Guidance for commissioners of primary mental health services

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This guide describes what good quality, modern, primary mental health care services look like. It has been written by a group of primary mental health care experts, in consultation with patients and …

This guide describes what good quality, modern, primary mental health care services look like. It has been written by a group of primary mental health care experts, in consultation with patients and carers. The content is primarily evidence-based but ideas deemed to be best practice by expert consensus have also been included.

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  • 1. Guidance for commissioners of primary mental health care services 1VolumeTwo:Practicalmental healthcommissioningGuidance for commissioners ofprimary mentalhealth care servicesJoint Commissioning Panelfor Mental Healthwww.jcpmh.info
  • 2. Joint Commissioning Panelfor Mental HealthCo-chaired by:Membership:www.jcpmh.info
  • 3. 2 Practical Mental Health CommissioningContentsExecutivesummaryIntroduction04What areprimary mentalhealth careservices?Why is primarymental healthcare importantto commissioners?05 05What do weknow aboutcurrent primarymental healthcare services?07What woulda good primarymental health careservice look like?08Supportingthe deliveryof the mentalhealth strategy14Resourcesand references16
  • 4. Guidance for commissioners of primary mental health care services 3Executive summary• Mental health problems should bemanaged mainly in primary care bythe primary health care team workingcollaboratively with other services,with access to specialist expertise andto a range of secondary care servicesas required.• Effective treatment of common mentalhealth disorders in primary care requiresintegrated services using a stepped caremodel. This should deliver evidence-based treatments that can be accessedvia flexible referral routes, includingself-referral, and offer a choice ofpsychological and non-psychologicalinterventions.• Primary mental health care servicesshould have a clear focus on preventionand early identification.• Primary mental health care servicesshould promote self-management bypatients, including use of personalisedcare plans.• Care co-ordination (case management)and methodical management ofsystematic care pathways are essentialto good primary mental health careservices.• Primary mental health care should beholistic – mental health has physical,psychological, social and spiritualelements.• The outcomes of primary mental healthcare work should be systematicallymeasured and reported.• Allocation of funds to reflect theseprinciples will result in better integratedpatient care pathways that are able tomeet a wider range of needs. Currently,gaps at the interface between primarymental health care and secondarymental health and acute services canmean that patients disengage, revolveor get ‘stuck’ in different parts of thesystem.• Improving the management of mentalillness in primary care will contributeto meeting the objectives of theNo Health without Mental Healthmental health strategy and the Quality,Innovation, Productivity and Prevention(QIPP) Challenge.
  • 5. The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• Service users and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.The JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health.1The JCP-MH has two primary aims:• to bring together service users, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioningIntroduction• to integrate scientific evidence,service user and carer experience andviewpoints, and innovative serviceevaluations in order to produce the bestpossible advice on commissioning thedesign and delivery of high quality mentalhealth, learning disabilities, and publicmental health and wellbeing services.The JCP-MH:• has published Practical MentalHealth Commissioning,2a briefing onthe key values and principles for effectivemental health commissioning• provides practical guidance and adeveloping framework for mental health• will support commissioners of publicmental health to deliver the bestpossible outcomes for communityhealth and wellbeing• has published a series of short guidesdescribing ‘what good looks like’ invarious mental health service settings.Who is this guide for?This guide is about thecommissioning of good quality,integrated primary mental healthcare and should be of value to:• the NHS Commissioning Board, as itwill hold the contracts for generalmedical services which should reflectwhat this guidance is saying aboutprimary mental health care• Clinical Commissioning Groups, asthe commissioning of both specialistand acute secondary mental healthservices needs to reflect the increasedactivity in integrated primary care teams,and reduced activity in secondary caresuggested by this guide, and• Health and Wellbeing Boards, as thecommissioning of public mental healthand wellbeing should sit alongside thepreventative activity in primary caredescribed in this guidance.How will this guide help you?This guide has been written bya group of primary mental healthcare experts, in consultation withpatients and carers.The content is primarily evidence-basedbut ideas deemed to be best practice byexpert consensus have also been included.By the end of this guide, readers should bemore familiar with the concept of primarymental health care and better equipped to:• understand what good quality,modern, primary mental health careservices look like• commission primary mental healthcare services• understand how and why a good primarymental health care service contributesto achieving the aims of the mentalhealth strategy and improves quality andproductivity, both in itself and by enablingchanges in other parts of the system.This guide also covers issues relating tocommissioning primary mental health careservices. It describes:• the benefits of primary mental healthcare services• the optimum skill mix in primary mentalhealth care teams.The guide draws on and refers topreviously published guidance, includingNICE guidelines for common mentalhealth problems (CG123), depression(CG28, 90, 91), various anxiety disorders(CG 26, 31,113), eating disorders (CG9)and self-harm (CG16).4 Practical Mental Health Commissioning
  • 6. Guidance for commissioners of primary mental health care services 5What are primarymental health careservices services?Primary mental health care is a relativelyrecent concept in health care. It isdefined by the World Health Organisationas follows3:• first line interventions that areprovided as an integral part of generalhealth care, and• mental health care that is provided byprimary care workers who are skilled,able and supported to provide mentalhealth services.The development of primary mentalhealth care has reflected a need for earlierdetection of problems, better managementof chronic illness and improved partnershipworking between the patient, the extendedprimary health care team and localcommunity support networks and providers.For many patients, developing a goodrelationship with their general practitioner(GP) is central to continuity of care, asthis facilitates good engagement with,and communication across, the wholeof primary care. Primary care is also mostpeople’s first port of call in timesof health care need. Good engagementand communication allows the GP, andindeed any member of the primary careteam, to deliver good collaborative care,working with other members of the teamand with mental health specialists.Patients will need appropriate evidence-based interventions, ranging from activemonitoring and guided self-help throughto higher intensity interventions suchas psychological therapy. Crucial to theeffective functioning of primary mentalhealth care teams is expert supervision andcase management with a consistent andsystematic focus on outcomes.Continuous professional development andtraining curriculums that reflect currentNICE guidance ensure that relevant skills aregained and maintained. Ideally, these