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Practical mental health commissioning explains the changing commissioning environment and how commissioners can make the most of available resources to improve the quality and outcomes of mental ...

Practical mental health commissioning explains the changing commissioning environment and how commissioners can make the most of available resources to improve the quality and outcomes of mental health and social care services in their area.

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    Practical mental health commissioning Practical mental health commissioning Document Transcript

    • Joint Commissioning Panelfor Mental Healthwww.jcpmh.infoPractical Mental Health CommissioningA framework for local authorityand NHS commissioners of mental healthand wellbeing services Volume One: Setting the Scene Produced by Andy Bennett Steve Appleton Catherine Jackson
    • AcknowledgementsThis framework is the product of contributions from many colleagues from the National Mental HealthDevelopment Unit. The authors would particularly like to thank the membership organisations of the JointCommissioning Panel for Mental Health for their written contributions and comments. Our thanks to: np National involvement PartnershipAndy BennettAndy has most recently worked across the National Mental Health Development Unit commissioningprogramme in conjunction with the ADASS mental health, drugs and alcohol policy network. He hasled on a range of actions to support and strengthen integrated commissioning in mental health andrelated areas across the NHS and local authorities. He has had broad previous NHS and social careexperience, including acute, community and social care commissioning. A social worker by profession,he has also worked as an interim NHS director of commissioning, among a number of senior roles.Steve AppletonSteve is an independent consultant at Contact Consulting, a specialist consultancy and researchpractice working at the intersection of health, housing and social care. He has previously worked atan operational and strategic level in local authorities and the NHS. His particular interests are thehealth, housing and social care needs of those with mental health problems, learning disability, substancemisuse, older people and offender health. In his work for the NMHDU commissioning programmehe has focused on the development of effective commissioning in mental health, housing and QIPP.He wrote The Commissioning Friend for Mental Health Services (NMHDU/CSL) in 2009.Catherine JacksonCatherine is a consultant editor and journalist specialising in mental health and social care. She has workedfor many years in the mental health field and was formerly editor of Mental Health Today magazine. Commissioned and supported by
    • A framework for local authority and NHS commissioners 3ForewordHealth and social care commissioners The JCP-MH represents: Joint Commissioning Panelin England are operating in a time of for Mental Health:* • a coming together of the Royalconsiderable change. Shaped by the Colleges of General Practitioners Dr Neil Deucharprovisions of the Health and Social Care and Psychiatrists Co-chair of JCP-MH and LeadBill, the new commissioning landscape for Commissioning, Royal Collegefor health and social care will be led at • in partnership with the Association of Psychiatristsa local level by GP consortia and local of Directors of Adult Social Services,authorities. British Psychological Society, Healthcare Professor Helen Lester Financial Management Association, Co-chair of JCP-MH and Lead forAt the same time, mental health services Mental Health Commissioning, Interprofessional Collaborative onwill also be shaped by No Health without Royal College of General Practitioners Mental Health, National CollaboratingMental Health, the new English mental Centre for Mental Health, NHS Kieron Murphyhealth strategy. This has a focus on Confederation and the Royal College Commissioning Programme Director,prevention, improved public mental of Nursing National Mental Health Development Unithealth, and better outcomes for peopleexperiencing mental ill health. • and spearheaded by the views of Steve Shrubb Mind, the National Involvement Director, Mental Health Network,In response, the Joint Commissioning Partnership, National Survivor and User NHS ConfederationPanel for Mental Health (JCP-MH) Network and Rethink Mental Illness.has launched its first publication, Richard WebbPractical Mental Health Commissioning Recognised by the Department of Honorary Secretary Elect, Association– Volume One: Setting the Scene. Health, and developed in collaboration of Directors of Adult Social ServicesThe JCP-MH is a new collaboration with the JCP-MH and other professionals, Paul Jenkinsbetween a range of leading organisations Practical Mental Health Commissioning Chief Executive, Rethink Mental Illnesswith the aim of improving effective – Volume One: Setting the Scene bothcommissioning for mental health, explains the current changes occurring Paul Farmerlearning disabilities and wellbeing within commissioning, and provides advice Chief Executive, Mind(visit www.jcpmh.info for more details). that aims to help all current and future Sarah Yiannoullou commissioners to develop and deliver high Programme Manager, quality, effective and efficient services. It National Survivor User Network encourages commissioners to take a broad Fran Singer whole systems approach to their work. Programme Co-ordinator, As the current reforms unfold, the National Involvement Partnership JCP-MH will continue to develop and launch the further volumes of the mental *These organisations were involved in the production of Practical Mental Health health commissioning framework. Commissioning – Volume One: Setting the Scene. Since then, the Royal College of Nursing, Drawing on the involvement of people Healthcare Finance Management Association, with experience of using services, Interprofessional Collaborative on Mental Health, carers, clinicians, commissioners, and the National Collaborating Centre for Mental Health and the British Psychological Society organisations providing services and have also become members of the JCP-MH, support, we will aim to provide the and will be involved in future work. values, evidence and practical advice that commissioners will need in these challenging times.
    • 4 Practical Mental Health CommissioningContents Introduction 1. The changing 2. What 3. Going forward: commissioning mental health what mental health landscape commissioning commissioners looks like now need to know 07 31 36 Conclusion Glossary Useful links Glossary 51 52 55 57
    • A framework for local authority and NHS commissioners 5IntroductionThis framework is the first of three Mental health describes a broad continuumbriefing documents for commissioners in of mental states that extends from mentallocal authorities and the NHS. It is intended illness, through mental ill health thatto explain the changing commissioning may not reach the threshold for a formalenvironment and how commissioners can diagnosis, to positive mental health andmake the most of available resources to wellbeing. People will move in and out ofimprove the quality and outcomes of mental these states throughout their life course,health and social care services in their area. depending on a range of factors and influences, although most of us will notWe are currently going through a period experience severe mental ill health.of change in the way mental health andsocial care services are commissioned. Mental health is important at individual andThese changes are outlined in the Coalition family levels; it is no less important withinGovernment’s Health and Social Care communities and still more widely withinBill and were first published in the White our society as a whole. Interventions thatPaper Equity and Excellence: Liberating improve the mental health of individualsthe NHS and the related policy document will also improve the mental health ofA Vision for Adult Social Care: Capable communities and promote and protect theCommunities and Active Citizens. mental health and resilience of the wider population. Better levels of mental healthAt the same time, our understanding of within the wider population also mean lessthe issues that mental health commissioning severe mental illness, and better levels ofneeds to address is developing just as support for those who are unwell.radically, informed by the growing bodyof evidence on the influence of wider Health and social care services are risingpsychosocial factors on mental health to the challenge to maximise quality andand wellbeing. cost effectiveness in all service provision while also supporting individuals along theirA comprehensive, strategic approach to recovery journey. Increasingly, services areimproving mental health needs to include evidence-based and the people receivingnot only direct service provision for people these services are genuinely engaged incurrently experiencing and recovering from decision-making, not just at individualmental health problems, but also prevention level but at organisational/strategicand early intervention for those at high levels too. Personalisation is now the keyrisk, and mental health promotion for the principle that guides all care and treatment.wider community. Personalisation places the individual at the heart of decision-making, enabling them to make informed choices about the care and support they need to achieve the outcomes and goals they have identified and that are meaningful to them.
    • 6 Practical Mental Health CommissioningThe framework The framework is in three partsThis framework is intended to guide It describes the key commissioning 1 The changing commissioningcommissioners as they traverse this enablers for achieving these three landscape – this section outlinescomplex and changing terrain. objectives. It seeks to knit into a coherent the policy background, the shift to whole the multiple strands of improving GP-led commissioning, the expandedThe framework’s main focus is on the quality, ensuring efficiency and productivity role of local authorities, the new mentalmental health system, across all tiers, and supporting people to become more health strategy, and the other keybut it also addresses population mental engaged in their own health care,2 while points such as quality standards andhealth and health improvement, and the also managing increasing need and outcomes frameworks that inform thelinks between mental and physical health,1 demand for services. commissioning process.especially for people with common andsevere mental illnesses. It recognises the multiplicity of factors 2 What mental health commissioning involved in achieving quality and looks like now – this section outlinesIt takes an all-age approach, covering the effectiveness in mental health and social the nuts and bolts of the commissioningwhole of the life course from the very care. Services need to be person-centred, cycle, the joint strategic needsearly years to old age. It does not delve in cost-effective, clinically effective and assessment and other key features ofsignificant detail into children and young safe. They have to work upstream, at the commissioning process.people’s mental health and mental health the preventive and promotion end of the 3 Going forward: what mental healthin older age, but it will be supported by spectrum, as well as downstream with commissioners need to know –further, companion documents describing people experiencing severe mental illness. this section describes, with examplesthe key commissioning issues in these areas. This requires commissioners to work in from the field, the imperatives that will partnership across the public, independent, drive commissioning forward and theIt explores the key policy imperatives voluntary and community sectors, beyond priorities that will continue through thedriving commissioning for mental health the conventional boundaries of mental period of transition and into the newinto the future: health provision. health and social care system.• improving population mental health This framework does not attempt to and wellbeing and shifting the locus of 1 Department of Health (2010). Healthy Lives, provide a definitive and detailed guide power and responsibility to individuals, Healthy People: Our strategy for public health in England. London: The Stationery Office. to commissioning across the spectrum communities and local government 2 Derek Wanless (2004). Securing Good of mental health need. Rather, it aims to• increasing people’s choice and control Health for the Whole Population: Final Report. contribute to and inform ongoing policy over services through personalisation London: HM Treasury, Department of Health. and practice development nationally and of assessment processes and service across local government. provision It has been written and produced with• system reform to support innovation input from a broad range of professionals, and free up resources to follow people’s individuals and organisations. In particular, choices through personalisation, it has been informed by and will be of Payment by Results (PbR) and related particular relevance to the memberships developments. of ADASS, the NHS Confederation and the Royal Colleges of Psychiatrists and General Practitioners.
    • A framework for local authority and NHS commissioners 7 Introduction 1. The changing 2. What 3. Going forward: commissioning mental health what mental health landscape commissioning commissioners looks like now need to know 07 31 36 Conclusion Glossary Useful links Glossary 51 52 55 571.1 NHS strategy and developing policy frameworks1.2 GP commissioning consortia1.3 The NHS Commissioning Board1.4 Health and wellbeing boards1.5 HealthWatch1.6 Public health1.7 Associated developments1.8 Providers1.9 Regulation – Monitor and the Care Quality Commission1.10 Mental health commissioning1.11 Commissioning structures and processes1.12 GP commissioning and mental health1.13 Primary care mental health1.14 Outcomes frameworks1.15 Quality standards1.16 Quality, innovation, productivity and prevention (QIPP)1.17 Public mental health1.18 Personalisation1.19 Payment by Results1.20 Equalities, diversity and inclusion1.21 Involving individuals and communities1.22 Safeguarding children and vulnerable adults1.23 Expanding choice of providers
    • 8 Practical Mental Health CommissioningThe changing commissioning landscape 1.1 NHS strategy and developing 1.2 GP commissioning consortia policy frameworksCommissioning for mental In recent months the Coalition Government Equity and Excellence: Liberating thehealth and wellbeing reflects has introduced legislation and strategic NHS and the Health and Social Care Billand is informed by the current policies to support high quality health and both describe a different NHS and localcommissioning landscape and social care interventions. government landscape and architecture.mental health policy, as well as A new clinical commissioning structure will • The Health and Social Care Bill,wider health, social care and public see GP commissioning consortia (GPCC) together with the White Paper Equityhealth policy. These are shaped largely replace primary care trusts (PCTs) and Excellence: Liberating the NHS,by two over-arching, linked aims: and take on responsibility for commissioning the Command paper Liberating the NHS: the bulk of NHS primary and secondary• to improve access to, and Legislative Framework and Next Steps mental health services, supported by and the delivery of, mental health and the Operating Framework for the accountable to a new, independent, national services with better outcomes for NHS in England 2010/11, set out the NHS Commissioning Board. individuals with a mental health Coalition Government’s plan for the disorder (and their carers), and NHS in England. The GPCC will include representation from • Children and young people’s NHS services every GP practice whose patient list they• to improve mental health and serve. They will be able to choose how best to are covered in the companion document wellbeing and prevent mental carry out their commissioning responsibilities Achieving Equity and Excellence for ill health in the whole population, – for example, by employing staff themselves, Children: how liberating the NHS will including those recovering by contracting with external organisations, or help us meet the needs of children and from a diagnosed mental or by collaborating with local authorities. young people. physical illness. • A Vision for Adult Social Care: Capable They will also be expected to drawImportantly, these aims broaden Communities and Active Citizens sets on expert advice from health and carethe focus of intervention beyond out the agenda for social care reform. professionals and establish robust systems inthe traditional arena of medical partnership with local authorities to involve • Healthy Lives, Healthy People: Ourand social care to address the patients and communities in their work. Strategy for Public Health in Englandwider determinants of mental explains the Coalition Government’shealth and wellbeing, such The GPCC will be required to commission vision for public health, including theas housing, the environment, some services on an ‘any willing provider’ expanded role of local authorities ineducation, employment and the basis – that is, the consortium will specify the health and health improvement. Itsocial networks that generate services and quality standards required and emphasises the importance of mentalsocial capital. any provider able to deliver those standards health, which is reflected in Healthy at the agreed price can express an interest in Lives, Healthy People: Transparency in providing them. Outcomes – Proposals for a Public Health Outcomes Framework. GPCC will be able to form partnership • No Health without Mental Health, arrangements with each other to commission the new cross-Government mental health some high cost, low volume specialist services outcomes strategy, outlines the Coalition that are not within the remit of the NHS Government’s vision for improving the Commissioning Board (see below). mental health of the population through It is recognised that some GPCC may high quality mental health services, early initially lack the necessary expertise in some intervention when mental illness arises, areas – care and support for children, for prevention of mental illness and promotion example, and for people with long-term of population mental wellbeing. mental health problems and people with learning disabilities. Joint commissioning arrangements with local authorities will be permitted to offset this.
    • A framework for local authority and NHS commissioners 91.3 The NHS Commissioning BoardThe NHS Commissioning Board will have The NHS Commissioning Board will also The Secretary of State will be required totwo main roles: it will support and regulate provide national leadership for driving undertake a formal public consultation onthe GPCC, and it will have a limited up the quality of care, including safety, the priorities set out in the annual mandatecommissioning function. effectiveness and patient experience. before issuing the final version. It will promote patient and publicIt will support and hold GPCC to account involvement and will foster and support The legislative framework will ensurefor the quality outcomes they achieve innovation and integration across the that GPCC are accountable for improvingand for their financial performance, and NHS, and with local authorities. quality of care within the resourceswill have the power to intervene if available to them. The GPCC and the NHSconsortia are failing or are likely to fail to It will be responsible for commissioning the Commissioning Board will be subject tofulfil their functions. core primary medical care services provided the duties in the Children Acts 1989 and by GP practices (including primary mental 2004 to discharge their functions in waysIt will support consortia by: health care), and the other family health that safeguard and promote the welfare services (including pharmacy services, dental of children, and to be members of Local• publishing commissioning guidance services and NHS sight tests). Safeguarding Children Boards. and model care pathways, based on the evidence-based quality standards It will also commission some national and that it will commission the National regional specialist services, including prison Institute for Health and Clinical Excellence and custody health care, high security (NICE) to develop psychiatric services, and health care for• developing model contracts and standard the armed forces and their families. contractual terms for providers Additionally, it will be able to commission• designing the Commissioning Outcomes some services on behalf of GPCC and enter Framework and the new quality premium into pooled budget arrangements with• designing the structure of price-setting, consortia to commission services that fall including best-practice tariffs and the outside the scope of national or regional CQUIN framework specialised commissioning.• helping, with NICE, to ensure that GPCC The functions of the NHS Commissioning have access to the most up-to-date Board will be set out in primary legislation, expert advice on the clinical and cost- rather than being at the discretion of effectiveness of different interventions, the Secretary of State. The Secretary including medicines of State will publish a mandate for the• providing a forum for GPCC to share NHS Commissioning Board, setting out knowledge, and support collaboration. the Government’s requirements and expectations for the NHS over a three-year period, updated annually. The mandate will include objectives for improvements in quality and outcomes, and equality and reduced inequality in health care provision, with specified targets. It will also specify financial allocations to the NHS Commissioning Board.
