Download Mental Health – Accessing services in primary care

Item 04 Appendix D
Greater London Authority
Scrutiny of Access to Primary Care Services
Mental Health
Dr Alan Cohen FRCGP
Director of Primary Care
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Sainsbury Centre for Mental Health
Executive Summary:
Primary care mental health services have specific problems in delivering a high
quality accessible service. These issues, whilst a problem throughout England, are
much worse in London, as a result of the specific characteristics of the capital.
These problems are:

Resources to assess and treat individuals appropriately

Mental health care of refugees and asylum seekers

Appropriate access to talking therapy services

Appropriate links with secondary care services

The inability to commission/significantly influence providers of mental health
services.
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Mental Health – Accessing services in primary care for
people with mental health problems
The GLA and the Mayor’s Office have initiated a scrutiny of access to primary care
services in London. A framework has been requested for the submission of written
evidence based on five areas:
 Recruitment and retention
 Changing role and responsibilities of primary care
 Patient involvement and information issues
 Equitable access
 Role of PCTs as commissioners of services
This evidence relates solely to mental health services, provided by primary care, or
commissioned by PCTs.
References and further background reading is provided at the end of the report.
Key facts:
 30% of all consultations in general practice have a mental health component
 Over 90% of people with mental health problems are dealt with entirely within
primary care
 Over 30% of people with a severe and enduring mental illness are managed
entirely within primary care.
 Between 30 – 50% of people with a mental health problem are not
acknowledged as having a mental health problem at that consultation by their
GP.
 Consultation length is increasing; in the 1980s the average length of
consultation was 8 minutes, in the 1990s, 9 minutes, and currently average
length of consultation is 10 minutes.
Primary Care as Providers of Mental Health Services.
Since 30% of consultations have a significant mental health component, it is not
surprising that mental health is a major area of concern to GPs and their primary
health care team (PHCT). The vast majority of patients seen in primary care with
mental health problems have a common mental illness, such as depression, or
depression with anxiety.
1. Primary care teams provide care by undertaking an assessment of the patient’s
needs, and advising on an appropriate treatment.
1.1. Assessment: The fact that 30 – 50% of individuals are not acknowledged at
that consultation to have a mental health problem is sometimes ascribed to
GPs being poorly trained or lacking interest in mental health problems. The
situation is however more complex. It is a tenet of general practice that an
assessment is not undertaken in a single consultation, but over several
consultations, using time as a tool to improve the relationship between
patient and doctor. Thus, over 3 – 4 consultations the accuracy of diagnosis
Item 04 Appendix D
increases to over 90%. Further, frequently those patients who are not
acknowledged as having a mental health problem are those with a coexisting physical illness, and may themselves not yet be ready to agree that
their symptoms are in part exacerbated by a co-existing depressive illness.
This agreement also takes time, and requires that there is a re-attribution of
physical symptoms.
2. Treatment: There are two broad modalities of treatment available for people with
common mental health problems: talking therapies or medication. Generally,
talking therapy is more effective for mild and moderate mental illness, and
medication for moderate and severe mental illness.
2.1. Many practices during the time of fund-holding invested in practice based
talking therapies. There is no survey that maps throughout London what
practice based services are available. Some primary care organisations
have invested significant sums in commissioning talking therapies from either
mental health trusts or independent organisations. Recent publications from
the Department of Health have given a structure on which to base this
commissioning, and there is an excellent publication from the Manchester
National Primary Care Research and Development Centre in collaboration
with the Counsellors in Primary Care organisation on this subject.
2.2. There has been little regional control/direction to the commissioning of these
services, which has resulted in a piecemeal approach, dependent on the
availability of local voluntary organisations, such as Relate, the resource
within primary care organisations to commission a service, and the ability of a
mental health trust to provide such a service. The result is that a talking
therapy service may be available depending on the area in which one lives.
2.3. A frequently voiced concern by general practitioners is the worry that not all
those voluntary sector organisations or individuals that set themselves up as
providers of talking therapy are able to provide a safe or effective service.
