Practical mental health commissioning

Joint Commissioning Panel
for Mental Health
www.jcpmh.info

Practical Mental Health Commissioning
A framework for local authority
and NHS commissioners of mental health
and wellbeing services

Volume
One:
Setting
the Scene

Produced by
Andy Bennett
Steve Appleton
Catherine Jackson

Acknowledgements

This framework is the product of contributions from many colleagues from the National Mental Health
Development Unit. The authors would particularly like to thank the membership organisations of the Joint
Commissioning Panel for Mental Health for their written contributions and comments. Our thanks to:

np National
involvement
Partnership

Andy Bennett
Andy has most recently worked across the National Mental Health Development Unit commissioning
programme in conjunction with the ADASS mental health, drugs and alcohol policy network. He has
led on a range of actions to support and strengthen integrated commissioning in mental health and
related areas across the NHS and local authorities. He has had broad previous NHS and social care
experience, 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 Appleton
Steve is an independent consultant at Contact Consulting, a specialist consultancy and research
practice working at the intersection of health, housing and social care. He has previously worked at
an operational and strategic level in local authorities and the NHS. His particular interests are the
health, housing and social care needs of those with mental health problems, learning disability, substance
misuse, older people and offender health. In his work for the NMHDU commissioning programme
he 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 Jackson
Catherine is a consultant editor and journalist specialising in mental health and social care. She has worked
for many years in the mental health field and was formerly editor of Mental Health Today magazine.

Commissioned and supported by

A framework for local authority and NHS commissioners 3

Foreword

Health and social care commissioners The JCP-MH represents: Joint Commissioning Panel
in England are operating in a time of for Mental Health:*
• a coming together of the Royal
considerable change. Shaped by the
Colleges of General Practitioners Dr Neil Deuchar
provisions of the Health and Social Care
and Psychiatrists Co-chair of JCP-MH and Lead
Bill, the new commissioning landscape
for Commissioning, Royal College
for health and social care will be led at • in partnership with the Association
of Psychiatrists
a 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 for
At the same time, mental health services Mental Health Commissioning,
Interprofessional Collaborative on
will also be shaped by No Health without Royal College of General Practitioners
Mental Health, National Collaborating
Mental Health, the new English mental
Centre for Mental Health, NHS Kieron Murphy
health strategy. This has a focus on
Confederation and the Royal College Commissioning Programme Director,
prevention, improved public mental
of Nursing National Mental Health Development Unit
health, and better outcomes for people
experiencing 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 Confederation
Panel for Mental Health (JCP-MH)
Network and Rethink Mental Illness.
has launched its first publication, Richard Webb
Practical 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 Services
The JCP-MH is a new collaboration with the JCP-MH and other professionals, Paul Jenkins
between a range of leading organisations Practical Mental Health Commissioning Chief Executive, Rethink Mental Illness
with the aim of improving effective – Volume One: Setting the Scene both
commissioning for mental health, explains the current changes occurring Paul Farmer
learning disabilities and wellbeing within commissioning, and provides advice Chief Executive, Mind
(visit www.jcpmh.info for more details). that aims to help all current and future Sarah Yiannoullou
commissioners to develop and deliver high Programme Manager,
quality, effective and efficient services. It National Survivor User Network
encourages commissioners to take a broad
Fran Singer
whole systems approach to their work.
Programme Co-ordinator,
As the current reforms unfold, the National Involvement Partnership
JCP-MH will continue to develop and
launch the further volumes of the mental *These organisations were involved in
the production of Practical Mental Health
health commissioning framework. Commissioning – Volume One: Setting the
Scene. Since then, the Royal College of Nursing,
Drawing on the involvement of people Healthcare Finance Management Association,
with experience of using services, Interprofessional Collaborative on Mental Health,
carers, clinicians, commissioners, and the National Collaborating Centre for Mental
Health and the British Psychological Society
organisations providing services and have also become members of the JCP-MH,
support, we will aim to provide the and will be involved in future work.
values, evidence and practical advice
that commissioners will need in these
challenging times.