    • 10 Practical Mental Health Commissioning1.4 Health and wellbeing boards 1.5 HealthWatchLocal authorities will lead the strategic Local authorities and the GPCC for their Local authorities will retain their currentco-ordination of commissioning prevention areas will undertake a joint strategic health scrutiny powers, either throughand promotion (health and wellbeing) needs assessment through the health and the existing health Overview and Scrutinyservices further upstream, drawing together wellbeing boards. Committees (OSCs) or through other meansNHS, social care and related children’s if they choose. Local Involvement Networksand public health services and working Health and wellbeing boards will also be (LINks) will evolve into local HealthWatch,with other local agencies and groups. the vehicle for the production of the supported and led by HealthWatchThey will do this through health and new joint health and wellbeing strategies England. HealthWatch England will bewellbeing boards, which will be a statutory (JHWS). The JHWS is intended to provide based within the Care Quality Commissionrequirement in every upper tier authority. the overarching framework for the (CQC) and will act as an independent development of the commissioning plans consumer champion. Local HealthWatch willThe core purpose of the health and agreed by the health and wellbeing board ensure that the views of users of services,wellbeing boards is to join up commissioning for local NHS, social care, public health and carers and the public are represented toacross the NHS, social care, public health other services. The JHWS could include commissioners, and will provide localand other services that the board agrees wider health determinants such as housing intelligence for HealthWatch England. Localhave a direct influence in health and and education. authorities will be able to commission localwellbeing, in order to secure better health HealthWatch to provide advocacy, adviceand wellbeing outcomes for their whole GPCC and local authorities will have and information to support people if theypopulation, better quality of care for users statutory responsibility for the production have a complaint and to help people makeof health and social care services, and better of both the JSNA and JHWS, and be choices about services.value for the taxpayer. required to pay regard to both in their commissioning plans, which must beThe boards will provide the platform for approved by the health and wellbeingNHS, public health and local authority board. The boards will be expected toleaders and commissioners to work together play an influential role in the developmenton a geographical basis, both within and of innovative solutions to commissioningbetween local authority areas. challenges, not simply to comment on commissioning plans.The core membership of these boards willinclude all the GPCC covering that area, Health and wellbeing boards will be ablethe director of adult social services, the to look at the totality of resources availabledirector of children’s services, the director for health and wellbeing in their localof public health and the local HealthWatch area, and decide how to make best use(see below), and at least one locally elected of the flexibilities at their disposal, suchmember. Additional membership will be as pooled budgets. Using the JHWS, theyat the discretion of each board, but might will be able to consider how prioritisinginclude representatives of the local voluntary health improvement and prevention, thesector and other relevant public service management of long-term conditions andofficials, professionals and community the provision of rehabilitation, recoveryorganisations that can advise on and give and re-ablement services will best delivervoice to the needs of vulnerable and less- reductions in demand for health services andheard groups. Board membership might also wider benefits for the health and wellbeinginclude some providers, so long as this does of the local population.not prejudice the level playing field withinthe local health and social care market.
    • A framework for local authority and NHS commissioners 111.6 Public health 1.7 Associated developments 1.8 ProvidersResponsibility for public health, including Accompanying these major structural On the provider side, there will be apublic mental health, will be transferred to changes will be a number of other continued move away from central control,a new Public Health Service, Public Health important developments in commissioning. with greater autonomy for NHS FoundationEngland. This will be located within the These include: Trusts and greater opportunities for more,Department of Health and will have its own and larger, social enterprises to move intoring-fenced budget. Directors of Public • closer collaboration between primary direct health and social care provision. TheHealth (DPH) will be located within local and secondary care clinicians and aim is to free up providers so that they canauthorities, which will have responsibility professionals to enhance clinical compete on a level playing field, focus onfor health improvement within their areas. leadership in commissioning. This improving outcomes, be more responsiveThe DPH will be expected to work with collaboration should be built on the to the needs of people using services, andpartner organisations – the NHS, the principles of integration and joint innovate.private, voluntary and public sectors and the working in both commissioning andGPCC – through the health and wellbeing delivering a comprehensive mental This process will be facilitated by the ‘anyboard. Local authorities will receive a health health service across primary, secondary willing provider’ concept outlined above.premium to reward progress against the and social care sectorsnew public health outcomes framework. • a major expansion of choice and involvement opportunities forPublic health will be part of the NHS individuals receiving primary, communityCommissioning Board’s remit, and GPs and secondary care, with greaterpotentially could receive enhanced personalisation of services, increasedincentives to deliver public health services. freedom, choice and control and, crucially, a concentrated focus on improved health, public mental health and social care outcomes • roll out of Payment by Results (PbR) for mental health services, and • an imperative to achieve value for public money through QIPP and local government efficiency programmes, often predicated on economies of scale and joint or wider collaborative commissioning approaches.
    • 12 Practical Mental Health Commissioning1.9 Regulation – Monitor and the 1.10 Mental health commissioning Care Quality CommissionThere will be a new regulatory system. commissioners and periodically reviewing Within this landscape, commissionersMonitor will take on the role of independent NHS providers. Instead, it will focus its of mental health services will be freedeconomic regulator, with three core resources on its provider inspection role. from the traditional, activity-focused,functions: promoting competition; setting The quality of providers’ services will be specialist service-oriented model. Multi-or regulating prices; and ensuring continuity judged from a wide range of sources: agency and partnership commissioningof services (see figure 1). To support these from patient feedback and complaints; for mental health and wellbeing willfunctions, Monitor will license all providers staff experience; and information become much more the norm. Servicesof NHS-funded care. from HealthWatch England and local will be commissioned from a wide rangeMonitor’s overarching duty will be to protect HealthWatch, health and wellbeing boards of organisations delivering a broadthe interests of users of health and adult and OSCs, GPCC, Monitor and the NHS spectrum of services across a locality, areasocial care services by promoting competition Commissioning Board. or region. Investment will be channelledamong providers, as appropriate, and into new areas of development, beyondregulation where necessary. The CQC will have wide-ranging the boundaries of traditional ‘mental enforcement powers, including the powers illness’ treatment and care.All providers of NHS care will compete on to issue statutory warnings, set additionalwhat is intended to be an equal basis, so registration conditions and impose fines. These new areas include:that they succeed or fail according to the Where those using services are thought to • social capital – building communityquality of care they give and the value for be at serious and immediate risk, the CQC networks and resources, investmentmoney they offer. will have powers (as now) to suspend or in peer support remove registration – in effect closing downThe role of the Care Quality Commission the service or provider. • citizen pathways – creatingin maintaining and pushing forward quality opportunities for people’s activeand safety of services will be expanded and The quality standards for all health care participation in local governmentstrengthened. All providers of services to and treatment interventions will be • mechanisms to ensure people havethe NHS will be required to register with the commissioned by the NHS Commissioning a voice at strategic, community andCQC, including primary care providers from Board from the National Institute for Health individual levels.2011. The CQC will no longer be responsible and Clinical Excellence (NICE).for assessing the performance of NHSFigure 1: Monitor’s core functions Licensing Regulating Promoting Supporting providers prices competition service continuity Setting general Setting special Setting prices Preventing Additional Special conditions for all conditions for where necessary anti-competitive regulation to administration providers individual providers conduct ensure continuity Using prices Carrying out to improve market studies, efficiency advising on competition Collecting and publishing information to deliver functions (price setting, supporting choice etc)Adapted from Department of Health (2010). Liberating the NHS: Regulating Healthcare Providers. A consultation on proposals.London: Department of Health.
    • A framework for local authority and NHS commissioners 131.11 Commissioning structures and processesThe basic structure and components of commissioning will remain largely constant:• needs assessment and engagement with the public and partners• strategy-making and prioritisation• procurement and contracting, and• monitoring and review, using outcomes and public value (quality and efficiency) as the yardstick.Figure 2 below and overleaf shows the potential components of a comprehensive mental healthservice, and where they may overlap and interlock within the commissioning process.Figure 2: The new commissioning structure for mental health and wellbeingCommissioning for mental health and wellbeing takes place across four tiers, covering both universaland targeted services across the whole population. Currently most health resources are tied up atthe narrow end of the triangle, at tiers 3 and 4, covering inpatient specialist services. But many of thequality and efficiency actions needed to change the profile of future demand rely on a connectedapproach at tiers 1 and 2, addressing population and public mental health, prevention, earlyintervention, personalisation and social care. Tier 1 – Universal services; education/ Tier 3 – NSF training; schools; leisure; community teams community resources (including social care) Tier 4 – Secondary Tier 2 – Primary care; and specialist supported housing/ employment; substance misuse; community safety QIPP – prevention; early intervention; diversion; personalisation
    • 14 Practical Mental Health CommissioningPutting strategy into action across the tiers also requires different approaches to commissioning, working throughbroader partnerships (such as Children’s Trusts or Community Safety Partnerships) at tier 1 and into tier 2. A greaterconcentration on joint commissioning between GPCCs and local authorities is needed at tiers 2 and 3 to ensureintegration and best outcomes. Then, as services get more specialised, wider collaborative arrangements are requiredat tier 4, to make the best use of resources and maximise the effectiveness of acute and specialist mental health carepathways across organisations at a sub-regional or regional level. Each of these commissioning approaches also relieson close partnership with providers and frontline clinicians and teams to ensure the potential for innovation andimprovement is harnessed across all the stages of the commissioning cycle. Tier 1 – Universal Tier 2 – Primary care; Tier 3 – NSF Tier 4 – services; education/ supported housing/ community teams Secondary training; schools; leisure; employment; substance (including social care) and specialist community resources misuse; community safety Partnership Joint Collaborative commissioning commissioning commissioning<<<<<<<< PROVIDER INNOVATION >>>>>>>>>Finally, following transition to the new NHS and expanded role of local government, the likely new localcommissioning responsibilities and overlaps are shown here. Again, the diagram emphasises the need forinter-connectedness between all parts of the new system as it evolves. Tier 1 – Universal Tier 2 – Primary care; Tier 3 – NSF Tier 4 – services; education/ supported housing/ community teams Secondary training; schools; leisure; employment; substance (including social care) and specialist community resources misuse; community safety LA and public GP Consortia NHS Commissioning health service and Local Authority Board<<<<<<< LOCAL HEALTH AND WELLBEING BOARDS >>>>>>>
    • A framework for local authority and NHS commissioners 151.12 GP commissioning and mental healthThe concept of GP commissioning is built Figure 3: Towards optimal primary mental health care3on the pivotal role that GP practices alreadyplay in co-ordinating care and advocating * Van Os J, Linscott RJ, Myin-for their patients. Given this long-standing Germeys P, et al (2009). Pathway to Severe Secondary A systematic review andproximity to their patients, it is seen to secondary mental health care meta-analysis of the psychosisbe a natural extension for GP practices to care illness service continuum: evidence for a inc psychosisplay the lead role in deciding what wider (1%*) psychosis-proneness-persistence- impairment model of psychotichealth care services to commission on their Common disorder. Psychological Medicinepatients’ behalf. Primary 39: 179–195. mental disorders First point health (17.6%11) care ** Deacon L, Carlin H, Spalding JGPs also currently play an important role in of contact Alcohol dependence (6%11) et al (2009). North West mental serviceinfluencing NHS expenditure, both through Illegal drug dependence (3%11) wellbeing survey. Liverpool: North West Public Healthreferral and prescribing decisions and (less Sub-threshold conditions Observatory (http://www.directly) through the quality and accessibility Psychosis (6%*) nwph.net/nwpho/publications/of the services they provide and the impact Common mental disorders (17%11) NorthWestMentalWellbeing%these have on emergency and urgent care Hazardous drinking (24%11) 20 SurveySummary.pdf).provided elsewhere in the health system. In Early Optimal mental wellbeingthis sense, GP commissioning gives groups identification (Only 20.4% of population haveof GP practices financial accountability for optimal mental wellbeing**) of vulnerabilitythe consequences of their decisions.There may be a tension in their dual role. This diagram shows a stepped care pathway through the primary and specialist mentalOn the one hand, GPs will be in a stronger health care systems (the central area of the pyramid), built on the maintenance of mental health and prevention of ill-health. The clinician will ensure the individual person’s needsposition to develop services that meet the are met with the required intensity of response at the appropriate level.particular needs of their patients, resultingin far more personalised, individual care and joint health and wellbeing strategy as a whole, in partnership with the localand treatment. However as commissioners, (JHWS), will be critical to maintaining this authority and other concerned agencies.GPs within the commissioning consortia will balance. These will provide the platformalso need to be concerned with the mental and mechanisms for GPs to contribute their Figure 3 illustrates the extent of territoryhealth and wellbeing of the local population clinical knowledge to strategic planning for for which primary care has responsibilityas a whole. the mental health of the local population along the patient’s care pathway.GP commissioners will have a key role in Transitional development and supportlocal health improvement and improvingmental wellbeing, as their remit will cover In mid-Essex, a pathfinder consortia of seven GP practices has prioritised a need forpromotion of mental health as well as leadership in respect of transitional arrangements for mental health and learning disability commissioning. A partnership approach has been established with Essex County Council,prevention of mental illness and they the Primary Care Trust and local NHS Foundation Trust. A project manager will oversee awill be working directly with Directors of first phase of four workstreams. It is intended that these workstreams will informPublic Health and local authorities through development of the new commissioning structures that will be needed.the local health and wellbeing boards, or These will include reviewing:equivalent structures. • needs analysis, strategy and prioritiesThe involvement of the GPCC on the • finance, activity and performance data for NHS and Social Carehealth and wellbeing boards, and in the spend for the consortia population • NHS and Social Care partnership issuesjoint strategic needs assessment (JSNA) • Health and Wellbeing Board representation, governance etc • pathway redesign with providers to better meet local needs.3 Adapted from: Ministry of Health Design of collaborative commissioning arrangements and identification of priority outcomes(2009). Towards optimal primary mental for services will help to inform and shape the development of thinking within consortiahealth care in New Zealand: a discussion across Essex and with the local authority.paper. Wellington: Ministry of Health.
    • 16 Practical Mental Health Commissioning1.13 Primary care mental healthIn the 1960s, when GPs in the UK were Primary care is also best placed to managebeginning to work in group practices, problems that straddle the interface 4 Shepherd M, Cooper B, Brown A et al (1966). Psychiatric illness in general practice. Oxford:Shepherd and colleagues4 suggested: between mind and body, such as medically Oxford University Press. unexplained symptoms. People with serious“… the cardinal requirement for 5 World Health Organization (1978). Alma Ata: mental illness say they greatly value the global strategy for Health for All by the Yearimprovement of mental health services… care provided in primary care settings by 2000. Geneva: World Health Organization.is not a large expansion of and proliferation their own GP.7 6 World Health Organization/ Worldof psychiatric agencies, but rather a Organization of Family Doctors (Wonca) (2008).strengthening of the family doctor in his/ From the perspective of the health care Integrating mental health into primary care:her therapeutic role.” system, effective primary care is cost- a global perspective. Geneva: World Health effective.8 Specialist mental health care Organization: 10.The World Health Organization echoed resources can then be directed towards 7 Lester H, Tritter JQ, Sorohan H (2005). Patients’this belief in 1978,5 stating that: those most in need and most likely to and health professionals’ views on primary care“the primary medical care team is the benefit from more intensive care. for people with serious mental illness: focuscornerstone of community psychiatry.” group study. British Medical Journal 330: 1122. Indeed, as Goldberg and Bridges9 first 8 Starfield B (1991). Primary care and health:The World Health Organization has demonstrated over 30 years ago, only a a cross-national comparison. Journal of themore recently defined ‘primary care American Medical Association 266: 2268–2271. small number of people with mental healthmental health’ as:6 9 Goldberg D, Bridges K (1987). Screening for problems are referred to secondary, specialist psychiatric illness in general practice: the general mental health services, and even fewer are practitioner versus the screening questionnaire.• “First line interventions that are ever admitted to psychiatric units. Journal of the Royal College of General provided as an integral part of general Practitioners 37(294):15–18. health care” and• “Mental health care that is provided by Figure 4: Numbers of people affected by mental health problems primary care workers who are skilled, able and supported to provide mental health care services.”There are numerous advantages toproviding mental health care in the primarycare setting, from the perspectives bothof people who use services and of thehealth and social care system. Care canbe provided closer to home, in a settingthat does not carry the stigma that is still <10/1000associated with mental health facilities, 20-30/1000by a health care worker who will ideallyknow the person and his or her family, who 130/1000will be able to provide holistic treatment 230/1000and continuity of care for the full range ofproblems including physical health needs, 250/1000and who has good links to local services tohelp with associated social issues. Mental health problems affect about one in four people – that is, 250 per 1000 at risk (see figure 4). Of those 250 people, the vast majority – about 230 – attend their general practice. Of these 230, about 130 are subsequently diagnosed as having a mental health problem, only between 20 and 30 are referred to a specialist mental health service, and fewer than 10 are ever admitted to a mental health hospital.
