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How to... commission mental health services

Patients with less severe mental illness are often neglected by current provision of services, but PBC offers a chance for GPs to put this right, says Dr John Hague

Patients with less severe mental illness are often neglected by current provision of services, but PBC offers a chance for GPs to put this right, says Dr John Hague

Most GPs can probably identify several groups of patients who seem to have been left behind by current mental health provision. Together they form a neglected majority whose needs are just not met, and who keep on returning to GPs' surgeries, leaving us to offer the 'usual care' of an SSRI and a few minutes of our time, and, if they are lucky, a few sessions of counselling.

Nine out of 10 of the million people claiming incapacity benefit for mental illness are 'not ill enough' to qualify for secondary mental health services. Another group costs a fortune in needless investigation of their 'medically unexplained symptoms', patients who represent 2% to 3% of all primary care workload in the UK, along with about 40% of outpatient attendances.

Those with long-term medical conditions often have depression or anxiety as well as the physical condition. Treating the co-morbid mental health problem can improve the physical health of patients (for example, increasing the number of diabetes patients with good control by 40%), and often saving money at the same time as improving health status (saving £2 to £3 for every pound spent on CBT for those with severe COPD, for example).

Evidence shows that psychological therapy offers patients with most common mental health problems a chance of recovery as good as medication, but with a better chance of staying well after therapy ends.

Despite improvements, 'talking treatments' are unlikely to be available at short notice. Practice-based commissioning offers a chance to redress the balance, and I recommend any new services serve those with chronic medical conditions, and a couple of other easily identifiable groups (see below).Initially it may be tempting to raid the coffers of your trust, close a few beds, asset-strip a couple of community mental health teams and use the money to fund practice-based counsellors or arrange for a practice-attached community psychiatric nurse.

A more productive plan is to assess what is needed, with the help of stakeholders (see box below right), then use this to design a service that meets local needs. This will ensure maximum local support and maximum use of stakeholder resources. Failing to follow this route will destabilise services for little long-term benefit.

To smooth the passage of your ideas through the PBC and PCT bureaucracy, it is a good idea to make sure all your suggestions are fully compliant with the National Service Framework for Mental Health, and with NICE guidelines. This need not be a burden, and in fact can be very helpful.

All of these policies contain large numbers of recommendations that apply directly to primary care mental health, which have not yet been implemented in most areas. Just sticking to these makes sense – they will help patients, provide a better service and are backed by evidence.

Just like the old saying 'nobody ever got fired for buying IBM', the same applies here. No one can criticise you for implementing national guidance, and it will be much harder for anyone within the bureaucracy to oppose your suggestions, if they have already been recommended by NICE or the NSF.

The stepped-care system

The Department of Health programme Improving Access to Psychological Therapies (IAPT) offers a wealth of resources to help you. IAPT firmly advocates NICE guidelines and stepped care, where all patients have the least burdensome treatment first, are assessed at the end of the treatment, and step up to a more intense treatment if needed.

Full implementation of stepped care involves changes at every step – for example encouraging community resources for minor depression, links with job centres to help people back to work, changes in primary care to ensure that assessment, advice, prescribing and referral are logical, of uniform good quality and as inexpensive as possible – for instance, do you need to use expensive branded antidepressants when there are SSRIs available generically?

When commissioning steps after primary care you could think about an initial 'low-intensity high-volume' step, which uses guided self-help and telephone follow-up. Patients who do not improve in response to this first step should be referred to a 'low-volume high-intensity' step, staffed by more experienced therapists, who supervise those in the lower tier.

Those working in secondary care will find the volume of patients needing low intensity interventions challenging (see box right). When commissioning new services you have to work out a way of paying for it.

You could do this by a combination of investment from other projects that free up resources, some judicious (and mild) re-organisation of current provision, or by targeting those with medically unexplained symptoms, projecting savings on antidepressant use, or by reducing acute admissions. You should marshal your arguments into a careful business plan. You need to think how the freed-up resources are to be monitored – if you are projecting a saving in admissions for COPD, for example, make sure this is monitored. There is a lot of work here, but PBC offers the best chance we have been presented with for years to improve mental health services so they really meet patients' needs. Go on, get involved; you can make a difference.

Dr John Hague is a GP in Ipswich and a mental health adviser to Suffolk PCT. At present he is working on the expert reference group for the IAPT programme, and leading on a county-wide mental health PBC project

PBC target groups

  • Those not working
  • Medically unexplained symptoms
  • Perinatal mental illness
  • The elderly
  • Adolescents
  • Step-down care for stable psychosis
  • Comorbidity
  • Those needing talking therapy

A stepped-care system

In the stepped care system delivered by the IAPT Doncaster demonstration site, the system managed 300 referrals a month (in a population of about 300,000, accepting referrals for all patients other than those treated by child and adolescent mental health services). Of these, between 750 and 850 at any one time will be on low-intensity treatment and 45 to 65 people will have been stepped up to high-intensity treatment, principally formal CBT. This level of activity is achieved within six months of the stepped care operating start date for low-intensity treatments and within a year for high-intensity CBT.

Source: Professor Dave Richards

Who to talk to Who to talk to

-At least two service users, who should have suffered from a common mental health problem
-Practice nurse and other members of the primary care team
-GPs
-PCT commissioner
-Public health consultant or specialist
-GP mental health lead
-LMC
-Mental health trust locality director
-Strategic health authority
-Community mental health team manager
-Community mental health team worker
-Social services
-Crisis team manager or worker
-Finance adviser from the PCT
-Job Centre Plus
-Voluntary organisations – especially those offering benefit, debt and employment advice
-Local ethnic minority organisations
-Primary care counselling or psychology
-Mental health trust psychologist
-Consultant psychiatrist

A stepped care system A stepped care system

In the stepped care system delivered by the IAPT Doncaster demonstration site, the system managed 300 referrals a month (in a population of about 300,000, accepting referrals for all patients other than those treated by child and adolescent mental health services). Of these, between 750 and 850 at any one time will be on low-intensity treatment and 45 to 65 people will have been stepped up to high-intensity treatment, principally formal CBT. This level of activity is achieved within six months of the stepped care operating start date for low-intensity treatments and within a year for high-intensity CBT.

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