Care provided by a mental health trust benefits from clinical governance and
the assurance that the highest levels of care are ensured. Equally, large
voluntary sector organisations such as Relate or Cruise, are able to ensure a
high quality service. However no such quality can be ensured by an
individual, who may or may not have appropriate qualifications, or the
infrastructure to deal safely and sympathetically with distressed individuals.
2.4. New investment in mental health services has followed the requirements of
the National Service Framework for Mental Health, with the vast majority
being invested in secondary care services, with a priority on providing for the
needs of people with a severe mental illness. This has meant that primary
care organisations can only find the resource to commission a new talking
therapy service from within current financial budgets – a difficult task when
faced with managing the deficits in acute trusts and mental health trusts.
The NHS Plan describes the introduction of 1000 primary care mental health
workers from April 2003, probably graduate psychologists, who will be able to
work in primary care providing evidence based short interventions. Their
introduction is welcomed but the concern is that they will be a scarce
resource; it is likely that each PCT will have no more than one or two such
workers.
2.5. There is evidence that the amount of anti-depressants being prescribed is
increasing significantly over the last two to three years, whilst the prescribing
of benzodiazepines is static or reducing. Indeed, compared to other parts of
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3.
4.
5.
6.
the country the amount of benzodiazepines prescribed in London is the low,
with the lowest levels seen in the Inner London areas – a practice to be
applauded.
In London an area of particular concern is providing care for people from other
cultures and ethnic backgrounds, especially asylum and refugee seekers. Their
mental health needs are poorly understood and there are few dedicated services
for their needs. Basic translation services are of variable quality, and advocacy
services are not available throughout London, which makes accurate assessment
of mental health needs virtually impossible. Even if an assessment is undertaken
the problem of finding a service that meets the needs of the individual is great –
few community mental health teams are experienced or knowledgeable at
helping refugees that speak English poorly (if at all), and have been tortured or
raped.
People with Severe and Enduring Mental Illness. Between 30 and 50% of people
with a severe mental illness are not in contact with secondary services. The
standardised mortality rate (SMR), the rate at which a specific population dies
compared to a standard population group is significantly higher in people with
severe mental illness. The SMR for cardiovascular and respiratory disease in
people with schizophrenia and bi-polar affective disorder is four times normal,
and the number who have diabetes is up to five times higher; the number who
smoke or use alcohol is also significantly raised which exacerbates all these
conditions. Managing these physical disorders is made more complex by the
severe mental illness, and remains the responsibility of primary care. The
London Regional Office has produced a training pack for GPs, and PHCTs to
improve their awareness and skills – it is free to download from the Sainsbury
Centre for Mental Health website at www.scmh.org
The numbers of people with severe mental illness is related to the degree of
deprivation of an area – the more deprived the population the more likely there
will be increasing numbers of people with severe mental illness. This is also
associated with increased mobility, difficulty in follow-up from the mental health
teams, and an increased use of alcohol and drugs. The association with drug and
alcohol misuse and severe mental illness makes the patient more likely to acquire
Hepatitis C, Hepatitis B, and HIV infections. This combination of deprivation,
mobility, severe mental illness, and significant physical health problems make
providing primary health care to these people very complex.
One significant bureaucratic barrier to accessing mental health services is unique
to London. Boundaries for general practices cross borough boundaries, as they
reflect natural communities. Community mental health teams, as they move
towards health and social care organisations, are limited geographically to
borough boundaries. This means that a practice with patients in two boroughs,
will have to relate to two community mental health teams, which reduces the
benefits of effective communication. In some parts of London where practices
have patients in several boroughs this represents a major problem. This
becomes a further problem as patients with a severe mental health problem
move from one area to another, retaining the same GP, but having to change
community mental health teams.
PCTs as Commissioners of Mental Health Services
A survey was undertaken on behalf of the London Regional Office to look at the
commissioning skills of primary care organisations to commission mental health
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services. The survey was undertaken in 2000, and although there has been some
changes in organisations, the conclusions seem equally valid.