    • A framework for local authority and NHS commissioners 17This means that over 90% of people with GPs used to be seen to have a poor record Numerous models have been developedany severity of mental health problems are on identifying depression among their to provide genuinely ‘shared care’ acrossmanaged entirely in primary care – including patients. More recent studies have found primary and secondary care.19 Much ofroughly one in four people receiving that they are very good at recognising the research has focused on attempting totreatment for psychosis. If this number is moderate to severe depression,12 where improve outcomes for people with commondisaggregated into levels of mental ill health, there is more benefit to be gained from mental health problems by integratinga GP with a list size of 2000 patients would treatment. new specialist mental health staff, suchexpect to be treating about 50 people with as counsellors and psychologists, into thedepression, 10 people with a serious mental Physical and mental health problems often primary care team.20 However, collaborativeillness such as schizophrenia or bipolar co-exist and overlay and interact with care, which originates from the US21 anddisorder, about 180 people with anxiety each other. The difficulties inherent in is based on new approaches to treatingdisorders and a further 180 or so with milder disentangling the two, and the associated people with chronic health problems such asdegrees of depression and anxiety.10 stigma of mental illness, may in part explain diabetes, is now attracting much interest as the gap between presentation and diagnosis a model for treating people with depressionAnalysis of the latest Adult Psychiatry in primary care and why only 23% of adults and serious mental illness.Morbidity Survey shows:11 with a common mental disorder (anxiety and depressive disorders) receive any treatment.11• 16.2% of the population experience Improved recognition, diagnosis and 10 Singleton N, Bumpstead R, O’Brien M at least one common mental disorder et al (2001). Psychiatric morbidity among intervention for mental illness in primary care adults living in private households. London: (anxiety and depressive disorders) in have the potential to significantly reduce The Stationery Office. the previous week the burden of these illnesses. The Improving 11 McManus S, Meltzer H, Brugha T, Bebbington• 23% of adults with a common mental Access to Psychological Therapies (IAPT) P, Jenkins R (eds) (2009). Adult psychiatric disorder receive treatment programme is also progressively increasing morbidity in England, 2007. Leeds: NHS treatment choice in primary care settings. Information Centre.• 14% receive psychoactive medication only 12 Thompson C, Ostler K, Peveler RC et al (2001).• 5% receive counselling or therapy, and Mental health policy for primary care Dimensional perspective on the recognition of has developed considerably over the last depressive symptoms in primary care. British• 5% receive both medication and therapy. Journal of Psychiatry 179: 317–323. two decades. There is growing policy interest in the configuration and delivery 13 Department of Health (1999). NationalMost (38%) of those with common service framework for mental health: modernmental disorders accessed GP services of evidence-based mental health care in standards and service models. London:and 18% made use of community or the post-institution era.13 Historically, from Department of Health.day care services. For those with two or 1999–2009, primary care had specific 14 Department of Health (2000). The NHS Plan:more common mental disorders, 16% responsibility for delivering standards a plan for investment, a plan for reform.made use of community day centres, two and three of the National Service London: Department of Health.10% accessed psychiatry and 10% Framework (NSF) for mental health and 15 http://guidance.nice.org.uk/CG22received social work input. was also integrally involved in the delivery 16 http://guidance.nice.org.uk/CG90 of the other five NSF standards. The NHS 17 http://guidance.nice.org.uk/CG82 18 http://guidance.nice.org.uk/CG38 Plan14 invested more than £300 million in 19 Bower P, Gilbody S (2005). Managing the implementation of the NSF, including common mental health disorders in primary care: funding for 1000 new graduate mental conceptual models and evidence base. health workers to work in primary care and British Medical Journal 330 839–842. promote a shared care approach. NICE 20 Bower P, Sibbald B (2000). On-site mental guidelines for treating people with anxiety,15 health workers in primary care: effects on depression,16 schizophrenia17 and bipolar professional practice. Cochrane Database Systematic Review (3): CD000532. disorder18 all emphasise the important role played by primary care. 21 Katon W, Unutzer J (2006). Collaborative care models for depression: time to move from evidence to practice. Archives of Internal Medicine 66 2304–2306.
    • 18 Practical Mental Health Commissioning 1.14 Outcomes frameworksThe new NHS, the advent of GP-led New outcomes frameworks have beencommissioning and the Government’s vision developed connecting public health, thefor social care provide real opportunities NHS and social care. These have beento further revitalise primary care mental designed to interlink so they work togetherhealth, in line with the Government’s towards shared outcomes and goals (seeprinciples of devolution of decision- figure 5 below).making, personalisation and localism.GP commissioning has the potential to Figure 5: Intersection between the NHS, social care and public health outcomes frameworksmake primary care the hub of all mentalhealth services and support, and thus Adult Social Care and Public Health: NHS and Public Health:ensure services are better able to meet the Maintaining good health and wellbeing. Preventing ill health and lifestyle Preventing avoidable ill health or injury, including diseases, and tackling theirspectrum of need of the wider population, through re-ablement or intermediate care services determinantsas well as those with severe mental illnesses. and early interventionThis model also takes a wellness andrecovery approach; it can enable peopleto continue living independently in theircommunities; it can, where appropriate, shiftresources (investment and skills) towards the Public Health NHScommunity end of people’s care pathways.It may also enable better and more activemanagement of people’s journeys into andout of specialist mental health services, inpart through increased availability of theseservices in surgeries and health centres. Adult Social CareEnhanced co-working and collaborationbetween primary care and mental healthteams, reinforced in service specifications, ASC, NHS and Public Health: Adult Social Care and NHS: The focus of Joint Strategic Needs Supported discharge from NHS to Social Care.can help to minimise risk and maximise Assessment: shared local health and Impact of re-ablement or intermediate care servicesopportunities for recovery. wellbeing issues for joint approaches on reducing repeat emergency admissions. Supporting carers and involved in care planningOverall, such an approach offers multiplebenefits. It gives increased potential Adapted from Healthy Lives, Healthy People: Transparency in Outcomes. Proposals for a Publicfor health, social care and other key Health Outcomes Framework. A consultation document. Department of Health. December 2010.stakeholders to collaborate at locality levelto meet the totality of individual or familyneeds. It ensures that commissioning is Importantly, all three frameworks accordbetter locked onto local needs. It gives equal importance to mental health andGP commissioners and local authorities physical health outcomes as a measure ofgreater flexibility to design and deliver effectiveness. Commissioners’ performancespecific services that meet specific local will be judged against these outcomes byneeds. It extends opportunities for shared the national NHS Commissioning Board,care and expands access to specialist and potentially at local level by health andprofessional skills where they are most wellbeing boards and local HealthWatch.needed and most useful, closest to people’shomes and within their communities.
    • A framework for local authority and NHS commissioners 191.14.1: The NHS outcomes frameworkThe NHS outcomes framework has five Domain 1, for example, connects to Domain 4 might encompass people’soutcome domains, each with a set of actions around suicide prevention and experience of mental health care,indicators to measure progress. For the lifestyle risk management. treatment and support, including choice,first year, 2011/12, the framework will be personalisation, peer support, involvementused only to set direction of travel and to Domain 2 could apply directly to enhancing in developing care plans, decisions aboutobtain baseline data. From 2012/13 quality of life for people with long-term care and treatment, and use of recognisedit will include ‘levels of ambition’ and the severe mental illnesses and to the mental measures such as Patient ReportedNHS Commissioning Board will be held to health contribution to physical long-term Outcome Measures (PROMs) and NICEaccount (and will hold GPCC to account) conditions, such as diabetes. Quality Standards.for delivery on these indicators. Domain 3 could apply to recovery from Domain 5 is about safeguarding people’sSome of the NHS outcomes framework episodes of severe mental ill health. wellbeing when accessing mental healthdomains have been given a mental health This – alongside medical treatment – might care and treatment, including clinicalspecific indicator (see table 1 below). include education, training and employment safety, informed by PROMS, NICE QualityOthers do not have a specific indicator that support, housing, social networks and Standards, and Care Quality Commissionrelates to mental health but will still have attention to wider social care and skills inspections of the care environment anddirect relevance to mental health service development issues. standards of practice.commissioning and provision.Table 1: NHS outcomes framework – the five domains Domain Overarching indicators Improvement areas Reducing premature death in people with serious mental illness 1. Preventing people from Mortality from causes considered Mental health indicator: Under 75 mortality rate in people dying prematurely amenable to health care with serious mental illness (shared responsibility with Public Health England) 2. Enhancing quality of life Enhancing quality of life for people with mental illness Health-related quality of life for for people with long-term people with long-term conditions Mental health indicator: Employment of people with mental illness conditions Emergency admissions for acute 3. Helping people to recover conditions that should not usually from episodes of ill health or require hospital admission; following injury Emergency readmissions within 28 days of discharge from hospital Improving experience of health care for people with mental illness 4. Ensuring people have a Patient experience of primary care; positive experience of care Patient experience of hospital care Mental health indicator: Patient experience of community mental health services 5. Treating and caring for Patient safety incident reporting; people in a safe environment Severity of harm; Number of and protecting them from similar incidents avoidable harm
    • 20 Practical Mental Health Commissioning1.14.2: The public health outcomes frameworkThe public health outcomes are still pending finalisation. Table 2 lists thedomains and outcomes proposed in the consultation document HealthyLives, Healthy People: Transparency in Outcomes.22Table 2: Proposed public health outcomes frameworkThe overarching vision for public health:To improve and protect the nation’s health and to improve the health of thepoorest, fastest. Supported by five key domains for public health outcomes thatreflect national, local and community level actions and target groups at higher risk. Domain 1. Health protection Protect the population’s health from major emergencies and remain resilient to harm and resilience This includes all the elements of the Public Health Outcomes Framework that relate to mental health 2. Tackling the wider Tackling factors that affect health and wellbeing and health inequalities determinants of health 3. Health improvement Helping people to live healthy lifestyles, make healthy choices and reduce health inequalities 4. Prevention of ill health Reducing the number of people living with preventable ill health and reduce health inequalities 5. Healthy life expectancy Preventing people from dying prematurely and reduce health inequalities and preventable mortalityDomain 1 sets the overarching goal that the Government expects Public Health Englandto achieve, supported by local delivery mechanisms. The other domains are sequencedacross the spectrum of public health, from influencing the wider determinants of health,to opportunities to improve and protect health, to preventing ill health (morbidity) andavoiding premature death (mortality).22 Department of Health (2010). Healthy Lives,Healthy People: Transparency in Outcomes.Proposals for a Public Health OutcomesFramework. A consultation document.London: Department of Health.
    • A framework for local authority and NHS commissioners 211.14.3: Proposed social care outcomes frameworkThe vision informing Transparency in Outcomes: a framework for adult socialcare, the proposed quality and outcomes strategy for social care, is three-fold:• to empower local citizens and support Table 3 lists the overarching measures and transparency. The focus of accountability outcomes proposed in the consultation will be local, with consistent evidence of document. Again, only the outcome improvement for local communities and measures related to mental health are support for holding organisations included here.23 to account The Coalition Government has made clear• to improve outcomes for those with care that it expects social care services to work and support needs. This means building not just with the NHS and Public Health the evidence base on how to achieve the England towards these outcomes but also, best outcomes in adult social care, and just as importantly, with partners in local ensuring this underpins service design, government and with local independent, commissioning and delivery. In doing so, mutual and voluntary and community the focus must be on what matters most organisations. to people and ensuring action to highlight and tackle inequalities• to improve the quality of social care 23 Department of Health (2010). Transparency services. This requires understanding in Outcomes: a framework for adult social care. what ‘high quality’ means in adult A consultation on proposals. London: social care, and how it can be delivered Department of Health. efficiently and effectively.
    • 22 Practical Mental Health CommissioningTable 3: The proposed social care outcomes framework Domain Overarching measures Outcome measures Supporting quality measures Enhancing independence and control over own support • The proportion of those using social care who have control over their daily life Enhancing quality of life for carers 1. Promoting • Carer-reported quality of life personalisation and Enhancing quality of life for people Promoting personalised services enhancing quality Social care-related with mental illness • Proportion of people using social care of life for people quality of life • Proportion of adults in contact with who receive self-directed support with care and secondary mental health services in support needs employment Ensuring people feel supported to manage their condition • Proportion of people with long-term conditions feeling supported to be independent and manage their condition Domain Overarching measures Outcome measures Supporting quality measures Emergency 2. Preventing readmissions within 28 deterioration, days of discharge from delaying hospital; admissions to dependency and residential care homes supporting recovery per 1,000 population Domain Overarching measures Outcome measures Supporting quality measures Improving access to information about care and support • The proportion of people using social Could be supported by relevant activity care and carers who express difficulty and finance data related to adult social in finding information and advice about care, as identified locally through the 3. Ensuring a Overall satisfaction local services services provided to users and carers who positive experience with local adult social respond positively or negatively to their of care and support care services Treating carers as equal partners experience of care. This domain is also likely • The proportion of carers who report to be able to be supplemented by local that they have been included or survey activity and complaints information consulted in discussions about the person they care for Domain Overarching measures Outcome measures Supporting quality measures Ensuring a safe environment for Providing effective safeguarding services 4. Protecting from The proportion of people with mental illness avoidable harm people using social • The proportion of repeat referrals to and caring in a safe care services who feel • Proportion of adults in contact with adult safeguarding services environment safe and secure secondary mental health services in settled accommodation
    • A framework for local authority and NHS commissioners 231.14.4: Mental health strategy Table 4: Mental health strategy shared objectivesThe mental health outcomes strategy, 1. More people will have good mental healthNo Health without Mental Health, isbuilt around a two-track, life course More people of all ages and backgrounds will have better wellbeing and goodapproach that aims to: mental health and fewer people will develop mental health problems• improve outcomes for people with 2. More people with mental health problems will recover mental problems, and More people will have a good quality of life – greater ability to manage their own• build individual and community lives, stronger social relationships, a greater sense of purpose, improved chances in resilience and wellbeing in order to education, better employment rates and a suitable and stable place to live prevent ill health. 3. More people with mental health problems will have good physical healthIt links closely with the Healthy Lives, Fewer people with mental health problems will die prematurely, and more peopleHealthy People strategy for public health with physical ill health will have better mental healthin England and – as a cross-Government,rather than a Department of Health 4. More people will have a positive experience of care and supportstrategy – expects input from all relevant Care and support, wherever it takes place, should offer access to timely, evidence-Government departments towards based interventions and approaches that give people the greatest choice and controlmeeting these aims. over their own lives, in the least restrictive environment; and should ensure people’sThe strategy is structured around six shared, human rights are protectedcross-Government and multi-agency mental 5. Fewer people will suffer avoidable harmhealth objectives (see table 4). These areconsistent with those set out in the NHS, People receiving care and support should have confidence that the services they usesocial care and public health frameworks. are of the highest quality and at least as safe as any other public serviceThe objectives are designed to support 6. Fewer people will experience stigma and discriminationdelivery of the twin aims. Public understanding of mental health will improve and, as a result, negative attitudes and behaviours to people with mental health problems will reduce
    • 24 Practical Mental Health Commissioning1.15 Quality standards 1.16 Quality, innovation, productivity and prevention (QIPP)As previously explained, the delivery of the QIPP in the NHS and similar approaches • out of area and other high costNHS, social care and public health outcomes in local authorities to delivering efficiency services (including secure provision)and objectives will be supported by a suite and value for money are intended to enable • acute care pathways, andof quality standards to be commissioned commissioners to drive up quality whilefrom NICE over the next five years. These improving productivity. • physical health and long-term conditions.will provide a detailed description of A wide range of actions can and are Health and social care services, through theirwhat high quality care looks like for each being taken in health and social care SHAs and regions, have supported thesecare pathway, drawing on best available economies nationally to improve quality areas of national work alongside specificevidence and practice. Quality standards and efficiency in mental health and related projects of their own that reflect local needfor depression and patient experience have services. These actions can impact in the and priorities. One example is a project setalready been developed, or are currently in short, medium and long term to help create up by Yorkshire & Humber Improvementprocess. GP commissioning consortia will a sustainable service and financial strategy. Partnership to explore how better provisionuse these standards when commissioning In terms of productivity and savings, of a range of different kinds of housingservices locally. The quality standards will some of these actions will provide one-off and housing-related support can reduceprovide the bridge between the outcomes benefits, while others will be recurrent in full use of out of area placements and improvethe NHS is expected to deliver and the or in part. It will be important to be able to people’s journeys along their care pathways.processes that will make delivery possible. quantify and project these effects accurately. The range of possible actions can be Seven indicators to improve assessment Support available online grouped into four distinct models: NHS Yorkshire and the Humber’s Quality QIPP efficiency programmes are underway • changes to the clinical pathway or Assurance and Improvement Scheme sets out in all regions. A National Advisory Group is seven indicators for mental health services evidence-based service model, including collecting examples of good practice from aimed at improving assessment for people public health improvement, mental illness across the country. experiencing acute mental health crisis. prevention, promotion and primary care These examples are available on the NHS Key standards are improved client mental health Evidence website at: http://www.library.nhs. experience, reduced distress for individuals • increasing people’s choice and control uk/qualityandproductivity/ and families and significantly reduced suicide A number of forums and tools have been and enhancing personalisation of services rates. The indicators specify the data to be designed to help local authorities and NHS collected, the sources of these data and how • improved procurement and contracting, commissioners identify potential areas for and when performance will be measured. including collaborative approaches generating efficiency savings and improving NHS commissioners and their partners can quality. They include: use these data both to demonstrate the • productivity improvements, either in outcomes achieved and to inform strategies service delivery or by minimising ‘back http://www.csed.dh.gov.uk for future investment and service direction. office’ costs. http://www.institute.nhs.uk/option,com_ See: http://www.institute.nhs.uk/world_ joomcart/Itemid,26/main_page,document_ class_commissioning/pct_portal/cquin_ A partnership between the Department of product_info/products_id,183.html schemes_in_mental_health.html#3 Health, NMHDU, ADASS, the Royal College http://vfm.auditcommission.gov.uk/ of Psychiatrists and the NHS Confederation RenderReport.aspx?Gkey=282VqIaaVSLhf8 is taking forward three work programmes izWEP0TODL6gywy9mlA6o%2bD1QFon2t to support delivery of QIPP in mental health ve0r3eeIWw%3d%3d at local consortium/ neighbourhood, health http://www.idea.gov.uk/idk/core/page. and social care economy, sub-regional and do?pageId=11216560 regional levels. The work programmes are:
    • A framework for local authority and NHS commissioners 251.17 Public mental healthThe greatest opportunities to reduce The case for public mental healththe levels of mental ill health in thepopulation in the long term lie in mental • Mental disorder and self-harm constitute around 23% of burden of illness in thehealth promotion, as well as mental UK – in comparison with 16% for cancer and 16% for cardiovascular disease.24illness prevention and early intervention.Improving individual and population • A recent estimate, cited in the mental health strategy No Health without Mentalmental health sits within the wider public Health, puts the economic, human and social costs of mental health problems inhealth agenda and brings together a broad England at close to £105 billion per year. 25range of local stakeholders to work towardsa society that values and promotes mental • 10% of children and young people have a diagnosable mental disorder although only a small percentage receive treatment,26 17.6% of adults have at least onewellbeing as being of equal importance common mental disorder,11 approximately 11 million people of working age in thewith physical health. They include primary UK have mental health problems,27 and 25% of older people have depressiveand secondary health care, voluntary, symptoms, rising to 40% in people aged over 85.28 Dementia affects 5% of thosecommunity and statutory agencies, and local over 65 and 20% of those over 80.29communities, schools, businessesand individuals. • A large proportion of the population also experiences mental disorder at levels that may not meet the threshold for a formal diagnosis but may still have an impact on quality of life and will significantly increase risk of developing more severe disorder. For instance, six per cent of 5–16 year olds have conduct disorder,26 but 18% have24 World Health Organization (2008). sub-threshold conduct disorder.30Global burden of disease report. Geneva: WHO.(http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html) • Children from families with gross weekly household income of less than £100 have25 Centre for Mental Health (2010). The economic a three-fold increased risk of mental disorder compared with those children fromand social costs of mental health problems in families with gross weekly income of £600 or more.26 Socio-economic inequality is2009/10. London: Centre for Mental Health. one of the two main determinants of mental health in adults, alongside alcohol26 Green H, McGinnity A, Meltzer H et al dependence – mental illness is several times more common in people on the lowest(2005). Mental health of children and young 20% of household income than in those on the top 20% household income.*11people in Great Britain, 2004. London: Officefor National Statistics. • The total annual costs (2007 figures for England) of treating mental illness, including27 Royal College of Psychiatrists (2010). statutory public sector services and informal mental health and social care, areNo health without public mental health: £22.5 billion. These costs are projected to increase by 45% by 2026.31the case for action. Position statement. London:Royal College of Psychiatrists. • Health promotion and prevention are particularly significant in relation to mentalhttp://www.rcpsych.ac.uk/pdf/Position%20 illness, as even optimal treatment at optimal coverage is only able to reduce theStatement%204%20website.pdf burden of mental illness by 28%.3228 Godfrey M, Townsend J, Surr C et al (2005).Prevention and service provision: mental health • Half of all lifetime mental illnesses first appear by age 1433 and three quarters by theproblems in later life. Leeds/Bradford: Institute mid-20s. Childhood and adolescence are thus important opportunities for preventingof Health Sciences and Public Health Research, lifetime mental ill health in adult life.Leeds University/ Division of Dementia Studies,Bradford University. • Between 25–50% of adult mental illness may be prevented through early29 Knapp M, Prince M (2007). Dementia UK:a report into the prevalence and cost of intervention in childhood and adolescence.34 The economic benefits of early childhooddementia. London: Alzheimer’s Society. interventions have been estimated on average to exceed their costs by a ratio of 1:6.3530 Colman I, Murray J, Abbott RA et al (2009).Outcomes of conduct problems in adolescence: * Further, detailed information on mental health inequalities can be found in the equalities impact40 year follow-up of national cohort. report accompanying the new mental health strategy.36British Medical Journal 338: a2981.
