Miranda Griffin asks the experts about the key challenges for GP commissioners in improving mental health outcomes for patients
Do you think most clinical commissioning groups (CCGs) will choose to commission mental health services themselves or delegate to someone else?
SG: It will depend on the level of mental health service, the size of the CCG and whether they are significantly constrained by running costs – in which case they may be forced to delegate more commissioning.
JK: Mental health is an important focus for a CCG's commissioning efforts. The issue is deciding what is appropriate for a CCG to commission and which areas are so complex or serious that they should be commissioned by the specialists. There needs to be a close working relationship between the NHS Commissioning Board and the CCG.
JH: If a CCG includes a GP with a particular interest in mental health it's likely that they'll be involved. Such a GP may be involved in commissioning for a cluster.
EO: There is a model to be applied, but I think we will see a patchwork approach. Policymakers have massively underestimated how much GPs are involved in mental health and it's feared where it doesn't have to be. The whole commissioning structure needs to support the patients and GPs once a diagnosis has been made, and at the moment that support isn't there.
It felt as if mental health wasn't an area many consortia chose to take the reins of under PBC. Why will things be different under CCGs?
JK: It is perceived as a very complex area of care. Sometimes PCTs didn't encourage commissioning efforts to focus on mental health services as efforts were concentrated more on areas such as improving cancer care or reducing admissions to hospital, which had more of a national focus.
But 40% of all contacts in general practice have a significant mental health element. Things will have to change now as the responsibility for the global care of the population will be with the CCG.
JH: CCGs should find it much easier to achieve change generally than it was under PBC, and this will mean certain things are now worth doing where they may not have been before.
EO: You cannot effectively identify depression along with other medical issues in eight to 10 minutes, so it's frustrating for GPs who are effectively setting themselves up to fail if they attempt to get to grips with the problem without the services to back them up. There are some great examples of practices that are not shying away from all the issues surrounding depression. One practice has been looking at integrating all the aspects of wellbeing into the practice with services to deal with things like loneliness and exercise. GPs need to commission these wellbeing services.
SG: Tariff didn't apply in mental health, which made it difficult to recommission subsets of mental health services. This was a barrier to recommissioning smaller sections of care.
What impact did Improving Access to Psychological Therapies (IAPT) have on mental health? What do you think will happen to IAPT now?
JH: I've been the NHS East of England clinical lead for IAPT, so of course I would say it's the best thing since sliced bread. But I do genuinely think it's been brilliant. I now have the ability to offer my patients a choice between medication or a talking treatment if appropriate. Four years ago I didn't have that choice.
I hope that IAPT will be the first step of an improved primary care mental health service. Ten to 15 years ago nothing was spent on primary care mental health, now we've got £200m being spent nationally and with GPs in the driving seat I hope it's seen that spending more is a good thing.
EO: It helped to lift the stigma of depression and opened the doors to using psychological therapies in depression. It's been a very healthy step in the right direction. But it's only a start.
There needs to be back-up for those patients – once you improve their confidence, they need to have somewhere to go to use it. We'd like to see the IAPT budget used in more creative ways with, say, community projects that will carry people through problems like isolation.
JK: IAPT has been very mixed. In some parts of the country it was a success, but in others it had low impact and became a bureaucratic nightmare with huge transactions involved in getting the patient to see the right person. It's got to evolve with a focus on an integrated process.
SG: The future of IAPT has to be about extending the sophistication of the services and the support to primary care, and starting to look at other clinical areas such as children's services and medically unexplained symptoms.
One in three GP consultations has a mental health element. Might GPs choose to ‘make' mental health services, for example employ their own counsellors, rather than ‘buy in' from another provider?
JH: In order to offer all the NICE recommended treatments you need a panoply of talking treatments such as interpersonal therapy and cognitive behaviour therapy – a proper, professionally led service. You can't do it with one person. In the average county it's going to cost £5-6m to deliver that sort of service.
JK: We've had counsellors in our practice for over 10 years and they've felt much more comfortable in an integrated care environment. We sometimes forget that patients with mental health problems also have physical health problems.
For those with more complex needs we had community psychiatric nurses, social workers and clinical psychologists all working with the general practice team and it worked incredibly well in overcoming problems with referrals and access.
SG: IAPT is a lot more sophisticated than just counselling services. It's about the patient accessing the right treatment and ensuring a range of services is available.
Practices could provide services other than just counselling, but the constraint would be making sure you had a robust service that could demonstrate high standards of both triage and delivery of care and follow the procurement rules.
How do you think Choose and Book has fared for mental health and should it have a place in the future?
JH: With the advent of the any qualified provider (AQP) model, Choose and Book has the potential to open up a bit and give patients the ability to choose their treatment more effectively. But how do they know if the treatment they choose is effective for their disorder? This could be overcome by referring to a single point of access which incorporates an assessment so the patient gets the appropriate treatment. Neighbouring services could then compete against each other.