SURVEY OF MENTAL HEALTH COMMISSIONING IN PRIMARY CARE GROUPS LONDON
One of the roles of a PCG or PCT is to commission services. A survey carried out
by the Sainsbury Centre for Mental Health looked at the knowledge, skills and
attitudes of those managers who commission mental health services. That report
showed that mental health commissioners were over worked, under skilled and
underpaid to commission services effectively. A concern that has recently been
voiced is that these few individuals who have been commissioning services for
Health Authorities will now have to commission services on behalf of PCGs, and that
their skills will be diluted. The Sainsbury Centre has repeated this survey, but this
time aimed at PCG commissioning managers, to try and assess what skills are
available to PCGs, and what their aspirations might be as regards to commissioning
and providing mental health services.
The survey was carried out in January and February 2000, 9 months after PCGs
were officially created. The survey was postal, with a follow up telephone call three
weeks after non response. The survey was undertaken with financial support from
the London Regional Office of the Department of Health.
Responses to the questionnaire was obtained from 197 PCGs of the 481 PCGs in
England, a response rate of 41%. Responses were obtained from 25 PCGs in
London, 41 did not reply, a response rate of 37.8%.
Named Clinical Lead: 147 PCGs of the 197 that responded were able to provide a
named clinical lead for mental health (in all cases a doctor). 50 PCGs did not have a
mental health lead. Nationally it can be estimated that three quarters of PCGs have
a named clinical lead.
In London 50 named leads were identified from the 66 PCGs – this figure was higher
than the postal response to the national survey, as further telephone reminders was
undertaken. Although some contact was made with all PCGs in London, it proved
impossible to get any meaningful response to the other questions from the remaining
PCGs.
Named Manager: 66 PCGs had a manager with some responsibility for mental
health. Nationally it can be estimated that only one third of PCGs have a manager
with some responsibility for mental health. Several PCGs replied that they were in
the process of appointing specific individuals to lead on mental health.
In London 13 of the 25 PCGs that responded had a manager that was responsible
for mental health.
Characteristics of the Managers: Managers were asked to describe how long they
had been working for the PCG, what their qualifications were, how much of their time
they spent on mental health, and their salary scale.
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All of the managers, with the exception of one, had other clinical areas to deal with ,
as well as mental health. A little over 90% of the managers spent less than 25% of
their time on mental health, the remainder of their time being spent on other clinical
areas.
A fifth of the managers had been working for the PCG for less than 6 months, two
fifths for between 6 and 9 months, and two fifths longer than 9 months. It should be
noted that PCGs only became live in April 1999.
Few managers answered the question about their qualifications, and even fewer
provided details of their salary scale. The responses to these questions cannot be
meaningfully summarised.
Findings for London are similar to the national picture and do not represent any
particular difference. The small number of replies make statistical interpretation
difficult.
PCG Operating Levels:126 PCGs are operating at level 2, and 21 at level 1. Level 2
PCGs should be commissioning at least 60% of their total budget, and that from April
2000 this should increase significantly. 73 of the 126 PCGs at level 2 are involved in
some way with commissioning mental health services. After April, as the proportion
of the budget that PCGs are responsible for increases, so the number that are
managing the mental health contract should increase.
The response from the London PCGs mimic the national findings with a similar
proportion operating at level 2.
Moving to Primary Care Trusts: At the time of the questionnaire, nationally 20 PCGs
were consulting about becoming a Trust in April 2000; ultimately only 17 were
successful. However 48 PCGs intend to become a Trust in 2001, and a further 23 in
2002. 36 PCGs thought that they would provide mental health services when they
were a Trust. These figures are broadly similar to those quoted in the medical press,
that a quarter of PCGs or more will apply for Trust status in April 2001, and that by
2002 over half the country will be covered by PCTs. There is no comparable data for
PCTs wishing to provide mental health services, but that on a proportionate basis
one could expect about a quarter of PCTs to seriously consider providing mental
health services, as well as commissioning the service.
The development of PCTs in London is more complex than elsewhere in the country
as the lack of co-terminosity of boundaries make configuration harder to achieve.
Thus the picture of PCT development is currently very fluid, with 2 PCTs starting in
April 2000, 2 PCT likely to start in October 2000, most of North East London and
some of South West London in April 2001, and the remainder of London by 2002.