    • 26 Practical Mental Health CommissioningThe evidence base for interventions to Within these categories, programmes mayprevent mental illness and promote mental be universal and available to everyone or 31 McCrone P, Dhanasiri S, Patel A et al (2008).health is summarised in a comprehensive targeted at specific groups or individuals Paying the price: the cost of mental health careframework for promoting wellbeing with particular needs, such as people with in England to 2026. London: King’s Fund.published by the Department of Health.37 learning disabilities, homeless people or 32 Andrews G, Issakidis C, Sanderson K et al (2004). Utilising survey data to inform publicFurther data can be found in the Royal people with dementia. One area where policy: comparison of the cost-effectiveness ofCollege of Psychiatrists’ position statement primary care approaches may be well placed treatment of ten mental disorders. British Journalon public mental health.27 The mental health to support families is in targeting parenting of Psychiatry 184, 526–533.strategy for England, No Health without support to families where there is mental 33 Kessler RC, Amminger GP, Aguilar-Gaxiola SMental Health, recognises the importance illness or drug and alcohol misuse. et al (2007). Age of onset of mental disorders:of locating mental health improvement a review of recent literature. Current Opinion inwithin the context of improving public Public mental health also offers Psychiatry 20 359–364.health more generally. opportunities for building efficiency 34 Kim-Cohen J, Caspi A, Moffitt TE et al and sustainability into the system by (2003). Prior juvenile diagnoses in adults withThis is a lifetime approach – from laying reducing the burden of mental disorder mental disorder: developmental follow-back of a prospective longitudinal cohort. Archives ofdown the foundations of good mental and consequent use of specialist services General Psychiatry, 60, 709–717.health in early childhood through to and secondary care. In this way it can 35 National Institute for Health and Clinicalmaintaining resilience into older age. It sees help achieve economic savings across Excellence (2009). Antisocial personality disorder:physical health as being central to good key public service sectors, in both the treatment, management and prevention.mental health, and vice versa. short and longer term. These self-evidently London: NICE. http://guidance.nice.org.uk/CG77 include health and social care economies. 36 Department of Health (2011). No healthPublic mental health encompasses a broad But they also include any sector where without mental health: a cross-governmentspan of interventions to address people’s mental wellbeing and good physical mental health outcomes strategy for people ofholistic mental health and wellbeing needs, all ages. Impact assessment. London: health are factors in improved outcomes. Department of Health.including: Education, employment, criminal justice, 37 HM Government (2010). Confident the Department for Work and Pensions communities, brighter futures: a framework• parenting programmes and the Treasury, and their local equivalents, for developing wellbeing. London:• pre-school and early education all stand to benefit from effective public The Stationery Office. http://www.dh.gov. programmes uk/en/Publicationsandstatistics/Publications/ mental health interventions.• school-based mental health promotion PublicationsPolicyAndGuidance/DH_114774• prevention of violence and abuse At its heart, public mental health is• prevention of suicide everyone’s business – we all need to take• early intervention in mental illness responsibility for improving mental health• alcohol, smoking and substance abuse and wellbeing, as individuals and within reduction and prevention organisations. As an example, the transition• promoting healthy lifestyle behaviours to GP-led commissioning may provide• promoting healthy workplaces and opportunities to engage families and, increasing employment in particular, parents in efforts to improve• reducing isolation and increasing social mental health at community level. networks for older people Local authorities will be well placed to• addressing social inequalities and support this work, given their role in enhancing social cohesion improving both educational and social• improving housing conditions outcomes for children, young people• reducing stigma and discrimination and families. Approaches may include• reducing health inequalities. promoting exercise and physical activity, which are both known to be linked with good mental health and wellbeing.
    • A framework for local authority and NHS commissioners 27 1.18 Personalisation Personalisation recognises the role of the The Operating Framework for the NHS Five ways to wellbeing individual as commissioner of their own 2011/12 highlights the work currently The Foresight Mental Capital and Wellbeing care and support. However, personalisation being undertaken to pilot personal health Project38 report produced wide-ranging cannot be achieved without a major cultural, budgets across England (including a number recommendations on how to enhance attitudinal and behavioural transformation of mental health sites40) and reinforces the the mental health and wellbeing of the across the whole mental health economy. Coalition Government’s commitment to population in order to maximise individual expanding their availability and uptake. and collective mental capital. It included Personalisation includes, but also goes well Personal health budgets are seen not only to a set of public messages to encourage beyond, allocating people personal social give individuals greater choice and control individuals to improve their mental and health care budgets so that they can wellbeing. These are: over the services but also to permit greater arrange and pay for their own care and integration between health and social care • Connect – with the people around you support with the aim of achieving better • Be active – go for a walk or run at the level of the individual. mental health outcomes and life goals. It • Take notice – be curious requires health and social care workers to Personalisation encourages commissioners • Keep learning – try something new • Give – do something nice for a encourage and enable people using services to move away from purchasing block friend, or a stranger. to exercise more choice and control over contracts of care and directly commissioning their own lives, including taking a much individual service packages. Instead, their The effectiveness of this approach to behaviour-change to improve mental more instrumental role in deciding the care role is likely to encompass activities such as wellbeing is being evaluated. and treatment they receive from social care achieving the right balance of investment in and health services. local services to ensure that those who still wish to can access more traditional forms Personalisation is about empowering of care. Their role may also include shaping individuals to make their own informed and developing the market to ensure that38 Foresight Mental Capital and Wellbeing decisions and choices about how they wantProject (2008). Final project report. London: personal health budget holders and people to live their lives and the help they need funding their own care have access to highGovernment Office for Science. to do so. This represents a significant shift quality, flexible, responsive and person-39 Glover H ( 2010). Presentation at the LifelongLearning and Empowerment in Mental Health away from traditional models of health and centred services to support their continuedconference. Paris, February. social care. Personalisation also foregrounds recovery and mental wellbeing.40 http://www.personalhealthbudgets.dh.gov.uk the concept of personal responsibility;41 SCIE (2009). Personalisation briefing it is about equipping people with the Commissioners will need to switch theirfor commissioners. London: SCIE. information, freedom and confidence focus towards commissioning for outcomes. to manage their own health and take This will in turn influence the development control of their lives. This marks a radical of a far more diverse provider market, departure from the historical dependency on bringing greater choice of providers traditional services and passive acceptance and services. There is also likely to be of ‘professional gifts’.39 considerable potential for GPCC and local Personalisation is also about respecting Good practice guide people’s ‘right to fail’, where someone may choose to take informed risks or make The National Mental Health Development choices that do not always work out, and Unit (NMHDU) has produced a they may need to try again or try out good practice guide on how to make personalisation a reality for people with different approaches. This is also an area mental health support needs. It includes where governance systems will need further information on what personalisation means development to ensure that this can happen for mental health services, examples of what within an agreed framework, both for needs to be in place to make personalisation people using services and for professionals. work, and pointers to good practice and sources of advice and information. See: http://www.pathstopersonalisation.org.uk
    • 28 Practical Mental Health Commissioning 1.19 Payment by Resultsauthority commissioners to work more PbR means that providers are paid for • it provides the chance to make morecollaboratively with others to develop new the number and type of people treated, informed operational and strategicpersonalised and cost-effective approaches to in accordance with national rules and a decisions for mental health services byachieving better mental health and wellbeing national currency. It relies on improved improving the information available tooutcomes for the populations they serve. availability of data on activity and commissioners. outcomes to support funding flows fromAs well as enabling an individual and their commissioners to providers. This can have Beyond these two key benefits, therecarer(s) to exert greater control and choice, the added benefit of backing up clinical are a number of other, related advantagespersonalisation also provides the means for commissioning conversations across primary, for commissioners, providers and peopleeveryone in a given community to play an secondary, social care and public mental using services.active role in promoting their own good health about service effectiveness andmental health and wellbeing. Personalisation • People using services should have well- options for redesign. Measures ofrequires everyone to have ready access to defined responses to their individual care the effectiveness of the new system willinformation and advice about local services needs, with clarity over treatment and need to be comprehensive to ensureso they can make informed decisions about support options. This approach could that ‘upstream’ actions around healthwhat would best meet their health needs. support the setting of personal health improvement, prevention and early budgets by allowing funding to be aligned intervention are also incentivised, alongsideAdditionally, everyone should have equal with and reflect people’s individual needs. the delivery of core services.access to universal public services that will • The mental health system will haveenable them to maintain and promote their A set of currencies will be introduced for contractual parity with other providers whoown wellbeing. These include transport, working age adult mental health services are also contracted on an activity basis.leisure and education, housing and health from 2012/13, based on a system of PbRservices, and opportunities for employment. • Commissioners can expect to have a mental health care clusters. clearer understanding of the number and The PbR mental health care clusters have nature of people being treated. They will SCIE personalisation tasks also have a transparent framework within been available for use since April 2010. In 2011/12, all those accessing mental which to align outcome measures and The Social Care Institute for Excellence health services for working age adults and the opportunity to have more meaningful (SCIE)41 has summarised the main tasks of personalisation for local authority older people should be allocated to a cluster discussions with providers about the commissioners. These can be seen to apply and local prices agreed. These should be service response to each care cluster. equally to mental health commissioners. ready for 2012/13 when the use of clusters Given that clusters focus on individuals, They include: they should also facilitate the co- with local prices becomes mandatory for • ensuring the right balance of investment contracting and payment purposes. Options ordination of multiple providers delivering between different services for moving to a national tariff will also be different aspects of care. • shaping the market to ensure that high explored, although the feasibility is under • In carrying out their preparation, providers quality, flexible and responsive services examination. will be able to gain a more detailed are available for personal budget holders understanding of their business. This and self-funders Implementing mental health PbR may includes the costs of interventions for • ensuring that people have access to appear to be an additional task in the individual users of services, the ability information and advice to make good current climate of change. However, to design and develop service provision decisions about their care and support two over-arching benefits make it a based on their characteristics, and a • using co-production as means to support worthwhile task: transparent means of demonstrating and actively engage people in the design, • it provides the opportunity to better their productivity and efficiency through delivery and evaluation of services understand the needs of users of services benchmarking with other providers. • developing local partnerships to produce a range of services for people to choose from and ensure that service responses to their needs are high quality (safe, effective and • providing opportunities for social inclusion and community development. a positive experience) and good value (by being efficient and productive)
    • A framework for local authority and NHS commissioners 291.20 Equalities, diversity and inclusionEqualities, diversity and inclusion are key Table 5: Equalities issues for mental health commissionersareas for commissioners. Commissioningprovides the mechanism to tackle health Equalities cover a range of issues that impact on health across and within communities.inequalities by ensuring that disadvantaged Inequalities will be identified through the Joint Strategic Needs Assessment. Inequalitiesand minority communities and individuals commonly encountered within NHS and social care services include:with specialist and complex needs receivethe levels of service provision needed to Agemaintain and improve their mental healthand wellbeing. Access for older people to services available to working age adults; failure to recognise mental health needs of older adults.The Equality Act 2010 pulls together existingequalities legislation covering disability, gender, Disabilityrace, religion/belief and sexual orientation, Access to physical and mental health care for people with other disabilities –and also introduces an age equality duty e.g. people with learning disability who can be overlooked both by mental healthon the public sector and a duty to consider services and public health initiatives such as screening.reducing socio-economic inequalities. Marriage and civil partnershipA core requirement is to pay due regardto the need to eliminate discrimination Rights and recognition of same sex partnerships.and promote equality. This provides anopportunity for commissioners to assess the Racelikely impact of proposed policies and servicedevelopments on groups with protected Inequalities in health and health outcomes; poorer access to and experience of services.characteristics (see table 5). Commissionersof mental health services will need to Religion or beliefensure that their decisions do not impact Provision of appropriate facilities, sensitive services.disproportionately on any one segment ofthe local population and that they protect Genderthe interests of minority and social excludedgroups and individuals. Safety issues, single sex accommodation, mental health impact of violence and abuse, gender variations in mental disorders and access to treatments; gender reassignment.There is a continued need to focus onequality of access to services and that Sexual orientationservices are responsive to local diversity ofneed and experience. Failure to do this can Gaps in service provision for lesbian, gay, bisexual and transgender people; discrimination.perpetuate inequality in service provision.Local authorities and the NHS can alsomake a significant contribution42 to buildingresilient and cohesive communities, which inturn contributes to achieving the CoalitionGovernment’s visions for the Big Society,public mental health and social care.