JK: Locally it didn't fare well at all. Many mental health services revolve around a community mental health trust so there wasn't a lot of choice. It was just a mechanism to support the choice agenda and won't survive if it doesn't show added value.
SG: There is a need for choice in mental health services, but I'm not sure whether Choose and Book is the right vehicle. IAPT is important in directing patients to appropriate choices, whereas Choose and Book is about empowering patients in the conversation with their GP in choosing equivalent providers for the same procedure. Choosing services for mental health provision is more nuanced than many other areas and therefore will require more specialist advice.
Mental health creates a large number of emergency admissions – how should GP commissioners tackle this?
EO: If you have really good services such as early intervention teams, you're not waiting until they're in crisis to do something about it. With depression, if you apply services that give effective support at home like peer-to-peer help, that safety net should cut hospital admissions to a minimum.
People with depression don't do well in current NHS hospital acute wards so there should be supportive environments for those who are feeling suicidal and need to come into a safe environment – which isn't necessarily a hospital.
JK: Too often we react to the crisis rather than being proactive with people with mental health problems. We don't always have systems to identify them, call them in for review and make sure they aren't lost to follow-up. Because of the nature of their illness, patients may miss appointments. Unlike patients with diabetes we don't call them in for a six-monthly check, and maybe we need to do that.
JH: You need to commission a primary care mental health service that provides advice for things that can provoke crises such as bereavement, housing problems and relationship problems to stop crises happening.
SG: There are models around the country in terms of crisis response services and early intervention in stepped care. It comes back to good access to services like IAPT and crisis response services for people with more severe disease, which give the patient a specialist assessment at home before it becomes a crisis requiring admission.
There's been a central directive for at least three mental health or community services to be delivered under AQP. Is this helpful?
JK: It is helpful as a short-term means to raise awareness of the choice agenda.
It's a way of showing that mental health patients also need to be allowed to choose where they get their service from.
SG: There are a number of challenges to overcome with the AQP model generally and, in terms of mental health particularly, how you join up the multiple providers of services to provide what to the patient, at least, is an integrated service.
But AQP may work better for mental health services than for other types of service where the patient may only access it once and therefore isn't in a position to use their experience to make a choice next time.
In long-term conditions such as many mental health problems, the patients have a clear view of what makes a good-quality service provider and can exercise their choices well – which may drive up the quality of the services offered.
What needs to change significantly for GP commissioners to bring about better care for patients?
JH: The interface between physical and mental health is very important. Commissioners can reach across the divide so people with COPD or heart disease also have services commissioned that effectively look after their mental health.
EO: For depression and anxiety the only way to commission good services is to do it in a strong collaborative way with medical and non-medical support services. The voluntary sector should be commissioned to help manage people in the longer term. If we can push mental health more into the public health arena, we're looking at more successful routes to recovery and positive impacts on wellbeing.
Which outcomes will define performance in mental health in the future? Are these the right ones?
JH: You need to ask your patients and local GPs which outcomes are important to them, but they'll probably be quite simple.
Was the person treated well? Did they get better? Has it helped them in their lives? Have they got a job?
JK: Outcomes framework indicators such as the patient experience and improving life expectancy will apply to mental health as well.
The patient's overall wellbeing is the important indicator – their schizophrenia may be well controlled but they may be isolated, so a service providing a social network could be the most important part of their wellbeing.
SG: We're only at a rudimentary level of understanding of what a good outcome is, but reduction of severity of symptoms, resolution of the immediate problem, prevention of relapse, reduction in progression of the disease, patient-reported outcomes such as quality of life, drop-out or DNA rates are all important.
How quickly we'll get this sort of data I don't know.
Miranda Griffin is a freelance journalist
Where are we at with mental health commissioning?
Mental health tariff
According to the DH the earliest possible date for a national tariff for mental health is 2013/14.The DH is gathering activity using a national data set which will be used to profile the tariff.
The proposal is that the tariff will be based on care groups – 21 or so different categories of need. Patients will be triaged into different care groups and the tariff will be based on whatever care group they are put into.
Choose and Book for mental health
The processes are slightly different for mental health referrals than for other referrals.
Urgent referrals should not be made this way and Choose and Book may not be appropriate for some vulnerable patients to use. BMA guidance can be found at: http://tinyurl.com/PC-Oct11-01.
The IAPT programme was created in 2006 to give people suffering from depression and anxiety disorders access to the ‘talking treatments', such as CBT.
Currently just over 50% of the adult population has access to a service under the programme.
Dr John Hague (JH): A GP in Ipswich, director of IPSCOM CCG in Ipswich and NHS East of England lead for IAPT
Emer O'Neill (EO): Chief executive, Depression Alliance
Dr James Kingsland (JK): NAPC president and national GP commissioning network lead
Dr Shane Gordon (SG): GP commissioning lead NHS East of England and co-lead of NHS Alliance GP commissioning federation