will beorganised so that different members of theprimary care team train together.Why is primary mental health careimportant to commissioners?Policy imperatives A number of relevant recentpolicy imperatives make theprovision of good qualityprimary mental health careservices a priority for clinicalcommissioning groups.These include:• the emphasis on providing care as closeto the patient’s home as possible• the need to take patients’ views intoaccount (‘No decision about mewithout me’1)• patients’ and their carers’ preferencefor being treated in primary care, wherethe environment is less stigmatising andwhere physical and mental health carecan more easily be delivered together.Mental health problemsare common and costly Some 17.6% of the adultpopulation (21.0% of womenand 11.9% of men) have acommon mental health problem(anxiety or depression).4A further six per cent have alcoholdependence, three per cent have drugdependence and 21% have nicotinedependence (42% of tobacco consumedin England is by people with a mentalillness).4,5Rates of personality disorderare 5.4% for men and 3.4% for women6and 0.4% have psychosis (schizophreniaor bipolar disorder).4A further 17% ofthe population experiences sub-thresholdcommon mental problems,4six percent have sub-threshold psychosis7and24% drink alcohol at levels defined ashazardous to their health.4Sub-thresholdhealth status presents an importantopportunity for prevention and earlyintervention.Broadly, this means that, in a groupof 2000 patients at any one time, anaverage general practice will be treating:• 352 people with a commonmental health problem• 8 with psychosis• 120 with alcohol dependency• 60 with drug dependency• 352 with a sub-threshold commonmental health problem• 120 with a sub-threshold psychosis• 176 with a personality disorder• 125 (out of the 500 on an average GPpractice list) with a long-term conditionwith a co-morbid mental illness• 100 with medically unexplainedsymptoms not attributable to anyother psychiatric problem (MUS).This means about one in four of a full-time GP’s patients will need treatment formental health problems in primary care.The overall annual spending on the NHSin England was approximately £105 billionin 2009.8Of this spend, around eightper cent is allocated to (all) primary careservices9and around 12% to secondaryand tertiary mental health services.10However 23% of the overall burden ofdisease is due to mental disorder andself-inflicted injury (by comparison, just16% is due respectively to cancer andto cardiovascular disease).1In England,most people with a mental disorder exceptpsychosis receive no intervention.4For common mental disorder which isthe most prevalent mental disorder, only24% receive any interventionPrevention andearly intervention Early intervention is vital,both to improve people’s lifechances and reduce healthcare costs. Primary care iswhere this should happen.Different levels of prevention includeprimary (preventing illness from occurringin the first place), secondary (earlyidentification and treatment) and tertiary(promotion of recovery and relapseprevention early intervention).
  • 7. 6 Practical Mental Health CommissioningWhy is primary mental health care important to commissioners? (continued)Prevention activities may avoid theneed for specialist secondary care, andits associated higher costs. But primarymental health care teams need to beresourced to undertake pro-active andoutreach work with at-risk groups, andto develop self-referral routes into services.This means that clinical and service leadsand commissioners need to understandthe high-risk groups and the ages atwhich mental illnesses are more likelyto occur. They also need to ensure thatskill mixes and service models includespecific roles to deliver preventive andearly interventions, such as, for example,psychological wellbeing practitioners.Particular groups are at much higherrisk of mental illness and therefore needto be targeted for preventive and earlyinterventions. They include:• people on low incomes (people withhousehold incomes in the lowest 20%are at higher risk of mental healthproblems than those with incomesin the highest 20%4) • black and minority ethnic groups(they are at two- to three-foldincreased risk of suicide11and a nearlyfour-fold increased of psychosis12)• people with learning disability (theyhave a two-fold increased risk ofdepression and a three-fold increasedrisk of schizophrenia13)• lesbian, gay and bisexual people(they are at higher risk of commonmental disorders, suicide attempt,psychosis and alcohol dependence14)• people with a chronic physicalillness (they have a two- to three-fold increased risk of depression incomparison with people in good physicalhealth, and this increases to a seven-fold increased risk in those with two ormore chronic physical illnesses15– one intwo people with advanced cancer alsodevelop mental health problems16)• older adults (they are at increased riskof depression and, particularly if livingalone, suicide)• children with conduct disorders(a significant proportion of adultmental health problems are precededby emotional or conduct disordersin childhood17).CarersCarers of people with long-term illness anddisability are at greater risk of poor healththan the general population. They areparticularly likely to develop depression. Inan Office for National Statistics survey, 30%of carers rated their health status as fair orpoor, and 33% said that caring made themdepressed at least some of the time. Thosecaring for a spouse or partner were mostlikely to report mental health problems.Thirteen per cent of carers said they hadconsulted a GP about being anxious ordepressed or about a mental, nervous oremotional problem, and one per cent haddone so in the previous two weeks.18Commissioners could work proactivelywith practices to identify carers who couldbe at risk of mental health problems.They could also ensure that social servicesdepartments systematically offer theassessments to which carers are legallyentitled and follow up any findings withappropriate referral or intervention. Thereis a statutory requirement to act on theoutcomes of the carer assessment if acritical risk is identified; systems should beput in place to ensure this happens.Early intervention in psychosisEarly intervention in psychosis servicesprovide care for young people aged 14–35years for periods of up to three years aftera first episode of psychosis. These earlyintervention services are recommended byNICE, are effective in changing the earlycourse of psychosis,19provide net savingsto the NHS and are rated highly for patientsatisfaction.20(Further details can befound in the forthcoming commissioningguidance on Specialist Community MentalHealth Services.)The overlap betweenmental and physical healthPeople with mental healthproblems have much higher ratesof physical illness. For instance,depression is associated withincreased risk of coronary heartdisease21and diabetes.22Thepresence of mental illness canalso complicate the managementof a physical illness and worsenthe prognosis.The health consequences of mentalillness are most extreme for people witha psychosis (schizophrenia or bipolardisorder). Men with schizophrenia living inthe community have a 20.5 year reducedlife expectancy; women have 16.4 yearreduced life expectancy.23The main causeof these excess deaths is cardiovasculardisease, suggesting that the deaths aremostly preventable.The quality andproductivity challengeOne of the three main themes ofthe national Quality, Innovation,Productivity and Prevention(QIPP) programme for mentalhealth is the alignment ofphysical health care with mentalhealth care services.If long-term conditions, co-morbid physicaland mental ill health and medicallyunexplained symptoms can be managedmore effectively in primary care settings,this will reduce demand on acute inpatientservices. Effective prevention and earlyintervention will also reduce demand onall types of secondary care, and integratedprimary care services are ideally placed todeliver this.