Configuration issues present more of a problem than elsewhere in the country.
Respondents were asked about their reasons for wishing to progress to PCT status.
They were offered the following choices:
 Independence from the HA – 58% responded positively nationally
 Opportunity to provide a salaried service for GPs – 25% responded positively,
nationally
 Opportunity to pool budgets – 81% responded positively, nationally
respondents were able to reply to more than one criterion
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Other reasons that respondents felt were important in their motivation to move to
Trust status were the ability to innovate, effective commissioning, and integration of
services.
However responses in London where quite different: None of the respondents felt
that any of the three choices were appropriate, but instead felt that concerns about
complexity of service provision, managing the deficits associated with some trusts,
becoming large organisations, losing local focus, and becoming a bureaucratic
organisation were all concerns that militated against becoming a Trust. It is
interesting to note those concerns when compared with the fact that it is anticipated
by the Regional Office that all of London will be covered by PCTs within two years.
There seems to be a tension between moving towards PCT status, but concerns
about the ability to deliver, and loss of local sensitivity. It is also significant that none
of the respondents in London felt that sharing budgets with the local authority was a
significant benefit of PCT status – nationally the response rate for this item was 81%.
Although conclusions are hard to draw from this simple survey, one can postulate
that the relationship between health and local authorities would not appear to be the
same as elsewhere in England, and that are greater opportunities for closer working.
Time Commitment on Commissioning: 73 PCGs are involved in commissioning
mental health services. Like the previous SCMH questionnaire, respondents were
asked to describe how much of their time (as a percentage of the total) was spent
on particular activities in relation to commissioning mental health services:
how much time per month?
0% 25% 50% 75%
Population based needs assessment
32
5
Locality planning
15
8
7
1
Quality monitoring
28
7
3
Contracting
29
7
3
0
Primary care development
24
6
4
Joint working (PCG and LA/vol. org.)
17
10
4
0
It can be seen from this table that only 38 PCGs ( about half of those who claim to be
commissioning services) responded to this question, and that few of the PCGs are
undertaking any of these tasks. Even primary care development, post the NSF,
might be considered a likely task for mental health managers in a primary care
group, but this seems not to be the case.
The responses from London PCGs are broadly similar.
Effectiveness of Commissioning: Respondents were also asked about the
effectiveness of their work; in retrospect this is probably an unfair question, since few
have been in place longer than 12 months, and therefore not in a position to judge if
their work has been successful.
how effective
0% 25% 50% 75%
Population based needs assessment
12
5
5
1
Locality planning
3
4
6
5
Quality monitoring
13
6
6
1
Contracting
12
4
5
3
Primary care development
5
5
3
4
Joint working (PCG and LA/vol. org.)
4
5
5
4
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Care must be used in interpreting this small group of respondents, but it would
appear that they believe they are effective at joint working, primary care
development, and planning, but not effective at quality monitoring or contracting.
Respondents were also asked which aspects of commissioning worked well in their
PCG. The few that responded cited joint working with either the Trust or the Local
Authority as working well. The vast majority (over 90%) failed to reply, which may
lead to the belief that not much is working well from a commissioning perspective
Strengths and Weaknesses of Commissioning: Respondents were asked about key
strengths and weaknesses in commissioning mental health services.
Key strengths nationally were seen to be predominantly joint working, providing a
locality focus to commissioning and being more closely linked to primary care. Joint
working does not only mean closer working with the Local Authority, but also closer
working with the specialist mental health Trust, and improving the interface between
primary and secondary care. The London response was characterised by being
much more about developing primary care services, rather than the joint working that
is a national response
The major key weakness was not surprisingly seen to be lack of resources. The
survey was carried out prior to the Budget, when the Government signalled a major
investment in the NHS. It remains to be seen if despite this significant influx of new
resources, it remains a key weakness in subsequent years. Other weaknesses that
were described included:
 IT systems. Many respondents made the point that effective communication
and commissioning required accurate information, which most Trusts were
unable to supply.
 The tension that was developing between providing services for the severely
mentally ill at the expense of those with a common mental illness.
