Practical mental health commissioning


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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 health and social care services in their area.

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Practical mental health commissioning

  1. 1. 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
  2. 2. 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
  3. 3. 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 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. 4. 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
  5. 5. 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. 6. 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.
  7. 7. 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. 8. 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.
  9. 9. 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. 10. 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.
  11. 11. 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. 12. 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.
  13. 13. 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. 14. 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 >>>>>>>
  15. 15. 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%*) 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. 16. 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 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.
  17. 17. 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 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 social work input. was also integrally involved in the delivery 16 of the other five NSF standards. The NHS 17 18 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. 18. 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.
  19. 19. 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. 20. 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.
  21. 21. 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. 22. 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
  23. 23. 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