  • 8. What do we know about currentprimary mental health care services?There is no standardised modelfor the commissioning andprovision of primary mentalhealth care services. The currentpatterns of service provisionvary greatly and in mostareas are likely to result fromhistorical factors.Signs that current primary care mentalhealth systems are not working well includethe following:• the primary–secondary care interfacein mental health fails to meet patientneed, leading to:– delays in access– disparity between estimatednumbers with illness and thosereceiving treatment– complex and changing care pathways– gaps in service provision wherepatients’ needs fall betweenservice providers– rigid, access criteria that do notreflect actual patient need.• response to people with commonmental health problems is variable –some, but not all, are diagnosed andreceive evidence-based treatments –and there is no systematic process forallocating patients to appropriate carepathways (most of which should bein primary care)• there is inconsistent assessment ofthe impact of mental distress andsymptoms of common mental illnesseson a person’s capacity to work, or ontheir family life and relationships, andoften no clear systems in place for earlyintervention to help people recover andreturn to work more rapidly• there is a lack of understanding ofhow collaborative care works, theroles and responsibilities of specialistsoperating in primary care settings andthe importance of the interface betweenpsychiatrists and GPs• the majority of patients experiencegood consultations with GPs but there issometimes a delay in getting a diagnosis,not all patients receive informationabout and an explanation of theirdiagnosis and treatment, and medicationmay be over-used because there are noalternative options• people with mental health problems arenot engaging with primary care eitherbecause they feel they would be wastingthe GP’s time, or because they feel GPsdo not have time to listen to them anddo not understand how they feel24• there may be a mismatch betweenthe GP’s views of the cause of themental health problem and how to treatit and those of the patient – the GPmay adopt a ‘one-size-fits-all’ model,and the patient may want simply to belistened to and helped to self-managetheir mental health, using a personalisedcare plan• GPs may lack confidence in theirability to provide appropriate services,particularly for people with psychosis,and may require patients to be seenin the psychiatric outpatient clinic onceor twice a year for monitoring againstrisk criteria.Guidance for commissioners of primary mental health care services 7
  • 9. What would a good primarymental health care service look like?Model of service deliveryThe key to developing patient-centred primary mental healthcare services is to put thepatient’s needs at their heart.This means ensuring servicesare conveniently located andeasily accessible in the primarycare setting. It also meansbeing emotionally availableand interested in the patient.A good primary mental health careservice is:• evidence based – treatments shouldbe based on sound clinical judgementinformed by NICE guidelines.• patient-centred – care should bepersonalised, people should be giventime to talk, should be listened to,provided with information and offereda choice about their care. Patientsshould actively participate in decision-making, feel engaged and have a senseof ownership.• Based on need – services should becommissioned and provided on the basisof need and the estimated prevalence ofmental health problems• age inclusive – services should recognisethat opportunities exist for preventionat all life stages, that the origins of mostmajor mental health problems lie in theearly years, and that care should not becompartmentalised or interrupted ongrounds of chronological age alone.• capable – the primary mental healthcare team needs to have the knowledgeand skills to understand how best toprovide appropriate services for peoplewith mental health problems. This mayrequire additional education and trainingopportunities.• integrated – commissioning primarymental health care services should beintegrated with the commissioningof specialist mental health services.The interfaces between differentparts of the system and with otheragencies (such as social services) needto be seamless, because people’sneeds straddle health and social care.• accessible – care pathways shouldinclude treatments that can be accessedthrough self-referral and should addressdiversity in local communities.This includes making reasonableadjustments for people with specialneeds. Patients should be treatedpromptly; they should not have to waituntil they become ill or their conditionbecomes more complex and theyrequire more intensive treatment.• Sufficient capacity – commissionedservices should have the sufficientcapacity to treat numbers estimated tohave different types of mental healthproblems• outcome-focused – treatments shouldbe systematic and their outcomesmonitored continuously using acommon set of measures appropriateto the patient’s problems. Accurateassessment requires high levels of pre–post data completeness. For people withdepression and anxiety disorders, this ismost easily achieved by routine, session-by-session outcome monitoring. Thisapproach also facilitates the choice ofinterventions and other clinical decisions.• recovery-focused – a recovery focus isessential to effective service delivery.Practitioners should support patientsto help themselves and reinforce themessage that recovery is possible, andthat they can regain employment andsocial networks. This is particularlyimportant for people who have been outof work for some time. Recovery is notsimply about a reduction in, or removalof, symptoms; it is about communicatinghope and restoring opportunity and asense of agency to patients.25• community-linked – primary mentalhealth care services should be linkedto a range of voluntary and communitysector services that patients can choose(ie. they are not limited to whatcommissioners choose to fund), andthat either work alongside or areintegrated with the primary mentalhealth care team.• preventative – interventions should betargeted at individuals identified fromGP service ‘Read Codes’ as at risk ofdeveloping mental health problems.8 Practical Mental Health Commissioning
  • 10. Guidance for commissioners of primary mental health care services 9Key components of the serviceNICE guidelines for depression(CG90 and CG91)15,26andsome anxiety disorders(CG31,113 but not CG26)27-29talk about a stepped modelof care (see below).This framework for service deliverydescribes the patient’s journey in the careof a multi-disciplinary team that offers thefull range of evidence-based interventionswithin an integrated care pathway.The core principle of stepped care is thatpeople are matched to an interventionthat is appropriate to their level of needand preference. The clinician needs tomake a balanced judgement based onwhat would deliver the best, sustainedhealth outcomes. The patient should alsobe able to change treatments as theyprogress, and their expectations, theirconfidence in the therapist, and theirviews about the suitability of the treatmentshould also be taken into account.The key operational consideration forstepped care models is that the patientcare plan is constantly reviewed throughactive case management, using session-by-session outcomes. Appointment timesand locations should also be flexible andresponsive. Patients can move betweentypes of therapy depending on theirlevel of need, but will still receive thesetreatments in primary care.NICE recommends cognitive behaviouraltherapy (CBT) for anxiety disorders butsuggests a broader range of treatmentsfor depression.15The Department ofHealth’s Improving Access to PsychologicalTherapies (IAPT) initiative has produced auseful patient information guide, WhichTalking Therapy for Depression (availableat www.iapt.nhs.uk/news/which-talking-therapy-for-depression/), which describesthe different psychological