    • 30 Practical Mental Health Commissioning1.21 Involving individuals 1.22 Safeguarding children 1.23 Expanding choice of providers and communities and vulnerable adultsThe Coalition Government has set out its In mental health, safeguarding duties The introduction of PbR in mental health,vision for the Big Society. The aim is to cover three core dimensions: the development of the new care clustersgive communities and individuals more and the continued roll-out of personalinfluence over local public service • people with mental health issues budgets will promote further expansion inprovision.43 This includes encouragement (as individuals or as parents/carers) the provider market to include a far widerto people to play an active role in their • safeguarding others, with particular range and diversity of providers. This sitscommunities; devolution of power and relevance to children and families within the framework of competition andgreater financial autonomy to local collaboration that applies to the NHS and • wider public protection issues andgovernment; support for non-statutory local authorities. It will be important for the application of statutory mentalorganisations; powers to take over local GP commissioning consortia to take advice health powers.facilities and services threatened with from specialist clinicians in secondary careclosure; and opportunities for public sector In mental health, safeguarding requires to ensure that the right clinical pathways areworkers to establish employee-owned connections to be further strengthened commissioned in a collaborative way. Thisco-operatives and bid to run the services and maintained across primary care, social is not incompatible with the need to ensurethey currently deliver.42 The result should care, community, specialist and acute health competition as long as commissioners canbe increased choice for local people, and care services and also link with the public, demonstrate that no one has been eithergreater responsiveness and accountability private, voluntary and community sectors. positively or inappropriately excluded fromfrom providers. those collaborative conversations. A significant level of unmet need currentlyThis approach resonates strongly with exists among children and young people NHS trusts will find themselves inthe recovery approach to mental health with mental health problems. This, as competition with independent andtreatment, with its emphasis on individual highlighted above, is a particularly important voluntary sector providers. This presentsempowerment and self-actualisation, group to target to prevent adult mental both opportunities and challenges fordrawing on peer (community) support. disorder. For instance, in 2004 only 25% commissioners. They will have a much of children and adolescents with conduct greater choice of care providers, but may or emotional disorder had active contact also need to support smaller, specialist with CAMHS, even though these are the voluntary sector agencies whose services42 Lawrence A (2008). Better together: a guidefor people in the health service on how you most common mental disorders in this age may be more acceptable and accessible tocan help to build more cohesive communities. group.26 Similarly, more than half of all particular groups – and no less effective –Coventry: Institute of Community Cohesion. children with autism or Asperger’s syndrome than those offered by larger agencies.http://www.cohesioninstitute.org.uk/Resources/ The ‘any willing provider’ requirement is were not diagnosed and did not receive anyToolkits/Health/HealthAndCommunityCohesion/ additional support in education or health. likely also to bring much greater choice forKeyNhsPriorities Safeguarding requires appropriate capacity users of services.43 Cabinet Office (2010). Building theBig Society. London: Cabinet Office. to enable early intervention for childhood Local commissioners will need to ensure thehttp://www.cabinetoffice.gov.uk/media/407789/ and adolescent mental disorder to preventbuilding-big-society.pdf place of these smaller, specialist providers more serious and long-lasting problems Russell G, Ford T, Steer C, Golding J (2010). is protected in this more commercial44 developing into adulthood.Identification of children with the same level of market place. A balance also needs to beimpairment as children on the autistic spectrum, maintained between individual choice andand analysis of their service use. Journal of Child collective protection.Psychology and Psychiatry 51(6): 643–651.
    • A framework for local authority and NHS commissioners 31 Introduction 1. The changing 2. What 3. Going forward: commissioning mental health what mental health landscape commissioning commissioners looks like now need to know 07 31 36 Conclusion Glossary Useful links Glossary 51 52 55 572.1 Needs assessment (JSNA)2.2 Commissioning, contracting and procurement2.3 Specialist commissioning2.4 The commissioning process2.5 Integrated and collaborative commissioning2.6 Current market characteristics
    • 32 Practical Mental Health CommissioningWhat mental health commissioning looks like nowOver the last ten years, A number of new roles have alsocommissioning in mental health been introduced to the mentalhas been driven largely by the health arena, including primary careNational Service Framework (NSF) mental health workers, support,for mental health. Building on the time and recovery (STaR) workers,NSF achievements, government and community developmentpolicy has focused on the dual workers, with a particular focuspriorities of improving the mental on minority ethnic communities.health and wellbeing of individuals Peer support services have alsoand the population and improving emerged, making visible thethe quality of clinical services for contribution people with experiencepeople with high level needs. of using services (personally, or as a carer) can bring to improvingCommissioners and providers have health and recovery outcomes.focused primarily on developingand embedding a range of primary The Improving Access toand community based services to Psychological Therapies programmesupport the shift in locus of care has also significantly expandedaway from the acute inpatient access to talking treatments inhospital. These include specialist primary care settings for peoplecommunity mental health teams with mild to moderate mentaland services that deliver: health problems.45• crisis resolution and home The new mental health strategy treatment confirms the importance of• assertive outreach promotion of mental wellbeing,• early intervention in psychosis. early intervention for mental illness and approaches supporting choice, personalised care and recovery. There will be a strong focus on achieving improved outcomes for people with a range of mental health needs, regardless of their age and background.45 http://www.nmhdu.org.uk/our-work/personalisation-in-mental-health-emerging-programme/peer-support-initiatives-practice-examples/?keywords=peer+support
    • A framework for local authority and NHS commissioners 332.1 Needs assessment (JSNA) 2.2 Commissioning, contracting and procurementLocal authorities and NHS commissioners The main areas of spend on specialist adult mental health and social care services arehave a statutory duty to produce a joint shown in figure 6 below.strategic needs assessment (JSNA),46as required by the Local Government and Figure 6: Commissioning spend by service areas for mental health and social carePublic Involvement in Health Act 2007.The JSNA forms the basis for local Total reported investment in Adult Mental Health Services in £000sagreements, strategies, and plans for meeting 2009/10 Mental Health Finance Mappingthe health needs of the local populationand addressing health inequalities. Thisresponsibility will continue as part of localauthorities’ responsibilities for co-ordinating 20%local commissioning. 25%The JSNA process draws in a wide range ofpartner organisations to obtain a genuinelyholistic picture of current and future local 3%health need that will allow organisationsand individuals to make more informeddecisions about the level and type of services 6%required.47 It places individual and populationneeds and outcomes at the heart of the 3%commissioning process. 1% 21%The JSNA should capture not just the needsthat are currently being met by existingservices but also unmet needs and those thatmay be masked by more dominant needs 21%within the wider community. This requiresclose collaboration between partner agencies. Source: Mental Health StrategiesGuidance about conducting JSNAs for mental Community teams (inc. Access and Crisis) (MHS) for Department of Health Clinical and Day Services (inc. Personality Disorder) (2010). The 2009/10 Surveyhealth can be found in The Joint Strategic Accommodation and Continuing Care of Investment in MentalHealthNeeds Assessment and Mental Health Mental Health Promotion and Carers Service Services.Commissioning Toolkit – A practical guide Other Community Hospitals and Support Services http://www.dh.gov.uk/en/Publi-at www.nmhdu.org.uk Psychological Therapies cationsandstatistics/Publications/ Direct Payments and Home Support PublicationsPolicyAndGuidance/ Secure and other High Dependency Services DH_117488 Current approaches to mental health At tier four, due to the low volume and high commissioning vary widely across the country cost of the services being commissioned, and often depend on the tier at which specialist commissioning groups have been services are being commissioned. At tiers one established that operate at a regional level, so46 Department of Health (2007). Guidance to three, the most common approach will be that risk is shared and procurement terms canon joint strategic needs assessment. London: more beneficial. joint commissioning between local authoritiesDepartment of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ and PCTs, lead commissioning, where onePublicationsPolicyAndGuidance/DH_081097 PCT takes the lead for a number of PCTs,47 NMHDU/CSL (2009). The commissioning and individual or aligned commissioning,friend for mental health services. London: where individual PCTs or local authoritiesNMHDU/CSL. commission separately or collaboratively.
    • 34 Practical Mental Health Commissioning2.3 Specialist commissioning 2.4 The commissioning processThere are currently ten regional specialised The commissioning process is a continuous This requires working across local/commissioning groups in England. They are cycle through three stages: strategic sub-regional/regional partnerships, andresponsible for commissioning some, or all, planning, procuring services, and monitoring collaboratively with others, to specifyof the Specialist Services National Definition and evaluation. services and outcomes, maximiseSet. These include forensic/secure mental procurement efficiencies and strengthenhealth services; perinatal mental health Commissioning is a dynamic process that joint contacting and performanceservices (mother and baby units); tier four is about identifying and prioritising need management.severe personality disorder services; and and apportioning resources to meet thosetier four child and adolescent mental needs and achieve positive outcomes in a A range of system/market managementhealth services. spiral of continuous improvement. and procurement approaches can be used to ensure service choice, diversity, quality,In addition, secure forensic services Commissioning to improve population safety and effectiveness. These includefor young people and high secure mental health and wellbeing requires the some of the newer system reform tools,commissioning are commissioned at a co-ordination of commissioning activity such as the commissioning for qualitynational level by the National Specialised for the whole population: and innovation framework (CQUIN),Commissioning Group. user/patient reported outcome measures • at a universal (tier one) level for people (PROMS), person-based resource allocationThese specialised commissioning accessing primary care and lower-level systems and commissioning currencies.arrangements can work well in terms advice and support services for a rangeof strategic management of investment of issues including depression, anxiety, The requirement to reduce managementand resources (for example, collaborative and medically unexplained symptoms. and infrastructure costs requirescommissioning of perinatal inpatient This level also involves universal and consideration of effective collaborativeservices), consistent management of clinical targeted interventions to promote mental structural arrangements to manage thegate-keeping and achieving procurement health and prevent mental illness stages of the commissioning cycle. Thisefficiencies through economies of scale. • for people recovering from severe may include, for example, merger of mental illness (tier two) shared services and clustering of NHSHowever, establishing pathways into commissioners’ functions.specialist services and back into mainstream • for people receiving active treatmentcommunity mental health services continues for severe mental illness, and peopleto present a considerable challenge, using medium/long-term care servicesrequiring collaboration between local and (tier three)specialist commissioners. • for people using specialist, intensive medical or forensic services (tier four).The new commissioning system willdeliver new opportunities to developalternatives along this pathway (suchas step down care) in order to facilitatethroughput and discharge, as well asother potential approaches (such asrobust multi-agency protection panels).
    • A framework for local authority and NHS commissioners 352.5 Integrated and collaborative 2.6 Current market characteristics commissioningJoint and wider collaborative commissioning Figure 7 illustrates the current share of the NHS mental health provider market betweenarrangements for mental health and NHS, non-statutory and social services.wellbeing vary across the country. Theyrange from individual mental health Figure 7: Mental health providers by sectorcommissioners working together acrossagencies, through Care Trust Plus models,to fully integrated, joint mental health Noncommissioning organisations. Some are 7% Statutoryusing devolved joint budgets secured underSection 75 commissioning agreements.Some are sharing risk through regionalor sub-regional procurement or specialist NHScommissioning arrangements coveringa number of ‘member’ commissioning 29% 64%organisations.The increasingly integrated nature of Socialcommissioning and provision brings together Servicesdifferent organisational cultures. Workingwith each others’ cultures, systems andprocesses presents particular challenges.47How to align different priorities andcompeting targets in order to facilitate Source: Mental Health Strategies (MHS) for Department of Health (2010). The 2009/10partnership working remains a key challenge Survey of Investment in MentalHealth Services. http://www.dh.gov.uk/en/Publicationsand- statistics/Publications/PublicationsPolicyAndGuidance/DH_117488on the commissioning agenda.Joint commissioning between the NHS Mental health touches all aspects of life. At the other end of the spectrum are(currently PCTs and, in time, the new GPCC) For this reason, the mental health provider specialist placements and rehabilitationand local authorities requires the alignment market is already well developed and services. Here too there is a good range andof mutual business functions around finance, contains a wider selection of agencies than large selection of independent providers, asgovernance arrangements and risk-sharing. most other sectors of health or social care. well as voluntary sector and NHS provision.This is particularly important for publicmental health interventions where the bulk This is most noticeable at the community and However the core secondary mental healthof economic savings tend to accrue to areas social inclusion end of the spectrum, where services are still contracted in the main fromoutside health. the voluntary sector plays a significant role in NHS mental health trusts, through large block the expansion of access to talking treatments contracts. This has limited the introduction of and the development of social businesses. the ‘any willing provider’ model that is better able to increase innovation, market diversity and choice for users of services.