Respondents noted that they were being asked to chose between providing
services for the relatively few severely mentally ill, at the “expense” of the
much greater numbers of people in primary care with a common mental
illness. They were unhappy both at having to make a choice, and the fact that
the NSF is quite clear about prioritising the SMI, but that there is considerable
pressure from the rank and file primary care practice to provide more services
and support for people with a common mental illness.
 and the capacity of the PCG to manage the current change agenda.
None of the respondents mentioned a lack of commissioning skills as a key
weakness.
Key weaknesses in London far outweighed identified strengths, and not surprisingly
the major concern was the tension between providing services for severe mental
illness, as opposed to care for mild to moderate mental illness.
Finally respondents were asked to describe how they changes they wished to see in
place to improve mental health commissioning. Three responses were consistently
provided:
1. Effective joint working – not only with the Local Authority, but with the
secondary services, a relationship that is build on mutual trust and partnership
2. Effective IT systems – effective commissioning seems to be impossible
without effective information systems
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3. Supporting Primary Care – by building services that support primary care to
deliver high quality mental health services
Discussion: This survey has a reasonable response rate, and so far as describing
the characteristics of PCGs nationally, and in London, fits with other surveys and
samples.
The responses in relation to mental health are interesting in that they start to
describe a mismatch, between aspirations and capacity. 73 PCGs believe that they
are actively commissioning mental health services, yet only 66 PCGs have a
commissioning manager, 90% of whom spend less than 25% of their time devoted to
mental health.
Few PCGs responded to the questions related to effectiveness of commissioning,
and it may be too early to be able to point to changes that identify effectiveness.
Responses to key strengths and weaknesses are characterised by the lack of
response, rather then a particular theme. Although PCGs seem unable to identify if
they are working effectively they seem much clearer about what would make some
their task more effective: better IT systems, more effective joint working, and better
support for primary care.
The survey supports findings already described that many PCGs are looking to
progress rapidly to PCT status. About a quarter of aspiring PCTs are considering
providing mental health services, as well as commissioning the service. At present,
there is no central guidance on the character and quality of what services might be
provided by a PCT, and it is unclear what aspiring PCTs will be delivering that is
different to the current provision.
Aspiring PCGs were clear however about the benefits of moving to PCT status, and
it is remarkable that the vast majority see pooled budgets, and joint working as the
major benefits. A salaried service for GPs was not seen as a particular inducement,
but independence from the Health Authority was a significant reason.
A London response:
By and large the responses from London PCGs mimic the national picture – with
some interesting and worrying differences. The most significant findings that differ
from the national picture are:
a) PCGs in London appear not to appreciate the benefits of closer working with
the Local Authorities, and pooling budgets. This is an area that needs further
investigation, as there are numerous possible explanations, but it is
recommended that the Regional Office identifies further developmental work
to investigate this issue.
b) The tension between SMI and MMI services is much more starkly drawn in
London compared to elsewhere in England. This response, although
predictable, is nevertheless disappointing, and again requires further
developmental work sponsored by the Regional Office to understand exactly
what this tension means, what its consequences might be, and what specific
actions are required to improve services.
Item 04 Appendix D
Conclusion: The pace of change to Trust status, and the desire of PCGs to both
commission mental health services, and in some cases to provide mental health
services, does not seem to be met by the management infrastructure, knowledge
and skills to support these aspirations. The weaknesses identified in mental health
commissioners at Health Authority level seem to have been multiplied five fold, as
PCGs take on this responsibility.
Update:
Since this survey has taken place there has been continuing links with primary care
organisations commissioning mental health services.
Significant changes have occurred both in primary care with the creation of over
30PCTs, but also the development of just 10 mental health trusts to provide care to
the whole of London. Each of these Trusts are very large and dwarf the PCTs that
commission the service. There is an increasingly voiced fear by PCTs that they are
not in a position to significantly influence mental health trusts, but have to accept the
service that is provided. A service has been secured for the population, rather than
a service being commissioned by a PCT that meets the needs of the local
population.