therapiesrecommended by NICE for treatmentof depression, how they work, and theoutcomes patients can expect from eachof them. IAPT has also produced a PatientExperience Questionnaire that can be usedto ensure that patients receive the carethey want, delivered in a person-centredway (www.iapt.nhs.uk/search/?keywords=patient+experience+questionnaire).Stepped care model of careCommissioners may wish tocommission a stepped caremodel that offers an integratedcare pathway for primarymental health care services.Step oneStep one includes supportedself-management of psychologicaland emotional wellbeing, socialprescribing, peer experts and mentors,health trainers, psychological wellbeingpractitioners trained in cognitivebehavioural treatments for people withmild to moderate anxiety and depression,and access to e-mental health servicessuch as on-line peer support groups.Peer experts and peer mentorsPatients and carers can be supported tosupport each other in patient and carergroups. Peer mentors and patient expertscan be employed in the primary mentalhealth care team to work alongsidepatients. Experts by experience cancoordinate and distribute informationabout self-management, co-ordinatementorship programmes, and offertraining and deployment of people withlived experience for specific purposes,such as advocacy.Health trainersHealth trainers can help patients accesscomputerised and internet therapies andsupport, teach techniques for enhancingpsychological resilience, promotewellbeing skills, teach the principles ofmental health first aid and introducethem to relevant organisations in thecommunity where they can get furtherhelp. The health trainer in each practiceteam could be responsible for liaisingwith their peers in other practice teamsto map and carry out quality assurance ofcommunity services used by their patients.Graduate primary care mental healthworkers, who used to perform a similarrole, have been shown to be cost effectiveand to improve patient satisfaction.30,31Social prescribingSocial prescribing, or ‘communityreferral’, supports improved accessboth to psychological treatmentsand to interventions addressing thewider determinants of mental health,such as exercise on prescription andneighbourhood schemes. Research intosocial prescribing32shows benefitsin three key areas: improved mentalhealth outcomes, improved communitywellbeing and reduced social exclusion.There is a strong case for commissioningsocial prescribing for mental health, basedon the relationship between mental healthand other outcomes, and on the growingevidence of demand for a wider range ofearly responses to psychosocial problems.For further information please see theKaris Neighbourhood Scheme (see page12). A number of patients presenting inprimary care will prefer to find healingthrough non-traditional and social careroutes. Some may feel their needs wouldbe best met through faith environmentsand networks. Innovative forms of socialprescribing include access to e-mentalhealth and online support networks.The New Savoy Partnership has produceda resource directory and guidelines forgood practice for these services(www.newsavoypartnership.org).
  • 11. 10 Practical Mental Health CommissioningWhat would a good primary mental health care service look like? (continued)Step twoStep two comprises co-ordinated careinvolving the primary care team, andincludes provision of low intensitytherapies and links to employmentsupport, carer support and other socialsupport services.Many patients will be supported wellby an individual clinician – most commonlya GP, but it could be a practice nurse,a health visitor, a psychological wellbeingpractitioner or a counsellor. This clinicianwill carry out the initial assessment andidentify which care cluster best describesthe needs of the patient. If the clinicianfeels that their skills alone are notsufficient, they will refer on, usuallyin-house, to a case manager or to anothercolleague with a different set of skills, forfurther assessment. Based on the furtherin-depth assessment, they will suggestadditional low intensity psychologicalinterventions or community resources.Patients may want their therapist at Steptwo to act as a care co-ordinator in termsof signposting and navigating access to thevarious NICE-recommended options, suchas structured exercise groups for depression.All primary mental health care teams shouldbe able to make referrals to therapiststrained in low intensity psychologicaltreatments, such as the short-term cognitivebehaviour therapies recommended forpatients with depression and anxiety andother common mental disorders.Step threeStep three comprises high intensitypsychological therapies and/or medicationfor people with more complex needs(moderate to severe depression or anxietydisorders, psychosis, and co-morbidphysical health problems).33-35Initial treatment should be NICE-recommended psychological therapydelivered by a high intensity worker, and/or medication. For people with moderateto severe depression whose symptomsdo not respond to these interventions,NICE recommends collaborative care.26There is evidence that this approachis effective with people with co-morbidlong-term conditions, and some emergingevidence that it may be helpful for peoplewith psychosis.The key components of collaborativecare are:• a multi-professional approach providedby practitioners from at least twodifferent disciplines.• a case manager (for example, acommunity psychiatric nurse, psychologistor graduate mental health worker),who works with the GP in primarycare and receives weekly supervisionfrom specialist mental health, medicalor psychological therapy clinicians.Their role would include the deliveryof (some) psychosocial interventions,care coordination and liaison with otherproviders to ensure smooth transitionalong care pathways, step up or down asrequired, regular and robust reviews ofprogress, and the delivery of systematicoutcomes measures.• integrated communication betweenproviders – for example, verbal/face-to-face contact between primary andmental health care providers, weeklyteam meetings, and shared recordsvia the existing primary care electronicrecords system.• education and facilitation of providers toensure rapid development of new roleswithin a collaborative care environment.The GP, in liaison with whoever is providingthe psychological care, will continue toreview and manage the prescribing ofpsychotropic medication, if the patientwants it, and oversee their physical healthcare. One GP or a team of GPs may takethis on for their whole practice or, insome cases, for a group of practices, as adesignated mental health liaison role in thedelivery of collaborative care.Step fourStep four comprises specialist mentalhealth care, including extended andintensive therapies.Clear, well understood pathways must bein place between the primary care mentalhealth team, IAPT services and specialistmental health services. The most obviousrelationship is with the specialist communitymental health services, but there mayalso be a relationship with acute liaisonservices (see the companion commissioningguidance on acute liaison). These providespecialist mental health input to acutehospitals, and also oversee acute inpatientand community-based interventionsfor comorbid long-term conditions andmedically unexplained symptoms.Appropriate management of medicallyunexplained symptoms should lead to asignificant reduction in the inappropriateuse of acute inpatient resources. Specialistmental health teams may operate acrossseveral practices, in which case eachpractice could have a practice-affiliatedspecialist team member (for instance acommunity psychiatric nurse) with whomthe primary care mental health team canwork (see the forthcoming companionguidance on Specialist Mental HealthCommunity Services).Specialist mental health care can beprovided in a primary care setting soprimary care staff can access expertisewithout the need for cumbersome referralprocesses and the stigmatisation thatsometimes affects patients in secondarycare settings.