4 Practical Mental Health Commissioning

Contents

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


Introduction

This framework is the first of three Mental health describes a broad continuum
briefing documents for commissioners in of mental states that extends from mental
local authorities and the NHS. It is intended illness, through mental ill health that
to explain the changing commissioning may not reach the threshold for a formal
environment and how commissioners can diagnosis, to positive mental health and
make the most of available resources to wellbeing. People will move in and out of
improve 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 not
We are currently going through a period experience severe mental ill health.
of change in the way mental health and
social care services are commissioned. Mental health is important at individual and
These changes are outlined in the Coalition family levels; it is no less important within
Government’s Health and Social Care communities and still more widely within
Bill and were first published in the White our society as a whole. Interventions that
Paper Equity and Excellence: Liberating improve the mental health of individuals
the NHS and the related policy document will also improve the mental health of
A Vision for Adult Social Care: Capable communities and promote and protect the
Communities and Active Citizens. mental health and resilience of the wider
population. Better levels of mental health
At the same time, our understanding of within the wider population also mean less
the issues that mental health commissioning severe mental illness, and better levels of
needs to address is developing just as support for those who are unwell.
radically, informed by the growing body
of evidence on the influence of wider Health and social care services are rising
psychosocial factors on mental health to the challenge to maximise quality and
and wellbeing. cost effectiveness in all service provision
while also supporting individuals along their
A comprehensive, strategic approach to recovery journey. Increasingly, services are
improving mental health needs to include evidence-based and the people receiving
not only direct service provision for people these services are genuinely engaged in
currently experiencing and recovering from decision-making, not just at individual
mental health problems, but also prevention level but at organisational/strategic
and early intervention for those at high levels too. Personalisation is now the key
risk, 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.


The framework The framework is in three parts

This framework is intended to guide It describes the key commissioning 1 The changing commissioning
commissioners as they traverse this enablers for achieving these three landscape – this section outlines
complex 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 expanded
The framework’s main focus is on the quality, ensuring efficiency and productivity role of local authorities, the new mental
mental health system, across all tiers, and supporting people to become more health strategy, and the other key
but it also addresses population mental engaged in their own health care,2 while points such as quality standards and
health and health improvement, and the also managing increasing need and outcomes frameworks that inform the
links between mental and physical health,1 demand for services. commissioning process.
especially for people with common and
severe mental illnesses. It recognises the multiplicity of factors 2 What mental health commissioning
involved in achieving quality and looks like now – this section outlines
It takes an all-age approach, covering the effectiveness in mental health and social the nuts and bolts of the commissioning
whole of the life course from the very care. Services need to be person-centred, cycle, the joint strategic needs
early years to old age. It does not delve in cost-effective, clinically effective and assessment and other key features of
significant 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 health
in 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 examples
the 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 the
It explores the key policy imperatives
voluntary and community sectors, beyond priorities that will continue through the
driving commissioning for mental health
the conventional boundaries of mental period of transition and into the new
into 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.


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
1.1 NHS strategy and developing policy frameworks
1.2 GP commissioning consortia
1.3 The NHS Commissioning Board
1.4 Health and wellbeing boards
1.5 HealthWatch
1.6 Public health
1.7 Associated developments
1.8 Providers
1.9 Regulation – Monitor and the Care Quality Commission
1.10 Mental health commissioning
1.11 Commissioning structures and processes
1.12 GP commissioning and mental health
1.13 Primary care mental health
1.14 Outcomes frameworks
1.15 Quality standards
1.16 Quality, innovation, productivity and prevention (QIPP)
1.17 Public mental health
1.18 Personalisation
1.19 Payment by Results
1.20 Equalities, diversity and inclusion
1.21 Involving individuals and communities
1.22 Safeguarding children and vulnerable adults
1.23 Expanding choice of providers


The changing commissioning landscape
1.1 NHS strategy and developing 1.2 GP commissioning consortia
policy frameworks

Commissioning for mental In recent months the Coalition Government Equity and Excellence: Liberating the
health and wellbeing reflects has introduced legislation and strategic NHS and the Health and Social Care Bill
and is informed by the current policies to support high quality health and both describe a different NHS and local
commissioning 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 Equity
health 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 draw
Importantly, these aims broaden Communities and Active Citizens sets on expert advice from health and care
the focus of intervention beyond out the agenda for social care reform. professionals and establish robust systems in
the traditional arena of medical partnership with local authorities to involve
• Healthy Lives, Healthy People: Our
and social care to address the patients and communities in their work.
Strategy for Public Health in England
wider determinants of mental
explains the Coalition Government’s
health and wellbeing, such The GPCC will be required to commission
vision for public health, including the
as housing, the environment, some services on an ‘any willing provider’
expanded role of local authorities in
education, employment and the basis – that is, the consortium will specify the
health and health improvement. It
social networks that generate services and quality standards required and
emphasises the importance of mental
social 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.