    • 36 Practical Mental Health Commissioning Introduction 1. The changing 2. What 3. Going forward: commissioning mental health what mental health landscape commissioning commissioners looks like now need to know 07 31 36 Conclusion Glossary Useful links Glossary 51 52 55 573.1 Population mental health and wellbeing3.2 Recovery3.3 All-age commissioning3.4 Clinical leadership and engagement3.5 Co-production and engagement3.6 Effective use of resources3.7 Realigning investment3.8 Elements of a whole system approach
    • A framework for local authority and NHS commissioners 37Going forward:what mental health commissioners need to knowThe Coalition Government’s plans During the first transitional year, 2011/12, • further developing relationships with Localfor the redesign of health and emerging GPCC will have the opportunity Involvement Networks (as they developsocial care commissioning will see to plan how they intend to carry out their into local HealthWatch) and with otherthe implementation of GP-led future functions. In particular, they will need community partners and advocacy groups.commissioning, the transfer of to decide what activities they will undertake In the final transitional year (2012/13)public health responsibilities to local for themselves by employing or engaging consortia will typically take on the leadauthorities and the abolition of their own staff, what activities they will carry responsibility for commissioning healthSHAs and PCTs by 2013. out on a collaborative basis (for example, through a lead consortium arrangement or care services. PCTs will still be statutorilyThe transition process is outlined through collaboration with local authorities), accountable but will transfer responsibilityin the Command paper, Liberating and what activities they wish to buy from for budgets and commissioning decisionsthe NHS: Legislative Framework external support organisations. to GPCC.and Next Steps.48 Building on these early findings, during From April 2012, the NHS CommissioningTransition to the new arrangements 2011/12 emerging GPCC and local Board will establish GPCC, based on thewill be carefully staged. From authorities will work with PCTs to develop applications prepared in the previous year,December 2010, cohorts of transition plans that include: or work with prospective consortia to helppathfinder GPCC have started to resolve any difficulties.test the key elements of GP-led • identifying posts for a transfer of staff Once established as statutory bodies incommissioning. From January from PCTs to consortia their own right, GPCC will be able to take2011 and throughout 2011/12, • identifying consortia intend to fill other on staff from PCTs. In the autumn of 2012,a growing number of shadow posts within their future staffing structures consortia will receive notification of theconsortia will become pathfinders • enabling PCTs, SHAs and the shadow budgets for which they will be statutorilyand start to take on responsibilities NHS Commissioning Board to identify accountable from April 2013 onwards. Fromfor commissioning, using powers where there will be significant demand April 2013 it is likely there will be a periodand budgets delegated to them by for external commissioning support, to of embedding and consolidating the newPCTs within the current statutory encourage potential providers to develop system, with further adaptation as consortiaframework. PCTs will start making support in these areas, and to consider learn from experience.staff available to assist consortia in how best to support consortia in accessingtheir new role. Early implementer There are, however, risks to services in times cost-efficient and effective supportarrangements for health and of transition. The transfer of commissioningwellbeing boards will also be tested • agreeing a managed process for responsibilities is also taking place withinin 2011/12, in preparation to be transferring any information and a highly challenging financial context. Asfully operative in 2012/13. IT systems associated with these GP-led commissioning begins to identify commissioning functions and address local priorities, it will be • identifying the individual contracts that important to engage with strategic and will need to be transferred from PCTs collaborative planning for mental health so48 Department of Health (2010). Liberating to consortia that shifts in investment are consistent withthe NHS: Legislative Framework and Next • identifying partnership arrangements, the overarching strategic direction of theSteps. London: The Stationery Office. including pooled budget and lead commissioning system as a whole. commissioner agreements, that will transfer The focus of commissioning has broadened, to consortia working with local authorities reflecting the need to view mental health to make future plans for these areas through a whole population lens. This • identifying how arrangements will operate includes moving towards more holistic for public health services and health and service delivery.47 wellbeing boards at a local level, and
    • 38 Practical Mental Health Commissioning3.1 Population mental health and wellbeingTo achieve sustainability in the medium Half of lifetime mental illness emerges by Moreover, as the Government Office forand long term, commissioners need to the age of 14, and three quarters by the Science has evidenced conclusively in itslook beyond the high profile specialist mid-20s. Given this evidence and the limited Foresight Project,38 investment in populationand acute services that are traditionally resources available, it will clearly be in the mental capital and wellbeing is essentiallabelled ‘mental health’ and commissioned interests of commissioners to invest in for society as a whole, and the nation’sprimarily from mental health trusts. early interventions for people experiencing economic prosperity. Mental capital is mental health problems in order to help defined as an individual’s cognitive andThe clear message from public reduce use of more expensive, longer-term emotional resources. Wellbeing describeshealth analysis and evidence is that interventions at a later point. the state in which a person is able tocommissioners in both the NHS and local develop their potential, work productivelyauthorities also need to focus more on This links to current work to develop and creatively, and build strong andmental health promotion, prevention a connected economic model for early positive relationships with others. Bothand early intervention. They need to intervention for conduct disorder, early are fundamental attributes of resilientinvest in improving the life chances diagnosis and treatment of depression in the individuals and also of cohesive, productiveand circumstances of everyone in the workplace, early intervention in psychosis and mutually supportive communities.communities they serve, particularly those and early detection of psychosis.49at higher risk, as highlighted earlier. It is therefore important for commissioners to take both a broad and a long view, and ensure a focus on commissioning for Feeling good about where you live mental health as well as mental illness. As previously referenced, even if all those Feeling Good About Where You Live (FGAWYL) is a multi-agency mental health experiencing mental illness received optimal promotion project targeting a deprived area of the London borough of Greenwich with high levels of poor mental health. It is a multi-partner initiative that involves NHS treatment, only 28% of the burden of Greenwich and Greenwich Council (which jointly fund the project), the Metropolitan disease would be averted. Police, local community groups and residents. The project builds on previous research with residents of Greenwich that revealed a strong cross-sectional association between the residential environment and mental 49 Knapp M, McDaid D and Parsonage M wellbeing, independent of demographic/socio-economic characteristics of residents. (2011). Mental health promotion and mental The research highlighted the need to intervene in both design and social features of illness prevention: The economic case. Personal residential areas to promote psychological health. Social Services Research Unit, London School of Economics and Political Science. Report to be FGAWYL is piloting an integrated, multi-agency approach to delivering low cost published by the Department of Health, London. physical and social interventions that maximise the effectiveness of existing routine services and local funding sources to address each of 13 factors operating at estate level (damp; noise; overcrowding; fear of going out during the day and night; liking the look of the place; needles and syringes left around; access to open space; lack of places to stop and chat; community and entertainment facilities; transport and accessibility). An intervention estate is being matched with a ‘control’ estate, which will enable the project to provide causal evidence of the relationships between the physical and social aspects of residential environments and psychological wellbeing and to develop a model that will be replicable across other areas of Greenwich. It is envisaged that the ‘control’ estate will also receive interventions following completion of the intervention research stage. http://webcache.googleusercontent.com/search?q=cache:DJVDol-0XT4J:www. selondonhousing.org/Documents/Aideen%2520Silke%2520presentation%2520Feelin g%2520Good%2520about%2520where%2520your%2520live.ppt+“Feeling+Good+ About+Where+You+Live”+(FGAWYL)&cd=1&hl=en&ct=clnk&gl=uko
    • A framework for local authority and NHS commissioners 39 3.2 RecoveryThe proposed health and wellbeing boards Mental health practice should aim always “...a deeply personal, unique process ofmay provide a catalyst for this, bringing to put the person’s needs at the centre changing one’s attitudes, values, feelings,together GPCC with local authority of care planning and service delivery. The goals, skills, and/or roles. It is a way ofcolleagues and citizens to develop a strategy mental health strategy, No Health without living a satisfying, hopeful and contributingfor the long-term, holistic investment in Mental Health, encourages recovery-based life even within the limitations caused byfuture mental health, as well as current approaches. This is further reinforced by the illness. Recovery involves the developmenttreatment and recovery. inclusion of recovery in the NHS Outcomes of new meaning and purpose in one’s life Framework and the proposed social care as one grows beyond catastrophic effectsCommissioners will need to align their outcomes framework. of mental illness.”50inputs with the broader strategies forcommunity wellbeing that are devised and The recovery model underpins the Care Recovery challenges conventionaldelivered through local partnership activity Programme Approach (CPA) and its four approaches to treating mental ill health. It isin other sectors, such as housing, transport, key elements: assessment, care planning, consistent with the Government’s vision forand employment. provision of a care co-ordinator and public health. This, as previously explained, regular review. takes a more holistic approach to mentalInvestment in community outreach and wellbeing and mental health improvement,voluntary sector groups with a prevention The CPA process aims to promote social rather than addressing mental illness inand mental wellbeing focus can help reduce inclusion and recovery, encourage the isolation from other important factors inthe likelihood of vulnerable groups with individual to take responsibility for their own people’s lives.severe and long-term mental health needs wellbeing, recognise the role of carers inrequiring support from specialist secondary facilitating recovery, and promote genuine The recovery approach has been adoptedmental health services. partnership working between the individual by many mental health services in England, and their mental health team. Systems have with varying success.Ensuring that the necessary range of been developed that have further supportedpreventive services and treatment options and ensured these aims and ensure a The Mental Health Recovery Star51 enablesare in place or are being developed will continuous link from the promotion of users of services to gauge and record theirbe central to improving mental health and wellbeing through relapse prevention to recovery progress, and enables providerswellbeing across localities. recovery, in line with the public mental to identify individual outcomes and health agenda. benchmark across services. The Centre for Mental Health and the National Mental In a mental health context, the term Health Development Unit have produced ‘recovery’ does not refer to ‘clinical a methodology to support commissioners recovery’ from a mental illness. Rather, and providers to work collaboratively on it is used very specifically to describe the organisational improvements that will individual’s personal, self-directed journey deliver recovery-oriented services.52 through life with mental illness. Recovery has been described as: 50 Anthony WA (1993). Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal 16(4): 11-23. 51 http://www.mhpf.org.uk/ recoveryStarApproach.asp 52 Shepherd G, Boardman J, Burns M (2010). Implementing recovery: a methodology for organisational change. London: Centre for Mental Health.
    • 40 Practical Mental Health Commissioning 3.3 All-age commissioning The recovery model and the objectives The aspiration for all-age inclusivity inMind’s portfolio of innovation of the CPA require mental health commissioning is not always reflected inMind in Croydon won the NHS Health commissioners to promote and increase the current resource allocation across adultand Social Care Award for mental health support and treatment choices available health and social care. A similar disparityand wellbeing for their highly innovative to individuals. They will need to stimulate is found between services for children andapproach to working with people with the market to include a wider range of young people and services for workingmental health problems. Mind in Croydon’s‘portfolio of innovation’ includes services providers and further unlock payment age adults. Limiting access to services onsuch as sailing, boxercise, horticulture and mechanisms (linked in to PbR) to allow the the basis of age is not only potentiallya service user documentary film group. expansion of personal health and social care discriminatory; it can also hinder transitionsThe work has enabled clients to engage budgets, giving more personalised options between care pathways and services.in unique and innovative projects that and choices to people across health andpromote their recovery and wellbeing. social care. Also, where an evidence base All-age commissioning means taking aThe projects also go a long way to is building, commissioners might consider wider approach to population health.challenging stereotypes and overcoming the value of certain complementary and Mental health, public health and otherthe stigma associated with mental health alternative therapeutic approaches. commissioners can address these difficultiesproblems as well as challenging ideas about by designing services and care pathwayswhat are seen as ‘suitable activities’ for The stimulation of the market will increase around need rather than age.those with mental health problems. the need to monitor types and levels ofPeople’s self-esteem and self-confidence activity to ensure best value across services Of particular importance when consideringimproved greatly – success in one area of and to review and change what does not all-age commissioning is the issue oftheir lives gave people the impetus and transitions. The transition from adolescence work or is not used. Access to good quality,confidence to move forward in other areas, to adulthood is a crucial stage in social,such as returning to college or work. up-to-date information is key if people are going to be able to exercise far greater personal and emotional development.53Danni, who has benefited from the multi- For young people in contact with mental choice. To support this, a national websiteaward winning Mind in Croydon boxercise health services, this period usually coincidesproject, which is run in partnership with has been developed to help people directly with this issue, at: with another important transition – fromthree times world champion boxer, DukeMcKenzie, accepted the award on behalf child and adolescent mental health services http://www.nhs.uk/Livewell/MentalHealth/of the team. She said: “Boxercise has been (CAMHS) to adult mental health or other Pages/Mentalhealthhome.aspxthe miracle I needed to put myself back relevant services.together. In March I got my Level 2YMCA fitness qualification...the project Services that meet the needs of younghas changed my life.” people and provide safe and co-ordinatedThe projects, funded by NHS Croydon, transitions between CAMHS and adultCity Bridge Trust, Film London and the Big services are rare. Health and social careLottery and Comic Relief via the Time to commissioners will need to work closelyChange anti-stigma campaign, also helped with providers in the NHS, local authorities,tackle some of the physical health problems schools, colleges and the third sector toassociated with mental health problems and ensure that appropriate, acceptable andpsychiatric medication, such as diabetes,heart disease and cancer. accessible services are commissioned and delivered to achieve improved outcomes for young people. 53 Lamb C, Hall D, Kelvin R, Van Beinum M (2008). Working at the CAMHS/adult interface: good practice guidance for the provision of psychiatric services to adolescents/young adults. London: Royal College of Psychiatrists.
    • A framework for local authority and NHS commissioners 413.4 Clinical leadership and engagementClinical leadership in commissioning in Local leadership is needed to bring theseEngland is still in development. It takes time two groups of clinicians together to discussaway from clinical care to be involved in the these issues and agree innovative solutions,commissioning process, but many clinicians and also to ensure the public mental healthhave found that the resulting improvement agenda is not overlooked. To make thesein resources and services is worthwhile.54 conversations effective requires action from both primary care organisations andThe information that clinicians hold is mental health trusts. Clinical leadership andinvaluable to developing services and engagement will be of particular benefit toenabling innovation. In mental health, the development of pathways, outcomesthe GP, psychiatrist and public health standards and access to services.clinician bring to the commissioning processa particular knowledge of local needs and Improving access to psychological therapiescircumstances to augment that provided bypartner agencies. Leadership is needed to Data relating to how IAPT services are planned, commissioned and delivered, includingdevelop commissioning networks that will health outcomes and users’ experience, is routinely collected locally, with some informationfacilitate conversations between clinicians optionally reported centrally to track implementation progress and for benchmarkingand the sharing of expertise. service performance. Full data were provided by 32 year-one IAPT sites. Overall, the findings support the IAPTPsychiatrists and other senior mental health model. Findings of particular significance for clinicians, mental health commissioners andstaff can advise on aspects GP commissioners include:of the care of people with severe and • psychological wellbeing practitioners and high intensity therapists are equally valuableenduring mental illness as well as other and services do best if they deploy both (plus employment advisors) in a functional,areas, about which most GPs have generic, stepped care approachrather than specialist, knowledge. GPs • initial symptom scores influenced the amount and type of treatment patients receivedcan advise on the physical health care of (in line with NICE guidance) and its outcomethese patients, including care of those with • self-referred patients recovered in fewer sessionsdiabetes and cardiovascular disease. Theymay also have some specific mental health • therapy that complied with NICE recommendations was associated with better outcomesknowledge from a primary care perspective • sites that offered more sessions had better outcomesthat can apply in day-to-day care. GPs • sites with more experienced staff achieved better outcomes.can also advise on the management Commissioners, working with their providers, can use these data to improve patientof people with common mental health outcomes by changing and refocusing local IAPT provision.problems, including the deployment of Data can be used to monitor the access of people with depression and anxietytalking therapy services. disorders to the full range of NICE-recommended, evidence-based psychological therapies, in accordance with the principles of stepped care. Working with IAPT service managers and clinical leads, outcome data may also be used to54 Simpson C (2000). Commissioning mental support investment in the continuing professional development needs of IAPT workers.health services: role of the consultant psychiatrist.Advances in Psychiatric Treatment 6 :72.
    • 42 Practical Mental Health Commissioning 3.5 Co-production and engagementExperience from other specialities in Co-production is a general description for Co-production requires commissionershealth, and from the Improving Access a process whereby people who use services, to engage meaningfully with otherto Psychological Therapies programme, and in particular those who can find it commissioners across sectors to ensureemphasises the importance of robust data hard to access services (such as people from clinically effective and cost-effectivein commissioning. The developing data set minority ethnic communities or people outcomes. Commissioners also need tofor mental health is beginning to yield useful with learning disabilities), work alongside engage with people who use services,information for clinicians about their practice. professionals as partners in the planning, carers and the public, to obtain informationUsing this data, and sharing information commissioning and delivery of services. to inform commissioning decisions.about effective clinical outcomes fromaround the country, can help to promote Co-production in Kirkleeswider clinical and professional engagementin the practical aspects of commissioning. Joint work with the New Economics Foundation (nef) provided the impetus forThis can also be further improved through commissioners across adult social care and health in Kirklees to test the principles ofmore accurate data collection, feedback and co-production within a formal procurement process that prioritised outcomes rather thandissemination between clinicians, information outputs. Three contracts were specified and assessed using the language of co-production.analysts and providers. From a commissioner perspective, potential providers were given much more freedom to describe how they would contribute to achieving the desired outcomes. The quality of tenders exceeded previous experience as providers responded creatively to the invitation. Mental health pathways One tender was orientated towards prevention in the context of work with nef on commissioning for wellbeing. With reference to outcomes associated with community A wide variation was noted in the capacity and personal resilience, this project additionally specified that a range of different mental health services provided in the delivery models should be included, specifically social enterprise, user-led organisations, different localities across Yorkshire and micro businesses and timebanking. Humber. Clinicians recommended actions for the SHA to take forward to improve A further product of the work with nef has been to accelerate an approach to looking provision. Of critical importance has been at social return on investment (SROI). All specifications in mental health now ask providers the implementation of generic mental to demonstrate how they evidence social return. Initial pilot work on employment confirmed health pathways. the prevailing view about the value of work. In six actual cases, the ’savings to the state’ worked out at between £600 and £11,000 pa. The key features of these pathways are: A full SROI exercise is now underway on the employment project in parallel with Sheffield • integrated primary/secondary and University. The general work on SROI is enhanced by the use of the Recovery Star51 to look health and social care at outcomes. A physical activity project (Active for Life), for example, only accepts referrals • care planning and care navigation from people supported by the Care Programme Approach. This project’s participants report supported by advocacy a quarterly improvement in their general wellbeing of around 25%. • single point of access Overall, there is a more cohesive approach to results, given that the framework includes • open access to a range of supportive outcomes, outputs, costs, social return and personal testimony. interventions provided by a range of providers. • care packages underpinned by NICE guidelines/good practice/evidence • care elements/packages can be allocated a cost so people can have their own budget • personal advisers or advocates available to support people to access the appropriate support • national standards for services enable benchmarking to take place. http://www.healthyambitions.co.uk/ Documents/HealthyAmbitions/NHS_ The_Mental_Health_Pathway.pdf
    • A framework for local authority and NHS commissioners 43This recognises that people who have used Co-production is also embedded in the Peer support in Australiaservices have unique knowledge that can recovery model. The recovery conceptbe used to improve their development sees the individual as an equal partner in A mental health peer support service wasand delivery. All those who offer services their own care and treatment, drawing introduced in an Australian adult mentaltherefore need to be able to promote and on a range of supports that may include health service with the aim to reducesupport the engagement of people using formal mental health services and medical hospital admissions and lengths of stay andthose services.55 treatment alongside other less formal improve early discharge support. sources. Thus, co-production has huge The evaluation looked in particular at bedEvery citizen is entitled to expect the potential at individual/clinician and days saved, crisis service contact, A&Esame from life and society as anyone else, commissioning levels. presentations, and readmission rates, andincluding opportunities to have a say in sought feedback from various stakeholdersdeciding priorities, strategies and services This approach is also key to ensuring including users of services, carers, mental health staff, GPs and peer support workers.that will meet local needs. Co-production individuals have more choice and controlrequires commissioners to break down over their care and treatment. Involvement In the first three months of operation,professional and organisational barriers of those using services in their own care, 49 support packages were provided and 300 bed days saved.and promote an inclusive, citizen-focused and also in providing support and peerapproach to the planning, commissioning services to others with similar care and Feedback from all stakeholders wasand delivery of services. treatment needs, has been shown to be overwhelmingly positive. The study concluded that using peers to provide both clinically effective and supportiveCurrently this can take place in mental support to consumers at this stage of their of recovery from mental illness and recovery appeared highly effective ashealth through a range of forums and maintenance of mental health, for provider an adjunct to mainstream mental healthother routes to engagement, including and service receiver alike. services, has personal benefit to users ofPartnership Boards and targeted social services and peers, results in substantialmarketing initiatives. It is important to Co-productive commissioning will require savings to mental health services, and hasbuild on these structures, and further investment in innovative peer support much potential for encouraging mentalopportunities are likely to arise through the initiatives and enabling access to activities health service culture and practice towardsnew commissioning system to better link and resources outside the conventional a greater recovery focus and improved collaboration with GPs.56into primary care and extend the influence understanding of mental health treatments,of people who use mental health services on in alliance with social care and wider localthe whole health and social care system. government services.55 Foster J (2005). Where are we going?The social work contribution to mental healthservices. London: Social Perspectives Networkfor Mental Health.56 Lawn S, Smith A, Hunter K (2008). Mentalhealth peer support for hospital avoidanceand early discharge: an Australian example ofconsumer driven and operated service. Journalof Mental Health 17(5): 498-508.
