance is more closely matched to commissioner expectation with well defined local input at ground level defining the detail of the population needs. Throughout all the models it is essential to have LA commissioners on board with a collaborative and joint vision. Environment, housing, benefits, social care and also the links and funding of third sector support services are essential to success.
It is essential to recognise the skills needed to effectively and safely commission mental health services. Service users and local population must be at the heart in all scenarios. You need commissioners who recognise the potency of effective self-management training for users as demonstrated through the Co-creating Health initiatives and the Expert Patients Programmes. Users of mental heath services across the system have some really clear messages to give us about the continuity and cohesiveness of care. GP commissioners are well placed to listen to, work with and co-create the very services that service users are looking for.
Having been involved locally with the development of our IAPT services and latterly with London IAPT, I have worked with several local community groups.
I have heard many service-user conversations which have made me even more aware that mental health is hugely complex with extraordinary challenges, risks and variety. CCGs need the capacity, confidence, courage and expertise to deliver against this; many may struggle. Elements could sit in local GP commissioning but taking this on as a whole could be extremely challenging.
Dr Peter Ilves is a GP and clinical commissioning lead for West Wandsworth CCG in London and primary care consultant to Big White Wall