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Mental health commissioning must switch to a community-based model

Dr Ian Walton welcomes parts of the latest Department of Health framework for mental health, but argues that it offers little direction for GPs and GP commissioners preparing to take on the work

GPs conduct the vast majority of mental health consultations in the NHS, and yet the recent publication of the ‘No Health without Mental Health' strategy mentions GPs a mere six times in 54 pages. GPs now also have a major responsibility for commissioning mental health services through CCGs and these CCGs will be answerable for the effectiveness of mental health services – even when the funding and commissioning of community services is held by local councils.

The new implementation framework appears to see us as passive recipients of the strategy rather than an active part of it. It is more than a decade since leading GP Dr Andrew Elder and psychotherapist Dr Jeremy Holmes called it ‘paradoxical' that family doctors – who conduct more psychiatric consultations than any other group of professionals in the health service – are often not considered true mental health practitioners.

The situation has not moved on. Community-based and GP-led mental health services are still the exception rather than the rule. Policy makers still continue to see mental health services in primary care as ‘bolt-on' services provided by mental health trusts. This continues despite the economic case for integrating wellbeing approaches into the management of long-term conditions and for improved primary prevention through public health approaches.

The vision of ‘No Health without Mental Health' was seen by many GPs as an opportunity for Dr Elder's whole-person approach to mental healthcare. We know that acute and community services need to tackle the comorbidity of physical and mental health problems and ensure that clinical and other staff are able to spot the signs of mental ill health. We know that older people, either living in their own homes or in residential care, are especially vulnerable to mental health problems such as loneliness, isolation and comorbid physical health needs that increase with age. So, frankly, I find the strategy document disappointing.

The charity I chair, Primhe (Primary Mental Health and Education), believes that GP training in mental health needs to be co-created in the communities they serve, and so I welcome the framework's call for improved training for GPs – but I must also raise a note of caution.

While psychiatrists are the acknowledged experts in specialist mental health, GPs are experts in the management of complex multimorbidity and disease of uncertain aetiology. It would be a tragedy if, while attempting to putmental health on a par with physical health, CCGs underestimated the capacity of GPs to become agents of change in the communities in which their patients live.

The framework is currently just a skeleton, without any meat on the bones, and comes with no investment or compulsion. At the same time, our patients are suffering huge cuts in local authority budgets that are affecting people with severe mental health problems.

It wasn't too long ago that diabetes was a secondary care illness and primary care was on the periphery.Given the emphasis elsewhere in the NHS on shifting service provision into primary care and the community, it is good to see a reference in the strategy to community-based support, parenting interventions, peer support, befriending services and so on. Like diabetes, the numbers requiring help with their mental health continue to increase – it is only by building capacity in primary care and the community that we will be able to afford effective services that can produce the outcomes CCGs will be measured on. As GPs and GP commissioners, we need to be leading on this.

Dr Ian Walton is the chair of the primary mental health education charity Primhe and a GP in Tipton, West Midlands


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