1.3 The NHS Commissioning Board

The NHS Commissioning Board will have The NHS Commissioning Board will also The Secretary of State will be required to
two main roles: it will support and regulate provide national leadership for driving undertake a formal public consultation on
the GPCC, and it will have a limited up the quality of care, including safety, the priorities set out in the annual mandate
commissioning function. effectiveness and patient experience. before issuing the final version.
It will promote patient and public
It will support and hold GPCC to account involvement and will foster and support The legislative framework will ensure
for the quality outcomes they achieve innovation and integration across the that GPCC are accountable for improving
and for their financial performance, and NHS, and with local authorities. quality of care within the resources
will have the power to intervene if available to them. The GPCC and the NHS
consortia are failing or are likely to fail to It will be responsible for commissioning the Commissioning Board will be subject to
fulfil 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 ways
It 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.


1.4 Health and wellbeing boards 1.5 HealthWatch

Local authorities will lead the strategic Local authorities and the GPCC for their Local authorities will retain their current
co-ordination of commissioning prevention areas will undertake a joint strategic health scrutiny powers, either through
and promotion (health and wellbeing) needs assessment through the health and the existing health Overview and Scrutiny
services further upstream, drawing together wellbeing boards. Committees (OSCs) or through other means
NHS, social care and related children’s if they choose. Local Involvement Networks
and 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 HealthWatch
They will do this through health and new joint health and wellbeing strategies England. HealthWatch England will be
wellbeing boards, which will be a statutory (JHWS). The JHWS is intended to provide based within the Care Quality Commission
requirement 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 will
The 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 to
across the NHS, social care, public health other services. The JHWS could include commissioners, and will provide local
and other services that the board agrees wider health determinants such as housing intelligence for HealthWatch England. Local
have a direct influence in health and and education. authorities will be able to commission local
wellbeing, in order to secure better health HealthWatch to provide advocacy, advice
and wellbeing outcomes for their whole GPCC and local authorities will have
and information to support people if they
population, better quality of care for users statutory responsibility for the production
have a complaint and to help people make
of 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 be
The boards will provide the platform for approved by the health and wellbeing
NHS, public health and local authority board. The boards will be expected to
leaders and commissioners to work together play an influential role in the development
on a geographical basis, both within and of innovative solutions to commissioning
between local authority areas. challenges, not simply to comment on
commissioning plans.
The core membership of these boards will
include all the GPCC covering that area, Health and wellbeing boards will be able
the director of adult social services, the to look at the totality of resources available
director of children’s services, the director for health and wellbeing in their local
of 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, such
member. Additional membership will be as pooled budgets. Using the JHWS, they
at the discretion of each board, but might will be able to consider how prioritising
include representatives of the local voluntary health improvement and prevention, the
sector and other relevant public service management of long-term conditions and
officials, professionals and community the provision of rehabilitation, recovery
organisations that can advise on and give and re-ablement services will best deliver
voice to the needs of vulnerable and less- reductions in demand for health services and
heard groups. Board membership might also wider benefits for the health and wellbeing
include some providers, so long as this does of the local population.
not prejudice the level playing field within
the local health and social care market.


1.6 Public health 1.7 Associated developments 1.8 Providers

Responsibility for public health, including Accompanying these major structural On the provider side, there will be a
public 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 Foundation
England. 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 into
ring-fenced budget. Directors of Public • closer collaboration between primary direct health and social care provision. The
Health (DPH) will be located within local and secondary care clinicians and aim is to free up providers so that they can
authorities, which will have responsibility professionals to enhance clinical compete on a level playing field, focus on
for health improvement within their areas. leadership in commissioning. This improving outcomes, be more responsive
The DPH will be expected to work with collaboration should be built on the to the needs of people using services, and
partner organisations – the NHS, the principles of integration and joint innovate.
private, voluntary and public sectors and the working in both commissioning and
GPCC – through the health and wellbeing delivering a comprehensive mental This process will be facilitated by the ‘any
board. 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 sectors
new public health outcomes framework. • a major expansion of choice and
involvement opportunities for
Public health will be part of the NHS individuals receiving primary, community
Commissioning Board’s remit, and GPs and secondary care, with greater
potentially could receive enhanced personalisation of services, increased
incentives 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.