  • 12. StandardsCommissioners will wantto commission primary caremental health services that candemonstrate that they meet therecognised standards for theirservice, such as the NICEquality standard for depression.The optimum primarymental health care teamTo provide the range of services set outabove, primary mental health care serviceswill need to include a range of staff withina multidisciplinary team. The professionalbackgrounds of the team members will bespecific to their local context.Primary mental health care teams mayinclude the following:• the core primary care team of theGP and the practice nurse• primary care mental health clinicians• primary care-based mental healthspecialists• third sector (not-for-profit) providersand social enterprises (eg. communityorganisations and networks, includingfaith groups)• other community-based, non-specialistpractitioners (for example, school nursesand health visitors)• service user and carer experts byexperience.IAPT teamsIAPT services offer integrated talkingtreatments for depression and anxietyacross a range of NICE-approvedmodalities. All IAPT therapies includeroutine, session-by-session outcomemonitoring.Treatment is provided by two types ofpsychological therapy practitioners:• psychological wellbeing practitionerstrained in cognitive behaviouralapproaches for people with mild tomoderate anxiety and depression(these approaches include guidedself-help and psycho-educationalgroupwork)• high intensity therapists trained in CBT,counselling for depression, interpersonalpsychotherapy, dynamic interpersonaltherapy, and couples therapy fordepression for people with moderate andsevere depression and anxiety disorders.All IAPT practitioners receive routine,outcomes-focused supervision andservices also include administrative staff,employment advisers and a GP adviserand have links with other services suchas housing, drugs advice and welfarebenefits advice.OutcomesThe following measures can be usedto ensure services achieve high clinical,cost, quality and safety outcomes.For cost effectiveness• locally agreed referral thresholds,including use of the mental healthclustering tool• percentage of people diagnosed witha long-term condition who have beenscreened for anxiety and depression• percentage of people with medicallyunexplained symptoms receivingevidence-based treatment inprimary care.36For effectiveness• personalised care plans andpatient goals• CORE (for effectiveness of talkingtreatments)• compliance with IAPT data standardand sessional monitoring (see www.iapt.nhs.uk/services/measuring-outcomes).For patient safety• under-75 mortality rate in people withserious mental illness (outcome 1.5 ofthe NHS Outcomes Framework 11/12)• QOF incentives to assess and managethe physical health of people with severemental illness (relates to shared objective3 of the No Health without MentalHealth mental health strategy1)• completed suicide rates (relates toshared objective 5 of the mental healthstrategy and the forthcoming cross-government suicide strategy).For recovery• employment rates of people withmental illness (outcome 2.5 of NHSOutcomes Framework 11/12), IAPTtargets and shared objective 6 ofthe mental health strategy1)• patient self-defined goals.Also worth consideration are:• the Mental Health Recovery Star,a self-assessment tool that patientscan use with clinicians to chart theirown progress towards their self-defined goals (see www.outcomesstar.org.uk/mental-health/), and• the Warwick–Edinburgh MentalWell-being Scale (WEMWBS), ascale for assessing positive mentalhealth (see www.healthscotland.com/documents/1467.aspx).For patient experience• patient ratings of consultations(relates to shared objective 4 of themental health strategy1with a goodapplication to 360 Degree Appraisaland, in time, medical revalidation).Guidance for commissioners of primary mental health care services 11
  • 13. What would a good primary mental health care service look like? (continued)Innovative practice modelsKaris Neighbour Schemewww.karisneighbourscheme.orgKaris Neighbour Scheme has beenoperating in Birmingham for over12 years. A voluntary sector organisation,it is underpinned by the belief thatspirituality is an important factor inpersonal and community health. Thescheme seeks to meet a variety of unmetneeds, largely through volunteer support.Partnership working with local services,especially medical centres and faith basedorganisations, is central to its work.Karis Neighbour Scheme is guided byChristian beliefs and principles; its directorsare Christian, as are many of the staff.This motivates the organisation, but inno way restricts its services to those whoshare their faith. It has close links withthe community healthcare chaplains at alocal medical centre that is known for theholistic health care it offers. Some of KarisNeighbour Scheme’s programmes are jointprojects with local churches.Karis Neighbour Scheme aims:A to reduce isolation, promoteconnectedness between people andenhance community cohesion by:• providing individual befrienders forthe isolated elderly, asylum seekersand refugees• organising community activities andevents that build relationships and createa sense of community, including:– day trips in the summer for youngfamilies– summer garden parties for the elderly– Christmas festivities for the elderlyat residential homes and churches– a personal faith discussion andsupport group at a residential homeand community centre– the annual Ladywood CommunityFun Day– a community allotment project– art and craft or language sessionswith free child care– a community engagement project(facilitated by The NehemiahFoundation – Training People toTransform Communities www.regenworker.com), which initiallyconducted a detailed public healthanalysis of the area, then workedwith local stakeholders to establishpriorities for action, and has nowset up a residence association and acommunity newspaper.B to improve mental health and ability tocope with adversity, increase individuals’sense of control and independence andso reduce demand on services by:• running drop-in advocacy sessionsoffering help with welfare benefits,utility bills, immigration and housingissues• practical support such as gardening,decorating and supplying second-handfurniture• free English language classes for thosenew to the UK• accompanying individuals toappointments with doctors, housingor benefit agency appointments• one-to-one counselling and groupsdealing with issues such as depression,anxiety, self-esteem, anger managementand confidence building• working with families and young peopleto promote emotional health and reducefamily dysfunction.Changing MindsEducation Centrewww.changingmindscentre.co.ukChanging Minds Education Centre hasdeveloped over a number of years. Itswork initially focused on primary caremedication, but it has expanded toincorporate new ways of working andnew workers, including graduate workersand community nurses trained in mentalhealth. Following an audit in 2005/06 andin parallel with national initiatives such asthe National Service Framework (NSF)for Mental Health and IAPT, the servicehas developed to provide a stepped carewellbeing service.12 Practical Mental Health Commissioning
