GPs are in a strong position to improve the commissioning of mental health care. We see the impact on individuals, their families and carers, and on the community as a whole.
We see whoever walks through the practice door, and taking a holistic approach allows us to target general health measures, as well as address specific issues, for example the risks of being on atypical antipsychotics.
This article outlines three main ways in which GP commissioners can improve mental health outcomes in their area.
Use the NHS Outcomes Framework
The first NHS Outcomes Framework sets out the outcomes and corresponding indicators that will be used to hold the NHS Commissioning Board to account for the outcomes it delivers through commissioning health services from 2012/13.
The main domains within the NHS Outcomes Framework are:
- Preventing people from dying prematurely
- Enhancing quality of life for people with long-term conditions
- Helping people recover from periods of ill health or following injury
- Ensuring people have a positive experience of care
- Treating and caring for people in a safe environment and protecting them from avoidable harm.
These goals are all relevant to mental health, and can be used as a starting point for discussion on how they might be applied to that area of care. Long-term conditions are of particular interest, with the known incidence of depression in diabetes, COPD, rheumatological and neurological conditions. Detailed guidance on each domain is available on the Information Centre website, including packages of the indicators for each domain.¹
Draw up outcomes-based measures
Commissioning is currently based on block contracts, and is activity-based – for instance numbers seen, or admissions prevented. Local commissioners may have built in some approaches that focus on patients’ recovery within service specifications, but it varies widely. Some areas operate user-centred recovery-based models, as recommended in NICE guidance on patient experience.²
Opportunities will emerge to unpick existing block contracts and develop outcomes-based measures with shadow Payment by Results (PbR). This is not the same as acute hospital PbR, but allows patients to be placed within a cluster, where appropriate interventions, based on NICE guidance, can be linked to care plans.
This is still being worked through in pilot sites, and is in shadow form in most of England. We can start to address cluster diagnoses and build recovery measures and outcomes: users can set targets or goals at outset with support, interventions can be evidence-based and agreed measurable outcomes can be agreed. Links to personalisation of health and social care budgets can have a positive impact on improving recovery, including that of people with personality disorder.
Here in Mid-Essex CCG, we decided to take a proactive approach to outcomes, despite the uncertainty of how organisations would be set up in the new world. We formed a joint working group with the local authority, who led an exercise with all the stakeholders to build a consensus on how, in our area, we will use outcomes within contracts.
We ran a productive two-day workshop with stakeholders, and developed a report outlining high-level performance indicators and outcomes that would be meaningful and measurable. These can then be taken by commissioners and put into more detail if this needs to be specified within a contract. An example might be showing the number of people successfully changing their lifestyle, an ‘outcome’ that could be broken into smoking cessation, participation in an exercise programme and reducing obesity levels, for instance (A few examples of our outcomes-based measures are in the box, below).
We will pilot the use of each outcomes-based measure within an agreed area, and review it next year. We will also feed it into our work on the PbR programme, and this will allow us to have a better understanding on whether PbR will generate more effective commissioning by CCGs and the local authority.
Better information is going to be critical – from coding through to performance monitoring. Users’ views need to be central to evaluation, as well as families and carers.
Our intention is to establish a partnership board with the local authority, to have a joint strategy and work programme for mental health and learning disability commissioning, and use similar methods in developing our commissioning intentions in the future.
Involve key stakeholders
A major challenge in mental health commissioning is the impact of social care as a determinant of recovery, especially as regards housing, personal finance, education and training and employment. As a consequence, integrated approaches to commissioning outcomes are the preferred approach.
There are many ways this can be done, including:
- Running fully integrated pooled budgets – a legally binding contract with the local authority to share resource in developing and implementing strategy
- Joining national pilots of community budgets, of which there are currently four (one being within Essex, where I work)
- Setting up partnership boards with the local authority to develop joint commissioning approaches, falling short of full pooled budgets.
Which model a CCG uses will depend on local culture, experiences of joint working and its appetite for risk sharing. In addition to local authorities, a number of other stakeholders need to be worked with to develop improved outcomes. It is vital that you include the third sector, as they allow greater choice and flexibility for users of services, and can often contribute to developing solutions with their wide experience in mental health, for instance through delivering advocacy services. Other stakeholders include local acute trusts, community trusts and services, schools, educational institutions, adult learning, job centres and Citizens Advice Bureaux.
Dr Caroline Dollery is the director of Mid Essex CCG and a GP in Danbury
1 NHS Outcomes Framework. ic.nhs.uk/statistics-and-data-collections/audits-and-performance/nhs-outcomes-framework-indicators
2 NICE. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. nice.org.uk/cg138
- We have given our Improving Access to Psychological Therapies (IAPT) service a CQIN aimed at improving access for the elderly population, with three linked outcomes (Patient Health Questionnaire 9, Generalised Anxiety Disorder 7 Recovery, and reduction in crisis referrals).
- We have asked for the ‘recovery star’ model to be used in all pathways in secondary care, with an outcome of assessing success of treatment programmes, and compliance with evidence-based treatments. It will also inform us of any gaps in service provision, and the need to make stepping up or stepping down a patient’s treatment more effective.
- Our main provider has agreed to use a Core Assessment and Outcomes Package across all pathways and to train doctors to use it.
- We have specified the need to improve physical health for mental health patients which will be achieved through primary care.
- We have asked to improve access for patients by developing more local care – linked outcomes for this will be reducing DNAs, improving completion of treatment and improving recovery outcomes. It will also be linked to medication outcomes – planned to be improving consistency in prescribing and reducing antipsychotics in the elderly and in patients with a learning disability.
- We are linking the accommodation strategy of the local authority with mental health services to encourage earlier discharge to appropriate supported housing. We hope this will make it easier to implement patient-held health and social care budgets.
- We have developed a learning disability outcomes framework to be used in contract negotiations with providers.