1.9 Regulation – Monitor and the 1.10 Mental health commissioning
Care Quality Commission

There will be a new regulatory system. commissioners and periodically reviewing
Within this landscape, commissioners
Monitor will take on the role of independent NHS providers. Instead, it will focus its
of mental health services will be freed
economic 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 commissioning
of services (see figure 1). To support these
from patient feedback and complaints; for mental health and wellbeing will
functions, Monitor will license all providers
staff experience; and information become much more the norm. Services
of NHS-funded care.
from HealthWatch England and local will be commissioned from a wide range
Monitor’s overarching duty will be to protect HealthWatch, health and wellbeing boards of organisations delivering a broad
the interests of users of health and adult and OSCs, GPCC, Monitor and the NHS spectrum of services across a locality, area
social care services by promoting competition Commissioning Board. or region. Investment will be channelled
among providers, as appropriate, and into new areas of development, beyond
regulation 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 additional
what 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 community
quality of care they give and the value for be at serious and immediate risk, the CQC
networks and resources, investment
money they offer. will have powers (as now) to suspend or
in peer support
remove registration – in effect closing down
The role of the Care Quality Commission the service or provider. • citizen pathways – creating
in maintaining and pushing forward quality opportunities for people’s active
and safety of services will be expanded and The quality standards for all health care participation in local government
strengthened. All providers of services to and treatment interventions will be
• mechanisms to ensure people have
the NHS will be required to register with the commissioned by the NHS Commissioning
a voice at strategic, community and
CQC, 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 NHS
Figure 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.


1.11 Commissioning structures and processes

The 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 health
service, and where they may overlap and interlock within the commissioning process.

Figure 2: The new commissioning structure for mental health and wellbeing

Commissioning for mental health and wellbeing takes place across four tiers, covering both universal
and targeted services across the whole population. Currently most health resources are tied up at
the narrow end of the triangle, at tiers 3 and 4, covering inpatient specialist services. But many of the
quality and efficiency actions needed to change the profile of future demand rely on a connected
approach at tiers 1 and 2, addressing population and public mental health, prevention, early
intervention, 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


Putting strategy into action across the tiers also requires different approaches to commissioning, working through
broader partnerships (such as Children’s Trusts or Community Safety Partnerships) at tier 1 and into tier 2. A greater
concentration on joint commissioning between GPCCs and local authorities is needed at tiers 2 and 3 to ensure
integration and best outcomes. Then, as services get more specialised, wider collaborative arrangements are required
at tier 4, to make the best use of resources and maximise the effectiveness of acute and specialist mental health care
pathways across organisations at a sub-regional or regional level. Each of these commissioning approaches also relies
on close partnership with providers and frontline clinicians and teams to ensure the potential for innovation and
improvement 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 local
commissioning responsibilities and overlaps are shown here. Again, the diagram emphasises the need for
inter-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 >>>>>>>


1.12 GP commissioning and mental health

The concept of GP commissioning is built Figure 3: Towards optimal primary mental health care3
on the pivotal role that GP practices already
play 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 and
proximity to their patients, it is seen to secondary mental health care meta-analysis of the psychosis
be a natural extension for GP practices to care illness service continuum: evidence for a
inc psychosis
play the lead role in deciding what wider (1%*)
psychosis-proneness-persistence-
impairment model of psychotic
health care services to commission on their
Common disorder. Psychological Medicine
patients’ behalf. Primary 39: 179–195.
mental disorders
First point health
(17.6%11) care
**
Deacon L, Carlin H, Spalding J
GPs also currently play an important role in of contact Alcohol dependence (6%11) et al (2009). North West mental
service
influencing NHS expenditure, both through Illegal drug dependence (3%11) wellbeing survey. Liverpool:
North West Public Health
referral and prescribing decisions and (less Sub-threshold conditions Observatory (http://www.
directly) through the quality and accessibility Psychosis (6%*) nwph.net/nwpho/publications/
of the services they provide and the impact Common mental disorders (17%11) NorthWestMentalWellbeing%
these have on emergency and urgent care Hazardous drinking (24%11) 20 SurveySummary.pdf).