  • 14. Changing Minds is now a practice-basedinitiative with an early intervention andrecovery focus. It employs 37 full-timeequivalent staff. The service includes peersupport and a parent support service, inaddition to the following three projects.• Changing Minds Wellbeing Teamsprovide a person-centred service forpeople in Northamptonshire who maybe at risk of, or who are experiencing,a period of mental distress. Their aimis to explain the information, resourcesand support available and help peoplemake positive lifestyle changes toimprove their mental wellbeing.• Learn2B is a partnership betweenChanging Minds and theNorthamptonshire County CouncilAdult Learning Service. The aim isto enhance wellbeing through a rangeof creative, social, recreational andtherapeutic groups for people in theirlocal communities. Currently 30 tutorsare running a variety of clinical/taskbased/social interaction groups.www.mentalhealth.org.uk/publications/learning-for-life/• PhyHWell (pronounced ’fuel’) is a two-year pilot funded by NorthamptonshireTeaching PCT that aims to reducemortality rates among people withsevere mental illness, improve theirphysical and emotional health, increasetheir compliance with medication andhelp develop their support networks.It does this by improving skills in theprimary care workforce and promotingdata sharing and collaborative working.It offers GP practices individual bespoketraining and, by inviting the practices’link community mental health nurse toparticipate, creates an opportunity toimprove links with the local communitymental health team. The project was thewinner of the Nursing in Practice Award2010. www.changingmindscentre.co.uk/v/phyhwell_projectHealth and WellbeingCentre with Navigatorswww.echwc.nhs.ukLaunched in December 2011, this isa partnership between Turning Point,the Terrence Higgins Trust, GreenbrookHealthcare and NHS dentists. The healthand wellbeing centre is designed to offerthe community easy access to a range ofprimary healthcare services co-locatedunder one roof. The building houses aGP-led health centre, community sexualhealth services and NHS dentistry, aswell as offering space for use by othercommunity groups.The service operates at the interfacebetween primary and community services.The reception is staffed by a team of‘wellbeing navigators’ who, in addition todealing with patients’ health questions,also deal with bookings for the communityroom space for local organisations, makelinks with other community hubs locallyand signpost to other sources of supportin the community. This navigator modelis based on a pilot project in Hartlepool,evaluated by the University of Durham,which successfully engaged people withlocal health and wellbeing services.37The partnership also plans to establisha wellbeing navigator apprenticeshipscheme, which will recruit and train localpeople who have used the navigatorservice to work as navigators themselves.This will both expand the existingservice and ensure its sustainability, andestablishing a systemic and structuredway to build on the strengths andexperiences of patients.Guidance for commissioners of primary mental health care services 13
  • 15. Supporting the delivery of the mental health strategyThe JCP-MH believes thatcommissioning that leads togood primary mental healthcare, as described in this guide,will support the delivery of themental health strategy1ina number of ways.Shared objective 1:More people will havegood mental health.Prevention, risk stratification, andearly intervention in primary carewill result in fewer members of theregistered practice population developingmental illness.Shared objective 2:More people with mentalhealth problems will recover.More mental illness will be managedin primary care, thereby reducingadmissions to secondary care. Patientswill enjoy increased agency, a betterquality of life, stronger social relationships,a better chance of maintaining safeand stable housing, and moreopportunities to participate in educationand gain employment.Shared objective 3:More people with mentalhealth problems will havegood physical health.Co-morbidity of physical and mental illnesswill be better addressed by collaborativeprimary care delivered by multi-disciplinaryteams that give equal importance toemotional, psychological and physicalhealth care needs.Shared objective 4:More people will have a positiveexperience of care and support.People with mental health problems preferto be treated in primary care whereverpossible, and say they prefer talkingtherapies to other forms of treatment.Shared objective 5:Fewer people will sufferavoidable harm.Reducing the likelihood of admissionto hospital also reduces exposure toavoidable harm.Shared objective 6:Fewer people will experiencestigma and discrimination.People who are treated in primary careare at less risk of losing their home andmore able to maintain their social networksin their community. Friends and familynetworks, education, employment anda safe and stable place to live are centralto quality of life. Using primary careservices can avoid the stigma attached tosecondary mental health services.14 Practical Mental Health Commissioning
  • 16. Guidance for commissioners of primary mental health care services 15Primary Mental Health CareExpert Reference Group Members• Helen Lester (ERG Chair)Lead for Mental Health CommissioningRoyal College of General Practitioners• Antonia BorneoPolicy ManagerRethink Mental Illness• Gillian BowdenConsultant PsychologistBritish Psychological Society (BPS)• Jonathan CampionConsultant PsychiatristSouth London and MaudsleyNHS Foundation Trust• Neil DeucharLead for CommissioningRoyal College of Psychiatrists• Alan FarmerConsultant PsychiatristEarly Intervention TeamWorcestershire Health and CareNHS Trust• Chris FearConsultant Psychiatrist2Gether NHS Foundation Trust• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Diane FrenchDirector of Performance and QualityRichmond Fellowship• Kate GlenholmesBusiness Unit LeadWorcestershire Health and CareNHS Trust• Jacky HammondDirector of OperationsMCCH• Simon LennaneGeneral PractitionerAlton St. GP Surgery, Ross-on-Wye• Kieron MurphyDirector of DeliveryJoint Commissioning Panelfor Mental Health• Zelda PetersDirector for Mental Health ServicesTurning Point• Paul SigelHead of Primary Care PsychologyCity and Hackney Primary Care TrustAcknowledgementsWe would also like to thank the Forum for Mental Healthin Primary Care and the team of National Advisers from theImproving Access to Psychological Therapies programme.Development processThis guide has been written by a groupof primary mental health care experts,in consultation with patients and carers.Each member of the Joint CommissioningPanel for Mental Health received draftsof the guide for review and revision, andadvice was sought from external partnerorganisations and individual experts.Final revisions to the guide were made bythe Chair of the Expert Reference Groupin collaboration with the JCP’s EditorialBoard (comprised of the two co-chairs ofthe JCP-MH, one user representative,one carer representative, and technicaland project management support staff).