    • 44 Practical Mental Health Commissioning 3.6 Effective use of resources As in most health and social care-related (social care, housing and elements of Carer engagement areas, the demand for services in mental universal services) in a given locality – Herefordshire Health and Social Care health can outpace the available resources. with the risks and benefits explicitly Mental Health Procurement Project Board Commissioning systems – clinical, locality- described and allocated across partners. (which included representation from based, regional or national – will need providers, board members, clinicians and to be able to demonstrate that resource An example of the commissioning cycle is commissioners) consulted the local mental set out in figure 8. This figure is a modified allocation decisions have been clearly and health reference group early in the process version of a commissioning guide for of procuring mental health services from out systematically linked to meeting defined priorities. mental health professionals produced by of county. The report of findings identified for the commissioners several worthwhile the London Development Centre and the projects and validated an emerging model Needs assessment, planning, prioritisation National Mental Health Development Unit. for effective engagement of carers, or other and budgeting cycles work best when they stakeholders, for service improvement. are aligned across agencies, and where It demonstrates how prioritisation, Information in advance of the formal report investment plans are jointly agreed for the investment decisions and the setting can be obtained from: medium to long term (see figure 8 below). of outcome criteria flow directly from alison.bolton@nhs.net the needs assessment and gap analysis Longer term goals for health and wellbeing process, as well as joint mental health improvements allow outcomes to be or wider strategic priorities, and how Co-production with service users measured in the round – ie. covering all the review process similarly can be used Camden Council, the New Economics mental health programme investment across to inform future commissioning and Foundation (nef) and the local voluntary and NHS and local authority commissioners decommissioning decisions. community sector have jointly developed an outcomes-based commissioning model Figure 8: Commissioning cycle at strategic, practice and individual levels based on principles of social inclusion, using funding from a government Invest to Save programme.57 The model is designed to promote co-production with service users; use existing social assets and networks; improve outcomes for those using services; and ensure that these outcomes are 1. Accessing enduring and embedded in local 7. Managing needs, reviewing communities. The resulting service model provider services and promotes volunteering and timebanking, performance gap analysis both among people using services and within the wider community. 6. Provider 2. Risk development management Involvement and engagement57 Department of Health (2010). Volunteering:involving people and communities in deliveringand developing health and social care services.London: Department of Health. http://www. 5. Contract 3. Decidingdh.gov.uk/en/Publicationsandstatistics/ implementation prioritiesPublications/PublicationsPolicyAndGuidance/DH_113969 4. Strategic planning
    • A framework for local authority and NHS commissioners 453.7 Realigning investmentMental health policy and practice share This is likely to require the implementation Figure 9 below was developed to show,a common aim: to improve outcomes of wider clinically-owned and championed in practical terms, what such a shift infor people, with treatment and services mental health care pathways, in order to spending might look like. By using localprovided as close to home as possible, in reduce admissions and average lengths of figures and categories, it can be used to helporder to enable investment to be shifted stay. Enhancing diversion or ‘step-up’ and build a common narrative/shared vision infrom complex, specialist and inpatient ‘step-down’ options around crisis services commissioning forums and partnerships. Itservices to local community services. The and secondary care will also reduce the need also illustrates how savings can potentiallytransfer of budget and commissioning for lengthy, high-cost placements (in or out be freed up by, where appropriate, shiftingresponsibilities directly to GPCC is intended of the local area) and admissions to secure investment from tier three and four servicesto introduce greater flexibility at local services. to public mental health, prevention, earlylevel for service remodelling and pathway intervention and personalisation.redesign to meet identified needs.Knowing where resources are committed, Figure 9: Changing mental health investment profilesand for what outcomes, is key to deliveringservice redesign. In this respect, Paymentby Results for mental health has significant Changing mental health investment profiles – £spotential to assist the delivery of efficient, Investment Prevention, Primary/ Community Other Acute Specialisedhigh quality and innovative services by levels public social care, teams – secondary – inpatient and securesupporting economic modelling and mental housing, liaison continuing services 2011/12 health day services carescenario-planning, as well as real-time shifts resourcesin investment.Delivery of government policy for mental £ £ £ £ £ £health and wellbeing, coupled with thequality and productivity challenge for theNHS and the need to improve value formoney in local authorities, requires a double 2016/17shift in investment. Overall spend has tobe reduced through increased productivity,and a proportion of the investmentcurrently funding acute, specialist and othersecondary care services (covering all tiersof provision) needs to be moved upstream,where appropriate, to preventive and earlyintervention services, in order to reducedemand on these downstream services inthe longer term.In this way, it will be necessary to free upresources in order both to deliver efficienciesin the short term and to re-invest in publicmental health, social care, employment,housing, psychological therapies, prisonhealth care, the criminal justice system andother areas. Such investments have thepotential to deliver further medium andlong-term reductions on the demand side.
    • 46 Practical Mental Health Commissioning3.8 Elements of a whole system approachMeeting people’s needs and using resources Lack of appropriate housing can be a Supported housingmore effectively to reduce dependence on significant contributor to delayed dischargehigh intensity provision requires attention to from hospital. A lack of housing or support The Supported Living Outreach Teama number of other key areas that impact on (SLOT) Birmingham is a specialist outreach can also lead to increased readmissionmental health and wellbeing. team that has enabled 26 people who rates, over-use of residential care and, in previously lived in specialist out-of-area some cases, the use of out of area or other3.8.1: The NHS outcomes framework placements and forensic services to move high-cost services. Investment in housing back to the city and live in ordinary housing. and housing-related support can contributeHousing is generally recognised to be central The team includes specialist NHS staff significantly to reducing demand on acutepart of an effective, recovery-focused care with experience in behavioural approaches and specialist services.pathway. It provides the basis for individuals and support planning. Each person lives into re-engage with their lives outside the private rented housing, with daily support Social care, housing and healthhospital environment, receive support using people recruited from the local area and employed by non-specialist third sector commissioners, particularly where jointand help from their social networks and commissioning arrangements cover all providers. Individual support planning helpscommunities, and in many cases return to people to build links with the local area, find these responsibilities, will need to workwork or education. This can be addressed work and get to know people. with providers to ensure that the roleboth through primary prevention (good of housing in effective care pathway The outreach team provides advice, crisishousing associated with improved physical intervention and training, and is available planning is recognised and prioritised.and mental wellbeing), secondary prevention 24 hours a day. This input reduces gradually(targeted interventions aimed at those at high over time. The scheme was identified byrisk of mental illness such as people living in the Department of Health as a Beacon Housing-related supportunstable accommodation – ‘the homeless Service in 2007. The evaluation of Lambeth’s Supportingwith housing’) and tertiary prevention, as http://www.dh.gov.uk/en/ People programme providing housing-illustrated in the case study below Publicationsandstatistics/Publications/ related support demonstrated its PublicationsPolicyAndGuidance/Browsable/ transferability across the system.However, accessing decent housing DH_4898076 The commissioning board of the PCT andand moving along a pathway of care to The outcomes delivered include large local authority was expanded to becomeappropriate accommodation still requires reductions in ‘challenging’ behaviour, a cross-cutting commissioning boardpeople to negotiate a range of obstacles.58 offending and use of medication. Eight to identify opportunities across partner people no longer need any specialist organisations for seeking employment support. Cost savings average around 33% (an intrinsic theme of the wellbeing agenda (£50,000 per person per year). for mental health).58 Appleton N, Molyneux P (2009). The impactof choice based lettings on the access of http://benpct.nhs.uk/download/doc-type/ A series of shared goals and outcomes havevulnerable adults to social housing. London: board-papers/ben-tb-0608learning_ been defined to underpin joint and cross-Housing Learning and improvement Network. disabilities_services.pdf cutting commissioning, which is monitoredhttp://www.dhcarenetworks.org.uk/_library/ via an integrated governance structure.Resources/Housing/Support_materials/Reports/ This is an example of a system improvingReport17.pdf the use of resources (money, people and places) through better partnership and joint commissioning. The programme is outlined in a presentation available at: http://www.lambeth.gov.uk/NR/ rdonlyres/BF622544-9D08-4811- 934E-DEC2FABF8469/0/LambethSP andtheLAAajourneynotadestination.pdf
    • A framework for local authority and NHS commissioners 473.8.2: Physical healthThe links between physical and mental Physical health standards in mental health serviceshealth are clear. There are shared risk factorsfor both illnesses. People with physical Scoping work by the Royal College of Psychiatrists, published in 2009, explored a rangeillnesses frequently present with both of issues concerning the general health of people with mental health problems. It madepsychological and physical symptoms, and recommendations about clinical practice, training and the identification of other prioritiesbeing physically ill, particularly with chronic in physical health care. The scoping included examples of good or improving practice,illnesses and disabilities, often negatively including the initiative outlined below.61affects mental health. People with two or Work done by the West London Mental Health Trust highlighted the need for clearmore long-term conditions are seven times standards in relation to the physical health of the people using its services. The standardsmore likely to have co-morbid depression they recommended are:than those without long-term conditions.59 • initial physical examination at admissionAs a result, they are more likely to use • a full physical health review to be completed with two weeks of admissionhealth care resources at all levels of the • appropriate physical investigations to be completed within first week of admissionsystem. Providing psychological treatments • plans to be put in place for ongoing physical health carehas been shown to improve outcomes and • use of health promotion • use of physical health standards for people in the community, including a sectionuse of health services for both the physical on physical health in CPA and discharge plans, and for CPA to include a review ofand mental health needs. physical health needs.It is also widely accepted that people with http://www.rcpsych.ac.uk/files/pdfversion/OP67.pdfmental illness have significantly higher rates ofmortality and morbidity from physical illnessessuch as cardiovascular disease, diabetesand obesity. In the UK, men with chronic 59 Moussavi S, Chatterji S, Verdes E et al (2007).schizophrenia die 20.5 years earlier than the Depression, chronic disease and decrements inpopulation norm, and women die 16.4 years health: results from the World Health Surveys.earlier.60 Despite this, people with severe Lancet 370: 851–858.mental illnesses frequently do not receive 60 Brown S, Kim M, Mitchell C et al (2010).the health interventions they need, including Twenty-five year mortality of a community cohort with schizophrenia. British Journal ofscreening. In particular, smoking is the leading Psychiatry 196: 116–121.factor in health inequalities affecting people 61 Royal College of Psychiatrists (2009). Physicalwith mental illness and yet they are less likely health in mental health: final report of a scopingthan the rest of the population to be offered group. London: Royal College of Psychiatrists.smoking cessation support.People with long-term physical illnessare also at raised risk of mental ill health.Commissioning needs to address thisincreased risk. Improved liaison between thephysical and mental health sectors (based onmore accurate coding/needs recording) willalso improve care and treatment of thosewith medically unexplained symptoms.Similarly, improved commissioning of earlyinterventions to promote physical health,prevent and treat physical illness in thoserecovering from mental illness, will addresshealth inequalities.
    • 48 Practical Mental Health Commissioning3.8.3: Criminal justice Revolving Doors Service, WarringtonStriking the balance between publicsafety and individual freedom presents Warrington police link adults they believe to have low level mental health needs and unaddressed problems with a full range of services. The person can be a victim orall commissioners of mental health and complaining about the police; they do not have to be an offender.related services with a major challenge.People with severe mental illness are more If someone agrees to be helped, the police refer them to the Revolving Doors Service,often victims than perpetrators of violence. part of the mental health service. The police unit that screens all referrals for vulnerableHowever a very small minority of people adults makes additional referrals to the service if anyone could benefit from its support.with mental health problems do pose a risk ‘Mental health’ is deliberately not mentioned, to avoid stigma and unnecessary concern.to the public and/or themselves, and are in Two social workers repeatedly attempt contact, including cold-calling where necessary.contact both with the NHS and the criminal People are then offered a meeting in a place of their choice with a holistic assessment ofjustice system. all their needs, not just their mental health. The workers provide direct services and brief interventions. Where appropriate, they link individuals with a full range of agencies andRates of prevalence of mental illness are offer support to help them keep appointments for up to eight weeks.significantly higher among prisoners. Forexample, the prevalence of psychosis is Over 25 organisations are involved with this service, which enables it to respond to all needs, not just mental health issues. Further solutions are discussed with colleagues and15-20 times higher among prisoners than at a multi-agency panel if required.in the general population;62 the suicide rate http://www.revolving-doors.org.uk/home/is ten times higher for prisoners, at 91 per100,000, compared with 8.5 per 100,000in the general population.63 Commissionershave recognised this and have sought to 62 Sainsbury Centre for Mental Health (2008).find ways to knit together policy and service Short-changed: spending on prison mentaldevelopment to ensure the provision of health care. London: SCMH. http://www. centreformentalhealth.org.uk/pdfs/short-effective services and reduce the potential changed.pdfrisks to public safety. 63 Mind (undated). Statistics 8: the Criminal Justice System. London: Mind. http://www.mind.The transfer of responsibility for org.uk/help/rights_and_legislation/statistics_commissioning prison health services to 8_the_criminal_justice_systemthe NHS has been the catalyst for a shift inculture and attitudes within prison healthcare services. Prison health care services arenow required to meet the same standardsas the rest of the NHS, which is a key driverfor improving quality.Given that this is a very complex and highcost area of mental health provision, GPsand other commissioners are likely to wantto work creatively with local communitysafety agencies and structures to addressthe health needs of offenders and supportprimary prevention and diversion.