provided elsewhere in the health system. In Early
Optimal mental wellbeing
this sense, GP commissioning gives groups identification
(Only 20.4% of population have
of GP practices financial accountability for optimal mental wellbeing**) of vulnerability
the 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 mental
On 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 needs
position to develop services that meet the
are met with the required intensity of response at the appropriate level.
particular needs of their patients, resulting
in far more personalised, individual care and joint health and wellbeing strategy as a whole, in partnership with the local
and 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 platform
also need to be concerned with the mental and mechanisms for GPs to contribute their Figure 3 illustrates the extent of territory
health and wellbeing of the local population clinical knowledge to strategic planning for for which primary care has responsibility
as 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 support
local health improvement and improving
mental wellbeing, as their remit will cover In mid-Essex, a pathfinder consortia of seven GP practices has prioritised a need for
promotion 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 a
will be working directly with Directors of first phase of four workstreams. It is intended that these workstreams will inform
Public 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 priorities
The involvement of the GPCC on the • finance, activity and performance data for NHS and Social Care
health and wellbeing boards, and in the spend for the consortia population
• NHS and Social Care partnership issues
joint 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 consortia
health care in New Zealand: a discussion across Essex and with the local authority.
paper. Wellington: Ministry of Health.


1.13 Primary care mental health

In the 1960s, when GPs in the UK were Primary care is also best placed to manage
beginning 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 Year
improvement of mental health services… care provided in primary care settings by 2000. Geneva: World Health Organization.
is not a large expansion of and proliferation their own GP.7 6
World Health Organization/ World
of 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: focus
cornerstone 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 the
more recently defined ‘primary care American Medical Association 266: 2268–2271.
small number of people with mental health
mental 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 to
providing mental health care in the primary
care setting, from the perspectives both
of people who use services and of the
health and social care system. Care can
be provided closer to home, in a setting
that does not carry the stigma that is still
<10/1000
associated with mental health facilities, 20-30/1000
by a health care worker who will ideally
know the person and his or her family, who 130/1000
will be able to provide holistic treatment
230/1000
and continuity of care for the full range of
problems including physical health needs, 250/1000
and who has good links to local services to
help 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.


This means that over 90% of people with GPs used to be seen to have a poor record Numerous models have been developed
any severity of mental health problems are on identifying depression among their to provide genuinely ‘shared care’ across
managed entirely in primary care – including patients. More recent studies have found primary and secondary care.19 Much of
roughly one in four people receiving that they are very good at recognising the research has focused on attempting to
treatment for psychosis. If this number is moderate to severe depression,12 where improve outcomes for people with common
disaggregated into levels of mental ill health, there is more benefit to be gained from mental health problems by integrating
a GP with a list size of 2000 patients would treatment. new specialist mental health staff, such
expect to be treating about 50 people with as counsellors and psychologists, into the
depression, 10 people with a serious mental Physical and mental health problems often primary care team.20 However, collaborative
illness such as schizophrenia or bipolar co-exist and overlay and interact with care, which originates from the US21 and
disorder, about 180 people with anxiety each other. The difficulties inherent in is based on new approaches to treating
disorders and a further 180 or so with milder disentangling the two, and the associated people with chronic health problems such as
degrees 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 depression
Analysis 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). National
Most (38%) of those with common
service framework for mental health: modern
mental disorders accessed GP services of evidence-based mental health care in standards and service models. London:
and 18% made use of community or the post-institution era.13 Historically, from Department of Health.
day care services. For those with two or 1999–2009, primary care had specific 14
Department of Health (2000). The NHS Plan:
more common mental disorders, 16% responsibility for delivering standards a plan for investment, a plan for reform.
made use of community day centres, two and three of the National Service London: Department of Health.
10% accessed psychiatry and 10% Framework (NSF) for mental health and 15
http://guidance.nice.org.uk/CG22
received 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.


1.14 Outcomes frameworks

The new NHS, the advent of GP-led New outcomes frameworks have been
commissioning and the Government’s vision developed connecting public health, the
for social care provide real opportunities NHS and social care. These have been
to further revitalise primary care mental designed to interlink so they work together
health, in line with the Government’s towards shared outcomes and goals (see
principles 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 frameworks
make primary care the hub of all mental
health 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 their
spectrum of need of the wider population, through re-ablement or intermediate care services determinants
as well as those with severe mental illnesses. and early intervention