  • 17. 16 Practical Mental Health CommissioningResourcesJoint Commissioning Panelfor Mental Healthhttp://www.jcpmh.infoThe JCP-MH is a collaboration betweenleading organisations with an interest inmental health and learning disabilities.Its aim is to achieve better outcomes forpatients by improving commissioning ofservices that meet patient need. It doesthis by:• publishing briefings on the keyvalues and principles for effectivemental health commissioning• providing practical guidance anda framework for mental healthcommissioning• supporting commissioners incommissioning mental health care thatdelivers the best possible outcomes forhealth and well being• developing guidance for best practicecommissioning in areas where disparitiesin outcomes exist• bringing together carers, serviceusers, clinicians, commissioners,managers and others to deliver thebest possible commissioning formental health and wellbeing.Wandsworth CommunityEmpowerment Networkwww.wcen.infoWCEN is a community based charityestablished as part of the National Strategyfor Neighbourhood Renewal and based onthe Doddington and Rollo estate in NorthBattersea. WCEN works with the poorestand most disadvantaged communitiesand people living in Wandsworth andsurrounding boroughs. Its core missionis to link the issues and concerns oflocal people and communities with theorganisations and public agencies thatmay be able to do something about them.Foundation for Positive Mental Healthwww.foundationforpositivementalhealth.comThe Foundation for Positive Mental Healthpromotes Positive Mental Training throughresearch, professional training and raisingpublic awareness. It works with healthcare organisations and with businesses.Positive Mental Training is offered throughthe NHS in Edinburgh as part of a steppedcare approach to treat anxiety, and is alsooffered by NHS primary care services inHalton and St Helens, Sandwell & Dudleyand Eden Valley.National Debtline andthe Money Advice Servicewww.nationaldebtline.co.ukwww.moneyadviceservice.org.ukNational Debtline provides a nationaltelephone helpline for people with debtproblems in England, Wales and Scotland.The service is free, confidential andindependent (0808 808 4000; Monday–Friday 9am–9pm; Saturday 9.30am–1pm).The Money Advice Service provides free,unbiased advice nationwide to anyoneseeking help to manage their money. Theservice is available online and over thephone on 0300 500 5000, Monday toFriday 8am–8pm.Primary Care Mental Healthand Educationhttp://primhe.ning.comPRIMHE aims to promote and improveunderstanding, skills and knowledge ofprimary care practitioners to work withpeople in distress, with and without aformal diagnosis of a mental illness.Useful publications/weblinksHaddad, M., Buszewicz, M. andMurphy, B. Supporting people with anxietyand depression: a guide for practicenurses. London: Mind. www.mind.org.uk/assets/0001/4765/MIND_ProCEED_Training_Pack.pdfNICE pathways: depression.http://pathways.nice.org.uk/pathways/depressionNICE cost impact and commissioningassessment: quality standard fordepression in adults.www.nice.org.uk/media/01D/C3/DepressionQSCostAssessment.pdf
  • 18. Guidance for commissioners of primary mental health care services 17References1 HM Government (2011).No health without mental health:a cross-government mental healthoutcomes strategy for people of all ages.London: Department of Health.2 Bennett, A., Appleton, S., Jackson, C.(eds) (2011). Practical mental healthcommissioning. London: JCP-MH.www.jcpmh.info3 Funk, M., Ivbijaro, G. (2008).Integrating mental health into primarycare: a global perspective. Geneva:World Health Organization/WONCA(World Organization of Family Doctors).4 McManus, S., Meltzer, H., Brugha, T.,Bebbington, P.E., Jenkins, R. (2009).Adult psychiatric morbidity in England,2007: results of a household survey.Leeds: NHS Information Centre forHealth and Social Care.5 McManus, S., Meltzer, H., Campion,J. (2010). Cigarette smoking and mentalhealth in England. Data from the AdultPsychiatric Morbidity Survey. London:National Centre for Social Research.www.natcen.ac.uk/study/cigarette-smoking-mental-health6 Singleton, N., Bumpstead, R.,O’Brien, M., Lee, A., Meltzer, H. (2001).Psychiatric morbidity among adults livingin private households. London: TheStationery Office.7 Van Os, J., Linscott, R.J., Myin-Germeys,I., Delespaul, P., Krabbendam, L. (2009).A systematic review and meta-analysisof the psychosis continuum: evidencefor a psychosis proneness-persistence-impairment model of psychotic disorder.Psychological Medicine 39, pp.179–95.8 Appleby, J., Crawford, R., Emmerson, C.