    • A framework for local authority and NHS commissioners 49Prevention is particularly important in this Improving support for offenders with mental health needsregard. For instance, the annual cost ofcrime by adults with conduct disorder and Faced with the challenge of one of the highest levels of offenders with mental health issuessub-threshold conduct disorder in England in the UK and increasing numbers of offenders with mental health problems and complexand Wales is estimated at £60 billion.64 health needs who needed levels of intensive support unmet by current provision, NHSBetween 40% and 70% of children and Manchester re-commissioned existing service supply. The Mental Health Joint Commissioningadolescents with conduct disorder will go on Team worked with Manchester City Council’s Drug and Alcohol Strategy Team to develop ato develop antisocial personality disorder in business case, in consultation with users, carers and stakeholders.adulthood.63 The resulting comprehensive and cohesive programme is increasing the range of services available, widening access to these services, raising awareness of mental disorders, enablingIn the general population, 0.3% have early detection and management of those at risk to themselves, and empowering peopleantisocial personality disorder; the rate to make decisions that positively impact on their health. The achievements of the serviceamong remand prisoners is 63%.11 have earned it a national Nursing Times Award, a regional award for innovation, and praiseHowever, there are effective low-cost from Lord Bradley.interventions to address conduct disorder The outcomes have had a significant impact both on people using services and those workingin childhood, such as intensive, targeted for service providers, including reductions in re-offending and risk to the community.parenting programmes. http://www.northwest.nhs.uk/whatwedo/ healthandsocialcareawardsexcellenceincommissioning/64 Sainsbury Centre for Mental Health (2009).The chance of a lifetime: preventing earlyconduct problems and reducing crime. London:SCMH. http://www.scmh.org.uk/pdfs/chance_of_a_lifetime.pdf
    • 50 Practical Mental Health Commissioning3.8.4: EmploymentEmployment (or meaningful activity) is • help for people in work to maintain their Investing in employment-related supportnow recognised as an essential element of job through times of mental distress, as can be a highly cost-effective approachrecovery from mental ill health. The link well as help for those with less serious to treating long-term disabling conditionsbetween lack of meaningful occupation and mental health difficulties to return to the such as depression and other commonmental ill health is well-evidenced. job market mental disorders, for example through • improved collaboration and integration the early detection and treatment ofA job is often top of the list when people depression at work.with long-term mental health problems are between health and employment services,asked about their goals in life. Yet people crossing a traditional divide Also of relevance is the Department forwith mental health problems are among • reform of services to make better use of Work and Pensions proposed Frameworkthe least likely of all those with disabilities existing resources in difficult economic for the Provision of Employment Relatedto be in employment, and the least likely circumstances. Services. This will see people seeking workto be able to get back into the job market given support tailored to their individualfollowing an episode of ill health.65 needs. The Work Programme replaces Individual Placement and Support previous employment programmes and willCommon elements of a work-focused be delivered by both private and voluntaryrecovery approach include: One of the main evidence-based approaches sector providers. The scheme is expected to to delivering improved employment outcomes for people is Individual Placement be in place during 2011.• an emphasis on prevention and early intervention for people with common and Support (IPS). Research has shown that large numbers of people with serious mental ‘Place-based commissioning’ (ie. working mental health problems in the general with all partners in a defined area to ill health have been supported by IPS to population, as well as people in contact secure and maintain paid employment. understand and harness joint investments, with secondary mental health services outcomes sought, and potential benefits/ IPS has seven key principles, each of which savings) provides a vehicle for partnership• mental health promotion in the is needed for the service to work well. They approaches to sharing the risks and cost- workplace, which also results in a include focusing on paid employment of an individual’s choice and continued support benefits of interventions with all concerned nine-fold return in investment after one once the person gets a job, together with agencies within a geographical area. year due to reduced absenteeism and clinical care and welfare benefits advice. improved productivity49 The service is tailored to a person’s needs• a focus on ensuring everyone, regardless and wishes, seeks to obtain rapid placement 65 Carolan S (2010). Mental health and of their mental health, has opportunity in work and provides ongoing support for employment – quality, innovation, productivity to work. This includes the provision of as long as needed. and prevention. Horley: NHS South East Coast. specialist help to gain and keep work for 66 Centre for Mental Health (2009). Doing what The Centre for Mental Health has published those in contact with secondary mental works: individual placement and support into a briefing paper summarising the evidence employment. London: Centre for Mental Health. health services base for IPS.66 http://www.centreformentalhealth.org.uk/ publications/doing_what_works.aspx?ID=592
    • A framework for local authority and NHS commissioners 51 This framework describes the current and emerging Effective commissioning also recognises the keyConclusion landscape within which tomorrow’s commissioners, pre- influence of inequalities on risk of mental disorder. and post-transition to the new commissioning structures, The impact of resulting mental illness then further will seek to promote the mental health and wellbeing of increases inequality across a broad range of outcomes, their populations. They will need to do this both through including physical health and premature mortality. public mental health interventions and the cost-effective Those at particular risk of mental illness and associated provision of clinically effective services. inequality include disadvantaged and minority groups – notably, people with learning disability. Addressing The transition to the new commissioning arrangements this through targeted prevention, promotion and will be guided both by national policy and detailed early intervention is crucial if commissioners are to knowledge of local needs and provision. Effective achieve the mental health improvement needed for a commissioning strategies are likely to take a life-course sustainable health and social care economy. approach to population health improvement; shift investment towards mental health promotion as well Commissioning can also promote recovery, choice and as prevention of mental illness and early intervention; control for those with diagnosed mental illness, as well enable greater freedom, choice and control through as safeguard and improve mental wellbeing among personalisation, and widen evidence-based service the general population. This will contribute to the options available to people with diagnosed mental ill accumulation of mental capital, with all the benefits health, including peer-led services. that this brings to individuals, communities and national prosperity and productivity. The current period of radical change and transition will require commissioners to work with public, private and The major challenge for commissioners for the third sector partners and providers to ensure continuity foreseeable future will be to continue to achieve of service provision and financial accountability. improved clinical and recovery outcomes at all five They will also need to ensure that the mental health levels described in the NHS Outcomes Framework, outcomes strategy is embedded into the system. while maintaining quality and safety at individual and community level and promoting wider population The policies and legislative machinery needed to mental health. They will have to do this within tighter progress the aims of the mental health strategy budgets, and in the face of the known demographic are rapidly falling into place. There is a robust and and health needs pressures. expanding knowledge base of what works best, for whom, and at what level. A follow-up publication will provide further evidence and information as legislation is enacted and the detail It is clear that effective commissioning requires close of the new commissioning system takes shape. Other collaborative working with partner agencies to address materials will also be produced to assist commissioners the determinants of mental health and physical health, with specific areas, such as commissioning for children both upstream before problems arise, and further and young people’s services and the role of housing in downstream when symptoms of illness first emerge, mental health. and then later to promote and maintain recovery. It is also clear that successful commissioning will involve co-production with individuals, communities and organisations with experience of the mental health and social care system, and learning about what works to remove barriers to access and recovery.
    • 52 Practical Mental Health Commissioning Accountability Collaborative care Glossary Legal and/or professional responsibility for the Clinicians and teams working together to meet the outcomes of decisions needs of people and carers, including learning and This glossary includes liaison for professionals and teaching and information technical and other Acute care pathway The person’s journey through acute psychiatric to help people manage their own health conditions terms commonly used in commissioning inpatient care and crisis/home treatment (see also Collaborative commissioning Care pathway below) Commissioners working with partners – clinicians Added value and providers – to assess, plan, procure and review Additional benefit brought to a group or process service provision to meet local health and care needs (for example, through the varied expertise, experience Common mental health problems and contacts of the individual members of the group) Mental health conditions with a mild to moderate Any willing provider and/or time-limited impact on the person (often Open to all providers that can meet required depression or anxiety) quality standards Co-morbidity Best practice tariff The co-existence of two or more disorders (eg. diabetes The cost or price of a programme that contains most and depression, alcohol misuse and psychosis) or all of the elements of best practice Contract Block contract A legally binding agreement between a commissioner An agreement, renewed annually, between a (the contract owner) and a provider (the contractor) commissioner and a contractor to provide a complete to deliver a product to an agreed specification (quality programme or service for a set amount of money and outcome) for a specific amount of money over a over a set amount of time set period of time Care pathway Contract negotiation The person’s journey (and that of their carer) through The process of agreeing the terms of a contract the mental health system setting out the planned care between a commissioner and a provider or supplier and treatment at each stage, what should be provided, Cost and volume contract by whom, how, when and where, and which indicators An agreement between a commissioner and a of quality improvement and clinical and social care contractor to provide services to a specific number outcomes should be used to demonstrate return on of people for a specific purpose and for a specific investment amount of money Case management Currency A system of care where one practitioner is identified The elements of a service that can be costed and priced as responsible for managing a person’s care and Diagnosis co-ordinating the input from a range of other A classification system for illnesses that enables professionals and services clinicians to predict the natural course of a particular Clinical commissioning disorder and how it will respond to treatment Groups of clinicians coming together to agree Framework agreement best practice and advise commissioners on what to A set of contractual terms, conditions and standards procure, the service specification and how outcomes that providers have to show they can meet when can be measured tendering for a contract Cluster Framework A group of people with a recognisable shared set A structural plan for activity of symptoms and signs of illness
    • A framework for local authority and NHS commissioners 53Functionality Patient-centredThe purpose for which a specific mental health service Practice that is respectful of and responsive to individualis designed (eg. crisis/home treatment, assertive preferences, needs, and values and that ensures thatoutreach etc). Can also be used to mean how well the person’s values guide all clinical decisionsteams/services/people work Payment by ResultsInvest to Save An annual transaction between a commissioner andSpending money on a service that can be shown a contractor that means the provider must be able tothrough economic modelling to save money or produce demonstrate that they have delivered the agreed levelbetter outcomes and/or better use of resources of activity and outcomes(human, technical or financial) in the long term Performance managementJoint commissioning The analysis, monitoring and management ofThe pooling of expertise, responsibilities, and/or organisational performance or delivery against contractsbudgets between two agencies (most commonly health and agreed outcomes.and social care services) to integrate service provision PersonalisationLiaison psychiatry Enabling people to make decisions about their ownA specialist psychiatric service that delivers mental care and support and organising services and systemshealth services, training and skills development in around their needsgeneral hospital settings Person-centredLocalism An approach to care that builds on a person’s strengthsThe devolution of power and responsibilities from and capabilities to work towards recovery and maintainthe centre to local authorities and communities mental healthMarginal analysis Place-based commissioningAnnual review of elements of a programme to A holistic approach to commissioning services across alldetermine those that add value and those that do not responsible agencies within a defined geographic areaMarginal rates Primary care mental healthDifferent levels of payments (usually less than Mental health services delivered in primary care settingsstandard values) for under- or over-performance (GP surgeries and health centres)against a contract Primary preventionMedically unexplained symptoms The prevention of a disorder occurring throughPhysical symptoms without an easily recognisable interventions targeted at individuals or groups of peoplephysical cause (also referred to as somatisation). at high riskOutcomes ProductivityThe effect or result of commissioning process (ie. Efficiency, turnover (eg. the number of people thatcommissioning), service or intervention/treatment can be seen in a clinic or assessed at their own homesOut-of-area services in a single day)Treatment delivered in a care setting outside the Professionalismperson’s home locality – either because of lack of Practice that is based on the values and body ofresources or because they have special needs that knowledge and skills acquired through education,can only be met elsewhere training and formal qualification in a profession Programme budget The amount of money allocated to procure, deliver and manage a service for a particular disease cluster, diagnosis or service
    • 54 Practical Mental Health CommissioningQuality StandardsThe effectiveness and safety of clinical practice The acceptable level at which specific activities,and services skills, competencies or behaviours should be deliveredRecovery to ensure quality and consistency in experienceThe achievement of wellbeing despite the and outcomes of services/processes and by whichpresence of ill health professionals or agencies can be held to accountRegulation TariffThe monitoring of adherence to professional or The overall cost or price of a programme or servicecorporate standards of clinical or managerial practice or unit of activityRelapse Tertiary preventionThe return of symptoms while in treatment The treatment of an established illness that aims to stop it getting any worseRemissionThe control of symptoms with treatment Transaction A change required by policy within organisationalResearch operating procedures. Can also be used to describeThe scientific testing of a hypothesis or exploration the purchasing of goods or services.of a phenomenon TransformationReturn on investment Large scale, negotiated change to behaviour andThe effect of an intervention in relation to the culture across an organisation/communityamount spent on it ValueRight care The desirability, worth, merit or importance ofEfficiency and effectiveness in clinical practice something (actual or perceived); the effectiveness(do it right, do it once) of an intervention or procedure; related to the bio-Secondary prevention ethical principles of beneficence (acting in the bestThe prevention of a serious disorder developing interests of people using services) and non-maleficencethrough intervention in response to early signs/ (doing no harm)symptoms Value for moneySevere mental illness (SMI) The cost effectiveness of interventions or modelsSerious, high-risk or complex forms of mental distress of care as demonstrated by productivity against(often as applied to schizophrenia and bipolar disorder) investment or economic modelling of financial benefit from investmentSocial capitalThe combined total resource of physical, emotional Values-based commissioningand mental health, wellbeing and resilience within The integration of scientific evidence with the wishes/a community preferences of the population, customers and/or other interest groups to inform commissioning decisionsSocial return on investmentValue measured in wellbeing and environmental Values-based practicebenefits/impact (ie. not money) The integration of scientific evidence with the wishes/ preferences of the person and/or carer to inform aSpot contract clinical or other professional decisionA one-off contract for a an individual’s care Whole-person or holism The inclusion of the physical, psychological, social and spiritual in assessing people’s needs and planning and delivering a therapeutic response that addresses all these aspects together
    • A framework for local authority and NHS commissioners 55 Policy Healthy Lives, Healthy People:Useful links Equity and Excellence: our Strategy for Public Health in England Liberating the NHS White Paper outlining how the Government plans to The NHS White Paper tackle the public health challenge in England. http://www.dh.gov.uk/en/Publicationsandstatistics/ http://www.dh.gov.uk/prod_consum_dh/groups/dh_ Publications/PublicationsPolicyAndGuidance/ digitalassets/@dh/@en/@ps/documents/digitalasset/ DH_117353 dh_122252.pdf NHS outcomes framework Healthy Lives, Healthy People: Transparency in Sets out the outcomes and indicators that will be Outcomes. Proposals for a Public Health Outcomes used to hold the NHS Commissioning Board to Framework. A Consultation Document account for the outcomes it delivers through Consultation paper setting out the Government’s commissioning health services from 2012/13. proposed outcomes and indicators that will set goals and measure progress in public mental health. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ http://www.dh.gov.uk/prod_consum_dh/groups/ DH_122944 dh_digitalassets/@dh/@en/documents/digitalasset/ dh_123113.pdf Liberating the NHS: Legislative Framework and Next Steps No Health without Mental Health: A Cross-Government Sets out further policy development based Mental Health Outcomes Strategy for People of All Ages on the consultation feedback to the Equity and http://www.dh.gov.uk/prod_consum_dh/groups/dh_ Excellence white paper. digitalassets/documents/digitalasset/dh_124058.pdf http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/ Quality and productivity DH_122661 NHS Evidence – mental health A Vision for Adult Social Care: NHS library that collects data from published research Capable Communities and Active Citizens in Annual Evidence Updates (AEUs) on a range of Sets a new agenda for adult social care in England mental health topics. to make services more personalised, more preventative http://www.library.nhs.uk/mentalHealth/ and more focused on delivering the best outcomes for CQUIN payment framework those who use them. The CQUIN payment framework makes a proportion http://www.dh.gov.uk/prod_consum_dh/groups/dh_ of providers’ income conditional on quality and digitalassets/@dh/@en/@ps/documents/digitalasset/ innovation. Guidance on using the payment framework dh_121971.pdf to develop CQUIN schemes is available at: http://www. Transparency in Outcomes: a Framework for dh.gov.uk/en/Publicationsandstatistics/Publications/ Adult Social Care – A consultation on proposals PublicationsPolicyAndGuidance/DH_091443 Consultation document proposing a new strategy for Acute and mental health example schemes, along with transparency, quality and outcomes in adult social care. other material to support use of the CQUIN framework, http://www.dh.gov.uk/prod_consum_dh/groups/ can be found at: http://www.institute.nhs.uk/world_ dh_digitalassets/@dh/@en/documents/digitalasset/ class_commissioning/pct_portal/cquin.html dh_122037.pdf
    • 56 Practical Mental Health CommissioningMental health and employment System reformRemoving Barriers: The facts about mental health NHS Standard Contractsand employment. Briefing from the Centre for Mental Available from: http://www.dh.gov.uk/Health on the barriers to employment for people with en/Publicationsandstatistics/Publications/both common and severe mental health problems and PublicationsPolicyAndGuidance/DH_111203at the initiatives that are being undertaken by the public,voluntary and commercial sectors to support their efforts Best practiceto find and sustain work. NHS Information Centrehttp://www.scmh.org.uk/pdfs/briefing40_Removing_ Central source of health and social care informationbarriers_employment_mental_health.pdf for frontline decision makers in England.Adult social care http://www.ic.nhs.uk/Care Services Efficiency Delivery (CSED) helps Mental Health Minimum Data Setcouncils to identify and develop more efficient ways A resource with data about the care of adults andof delivering adult social care. older people using secondary mental health serviceshttp://www.dhcarenetworks.org.uk/csed/ 2003–2007.Public mental health http://www.ic.nhs.uk/mhmdsThe NMHDU public mental health programme Social Care and Mental Health Indicatorswebsite includes useful information on the evidence Further analysis on indicators drawn from thefor public mental health. National Indicator Set for England 2008–09http://www.nmhdu.org.uk/our-work/promoting- http://www.ic.nhs.uk/pubs/socmhi08-09wellbeing-and-public-mental-health/ The Quality and Outcomes Framework 2009/10Enabling effective delivery of health and wellbeing QOF indicators and prevalence for depressionAn independent report commissioned by theDepartment of Health with information and www.ic.nhs.uk/qofrecommendations on how better to improve public NHSIC Commissioning resourceshealth and wellbeing. Resources available from the NHS Informationhttp://www.dh.gov.uk/en/Publicationsandstatistics/ Centre, including workforce information, public healthPublications/PublicationsPolicyAndGuidance/ indicators, patient-reported outcomes measuresDH_111692 http://www.ic.nhs.uk/commissioningLocal Government Improvement and Development NICE commissioning guidesLocal Government (LG) Improvement and Development Including mental health and behavioural conditionssupports improvement and innovation in local and public healthgovernment, including public mental health activities. http://www.dhcarenetworks.org.uk/nl/?ln=606_1_1http://www.idea.gov.uk No Health without Mental Health: the Case for Action Royal College of Psychiatrists position statement on public mental health. http://www.rcpsych.ac.uk/pdf/Position%20 Statement%204%20website.pdf
    • A framework for local authority and NHS commissioners 57 ADASS NHS ConfederationPartner http://www.adass.org.uk/ http://www.nhsconfed.organd otherorganisations CQC NHS Evidence http://www.cqc.org.uk/ http://www.evidence.nhs.uk Department of Health NHS Institute http://www.dh.gov.uk http://www.institute.nhs.uk/ DH Care Networks Royal College of GPs http://www.dhcarenetworks.org.uk/ www.rcgp.org.uk Local Government Association Royal College of Psychiatrists http://www.lga.gov.uk http://www.rcpsych.ac.uk/ National Involvement Partnership SCIE http://www.nsun.org.uk/ http://www.scie.org.uk/ All web addresses in this document were accessed in March 2011.
    • A large print version of this document is available fromwww.jcpmh.infoPublished March 2011Produced by Raffertys