This model also takes a wellness and
recovery approach; it can enable people
to continue living independently in their
communities; it can, where appropriate, shift
resources (investment and skills) towards the Public Health NHS
community end of people’s care pathways.
It may also enable better and more active
management of people’s journeys into and
out of specialist mental health services, in
part through increased availability of these
services in surgeries and health centres.
Adult Social Care
Enhanced co-working and collaboration
between primary care and mental health
teams, 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 services
opportunities for recovery. wellbeing issues for joint approaches on reducing repeat emergency admissions.
Supporting carers and involved in care planning
Overall, such an approach offers multiple
benefits. It gives increased potential Adapted from Healthy Lives, Healthy People: Transparency in Outcomes. Proposals for a Public
for health, social care and other key Health Outcomes Framework. A consultation document. Department of Health. December 2010.
stakeholders to collaborate at locality level
to meet the totality of individual or family
needs. It ensures that commissioning is Importantly, all three frameworks accord
better locked onto local needs. It gives equal importance to mental health and
GP commissioners and local authorities physical health outcomes as a measure of
greater flexibility to design and deliver effectiveness. Commissioners’ performance
specific services that meet specific local will be judged against these outcomes by
needs. It extends opportunities for shared the national NHS Commissioning Board,
care and expands access to specialist and potentially at local level by health and
professional skills where they are most wellbeing boards and local HealthWatch.
needed and most useful, closest to people’s
homes and within their communities.


1.14.1: The NHS outcomes framework

The NHS outcomes framework has five Domain 1, for example, connects to Domain 4 might encompass people’s
outcome 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, involvement
used only to set direction of travel and to Domain 2 could apply directly to enhancing in developing care plans, decisions about
obtain baseline data. From 2012/13 quality of life for people with long-term care and treatment, and use of recognised
it will include ‘levels of ambition’ and the severe mental illnesses and to the mental measures such as Patient Reported
NHS Commissioning Board will be held to health contribution to physical long-term Outcome Measures (PROMs) and NICE
account (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’s
Some of the NHS outcomes framework episodes of severe mental ill health. wellbeing when accessing mental health
domains have been given a mental health This – alongside medical treatment – might care and treatment, including clinical
specific indicator (see table 1 below). include education, training and employment safety, informed by PROMS, NICE Quality
Others do not have a specific indicator that support, housing, social networks and Standards, and Care Quality Commission
relates to mental health but will still have attention to wider social care and skills inspections of the care environment and
direct 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


1.14.2: The public health outcomes framework

The public health outcomes are still pending finalisation. Table 2 lists the
domains and outcomes proposed in the consultation document Healthy
Lives, Healthy People: Transparency in Outcomes.22

Table 2: Proposed public health outcomes framework

The overarching vision for public health:
To improve and protect the nation’s health and to improve the health of the
poorest, fastest. Supported by five key domains for public health outcomes that
reflect 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 mortality

Domain 1 sets the overarching goal that the Government expects Public Health England
to achieve, supported by local delivery mechanisms. The other domains are sequenced
across the spectrum of public health, from influencing the wider determinants of health,
to opportunities to improve and protect health, to preventing ill health (morbidity) and
avoiding premature death (mortality).

22
Department of Health (2010). Healthy Lives,
Healthy People: Transparency in Outcomes.
Proposals for a Public Health Outcomes
Framework. A consultation document.
London: Department of Health.


1.14.3: Proposed social care outcomes framework

The vision informing Transparency in Outcomes: a framework for adult social
care, 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.


Table 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

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

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

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


1.14.4: Mental health strategy Table 4: Mental health strategy shared objectives

The mental health outcomes strategy, 1. More people will have good mental health
No Health without Mental Health, is
built around a two-track, life course More people of all ages and backgrounds will have better wellbeing and good
approach 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 health
It links closely with the Healthy Lives,
Fewer people with mental health problems will die prematurely, and more people
Healthy People strategy for public health
with physical ill health will have better mental health
in England and – as a cross-Government,
rather than a Department of Health 4. More people will have a positive experience of care and support
strategy – 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 control
meeting these aims.
over their own lives, in the least restrictive environment; and should ensure people’s
The strategy is structured around six shared, human rights are protected
cross-Government and multi-agency mental 5. Fewer people will suffer avoidable harm
health objectives (see table 4). These are
consistent with those set out in the NHS, People receiving care and support should have confidence that the services they use
social care and public health frameworks. are of the highest quality and at least as safe as any other public service
The objectives are designed to support 6. Fewer people will experience stigma and discrimination
delivery 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

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