As an example, South West London and St Georges MH Trust provides a service to
5 boroughs in SW London. That service model is the same for all the boroughs even
though the needs of the boroughs may be different. The Trust understandably says
that it can only provide what is stipulated in the national service framework, nor can it
be expected to provide different models of care in different boroughs. Thus the
room for commissioning a service that meets the needs is extremely limited; linked to
the capacity of the PCT to commission effectively as demonstrated in the survey, it is
not surprising that PCTs feel disempowered from developing mental health services.
Item 04 Appendix D
References and Further Reading:
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with schizophrenia. Psychological Medicine (1999) 29 697–701.
Brown, S., Inskip, H. & Barraclough, B. Causes of the excess mortality of schizophrenia.
British Journal of Psychiatry (2000) 177 212–7.
Burns,T & Cohen,A. Item of Service payments for general practitioner care of
severely mentally ill patients: does the money matter? British Journal of General
Practice (1998) 48 1415–1416.
Cohen,A. & Paton, J. (1999) A Workbook for Primary Care Groups. London:
The Sainsbury Centre for Mental Health.
Cohen,A. & Singh, S. (2001) A General Practitioner’s Guide to Managing Severe
Mental Illness. London:The Sainsbury Centre for Mental Health.
Department of Health (1994) On the State of the Public Health – Annual Report
of the Chief Medical Officer. London:HMSO.
Department of Health (1999) The National Service Framework for Mental Health.
Goldman, L.S. Medical illness in patients with schizophrenia. Journal of Clinical
Psychology (1999) 60 (suppl 21) 10–15.
Gournay, K. Setting clinical standards for care in schizophrenia. Nursing Times (1996)
92 36–37.
Harris, E.C. & Barraclough, B. Excess mortality of mental disorder. British Journal
of Psychiatry (1998) 173 11–53.
Heath Education Authority (2000) Physical Activity and Mental Health – National
Consensus Statements and Guidelines for Practice.
Jeste,D.V., Gladsjo, J.A., Lindamer, L.A. & Lacro, J.P. Medical comorbidity in
schizophrenia. Schizophrenia Bulletin (1996) 22 413–27.
Kendler, K.S. (1986) A twin study of mortality in schizophrenia and neurosis.
Arch of General Psychiatry 43 643–649.
Kendrick,T. et al. Randomised controlled trial of teaching general practitioners
to carry out structured assessments of their long term mentally ill patients.
British Medical Journal (1995) 311 93–98.
Kendrick,T., Burns,T. et al. Provision of care to general practice patients with
disabling long term mental illness – a survey in 16 practices. British Journal of
General Practice 44 301–305.
Koran, L.M., Sox, H.C., Marton, K.I. et al. Medical evaluation of psychiatric patients. 1.
Results in a state mental health system. Arch Gen Psychiatry (1989) 46 733–40.
Makikyro,T., Karvonen, J.T., Hakko, H., Nieminen, P., Joukamen, M., Isohanni, M., et al.
Comorbidity of hospital treated psychiatric and physicaldisorders with special
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general population birth cohort. Public Health
(1998) 112 221-8.
Melzer (1995) D. OPCS Surveys of Psychiatric Morbidity in Great Britain: Report 1.
London:HMSO.
Nazareth et al. Care of Schizophrenia in General Practice. British Medical Journal
(1994) 307 910.
NHS Executive (1999) Health Service Circular (HSC 1999/107). London: NHSE.
Paffenbarger, R.S. Physical activity, all causes of mortality, and longevity of college
alumni. NEJM 314 605–613.
Phelan, M., Stradins, L. & Morrison, S. Physical health of people with severe mental
illness. British Medical Journal (2001) 322 443–444.
Rigby, J.C. & Oswald,A.G.An evaluation of the performing and recording of physical
examinations by psychiatric trainees. British Journal of Psychiatry (1987) 150
533–335.
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Department of Health. The National Service Framework for Mental Health. 1999.
HMSO. Reform of the Mental Health Act (1983) Consultation Document. 1999.
Royal College of General Practitioners. Profile of UK Practices. 1997.
Royal College of General Practitioners. General Practitioner Workload. 1997.
Primary Care Subgroup – Workforce Action Team, National Service Framework for Mental Health
2000
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