(2009). How cold will it be? Prospectsfor NHS funding: 2011–17. London:Kings Fund/Institute for Fiscal Studies.9 Goodwin, N., Dixon, A., Poole, T.,Raleigh, V. (2011). Improving the qualityof care in general practice: report of anindependent inquiry commissioned byThe King’s Fund. London: King’s Fund.10 Sainsbury Centre for Mental Health(2003). The economic and social costsof mental illness. Policy paper 3. London:Sainsbury Centre for Mental Health.11 Bhui, K.S., McKenzie, K. (2008).Rates and risk factors by ethnic groupfor suicides within a year of contactwith mental health services in Englandand Wales. Psychiatric Services 59(4),pp. 414–20.12 Kirkbride, J., Fearon, P., Morgan, C.,Dazzan, P., Morgan, K., Tarrant, J. et al(2006). Heterogeneity in incidence ratesof schizophrenia and other psychoticsyndromes findings from the 3-centerÆSOP study. Archives of GeneralPsychiatry 63, pp. 250–58.13 Smiley, E. (2005). Epidemiology ofmental health problems in adults withlearning disability: an update. Advancesin Psychiatric Treatment 11, pp. 214–22.14 Chakraborty, A., McManus, S.,Brugha, T., Bebbington, P. (2011).Mental health of the non-heterosexualpopulation of England. British Journal ofPsychiatry 198, pp. 143–48.15 NICE (2009). Depression with a chronicphysical health problem: the treatment andmanagement of depression in adults withchronic physical health problems (partialupdate of CG23). Clinical guidance 91.London: NICE.16 Miovic, M., Block, S. (2007).Psychiatric disorders in advanced cancer.Cancer 110(8), pp. 1665–76.17 Kim-Cohen, J., Caspi, A., Moffitt, T.E.et al (2003). Prior juvenile diagnoses inadults with mental disorder: developmentalfollow-back of a prospective longitudinalcohort. Archives of General Psychiatry60, pp. 709–17.18 Office for National Statistics (2002).The mental health of carers. London:ONS.19 Bird, V., Premkumar, P., Kendall, T.,Whittington, C., Mitchell, J., Kuipers,E. (2010). Early intervention services,cognitive behavioural therapy and familyintervention in early psychosis: systematicreview. British Journal of Psychiatry 197,pp 350–56.20 McCrone, P., Craig, T.K.J., Power, P.,Garety, P.A. (2010). Cost-effectivenessof an early intervention service forpeople with psychosis. British Journal ofPsychiatry 196, pp. 377–82.21 Nicholson, A., Kuper, H., Hemingway,H. (2006). Depression as an aetiologic andprognostic factor in coronary heart disease:a meta-analysis of 6362 events among146,538 participants in 54 observationalstudies. European Heart Journal 27(23),pp. 2763–74.22 Fenton, W., Stover, E. (2006). Mooddisorders: cardiovascular and diabetescomorbidity. Current Opinion in Psychiatry19(4), pp. 421–27.23 Brown, S., Kim, M., Mitchell, C., Inskip,H. (2010). Twenty-five year mortality ofa community cohort with schizophrenia.British Journal of Psychiatry 196: pp.116–21.24 Lester, H.E., Tritter, J.Q., Sorohan, H.(2005). Providing primary care for peoplewith serious mental illness: a focus groupstudy. British Medical Journal 330: pp.1122–28.
  • 19. References (continued)25 NIMHE (2005). NIMHE guidingstatement on recovery. London: NIMHE.15 NICE (2009). Depression: the treatmentand management of depression inadults (update). (Partial update of CG23depression: management of depression inprimary and secondary care). London: NICE.27 NICE (2005). Obsessive compulsivedisorder (OCD) and body dysmorphicdisorder (BDD). Clinical guidelines CG31.London: NICE.28 NICE (2011). Generalised anxietydisorder and panic disorder (withor without agoraphobia) in adults:management in primary, secondary andcommunity care. Clinical guidelinesCG113. London: NICE.29 NICE (2005). The management ofPTSD in adults and children in primaryand secondary care. Clinical guidelinesCG26. London: NICE.30 England, E., Lester, H.E. (2007).Implementing the role of the graduateprimary care mental health worker:a qualitative study. British Journal ofGeneral Practice 57, pp. 204–11.31 Lester, H.E., Freemantle, N., Wilson,S., Sorohan, H., England, E. (2007).Cluster randomized controlled trial of theeffectiveness of graduate primary caremental health workers. British Journalof General Practice 57, pp. 196–203.32 Friedli, L., Watson, S. (2004). Socialprescribing for mental health. Durham:Northern Centre for Mental Health.33 Bower, P., Gilbody, S., Richards,D., Fletcher, J., Sutton, A. (2006).Collaborative care for depressionin primary care. Making sense of acomplex intervention: systematic reviewand meta-regression. British Journal ofPsychiatry 189, pp. 484–93.34 Gilbody, S., Bower, P., Fletcher,J., Richards, D., Sutton, A. (2006).Collaborative care for depression:a cumulative meta-analysis and reviewof longer-term outcomes. Archives ofInternal Medicine 166, pp. 2314–21.35 Fletcher, J., Bower, P.J., Gilbody,S., Lovell, K., Richards, D., Gask, L.(2009). Collaborative care for depressionand anxiety problems in primary care.Cochrane Database of SystematicReviews, Issue 2.36 Bonnar, F. (ed.) (2010). Medicallyunexplained symptoms (MUS):a whole systems approach. London:Commissioning Support for London.www.londonhp.nhs.uk/wp-content/uploads/2011/03/MUS-whole-systems-approach.pdf37 Wistow, G. and Callaghan, G. (2011).Empowering local communities tocommission for health and wellbeing:the connected care initiative in England,Journal of Management and Marketingin Healthcare, 4(1), February 2011, pp.63–71 (9).18 Practical Mental Health Commissioning
  • 20. Guidance for commissioners of primary mental health care services 21A large print version of this document is available fromwww.jcpmh.infoPublished February 2013Produced by Raffertys