April heralded the full implementation of the Government’s new framework for commissioning NHS patient services. Control of the larger part of the NHS budget has now passed from Primary Care Trusts to some 212 Clinical Commissioning Groups (CCGs).
These CCGs are GP-led, and Government ministers believe they will be more attuned to and therefore better able to commission care that meets the needs of local populations and individuals, as well as make the NHS more efficient and improve quality of care.
In the arena of primary care psychological health, the extent to which the new framework will live up to expectations and deliver more effective and efficient services to patients will be influenced by two critical and related factors. First is the Government’s intention to establish parity between physical and mental health; second is the emergence of technology-based solutions to mental health problems.
Figures from the Psychiatric Morbidity Survey (PMS)1 show that the proportion of the population likely to be suffering a common mental disorder (CMD) – anxiety, depression, phobias, mixed anxiety and depression – is around 15 per cent. Based on UK census data,2 that would mean almost eight million people have a CMD. Even in the unlikely event that the IAPT programme reaches its target of treating 900,000 per year, this still leaves an enormous level of unmet need.
There will be no further resources in CCG budgets to achieve the required parity between physical and mental health, that much is clear. We cannot pretend that psychological therapy will fill the unmet need; there will need to be radical solutions, because failure to achieve something that looks like parity will not be an option. It will fall to CCGs to find creative ways to implement new solutions and extend their reach.
The NHS Confederation3 advocates e-mental health as part of the answer – web-based platforms enabling the delivery of therapy to individuals and groups online, sites like the Big White Wall that offer self-help, peer support and online therapy, and apps, either as aids to patient management or as stand-alone solutions. For the latter, think of a digital version of books on prescription and you won’t be too wide of the mark.
There are undoubtedly some people who, although significantly troubled, are nonetheless resourceful and will be able to benefit from a minimal level intervention, whatever that may be. What concerns me about the drive for parity is the form it will be seen to take, and whether our current imperfect system will be further compromised by the introduction of a range of new interventions whose effectiveness it may be difficult to properly evaluate.
What of counselling and psychotherapy in this brave new world? Forever the optimist, I believe there are opportunities. Setting aside the protection of vested interests, some commissioners will be prepared to buck the current trend and commission outside the list of NICE-compliant therapies if the alternatives offer demonstrable advantages (such as quicker access to treatment) for their patients. It is also likely that more therapies will be approved by NICE over time, giving greater meaning to the notion of patient choice. Whatever form these new therapies take, however, they will need to be demonstrably effective.
And remember that, while CCGs will control much of the NHS budget, it will be limited to around 60 per cent of the total. Individual GPs also have their own practice budgets, as the following example of a BACP member demonstrates.
The member in question has a contract for service with a GP practice that was due for review. The practice values her service in terms of speed of access and client feedback, but wanted to know how her outcomes compare with IAPT benchmarks. She was already routinely using both PHQ-9 and GAD-7 so, with a little guidance, she was able to work out the proportion of her clients who recovered, using the IAPT model.
In all, 77 per cent of her clients reached the criteria for recovery. The highest reported IAPT PCT recovery rate for which there were finalised data at the time was 72 per cent. Our member had broken the IAPT ceiling – albeit based on PCT mean recovery rates – by some distance. That’s a nice message to be able to take to your commissioning GP.
1. NHS Information Centre. Adult psychiatric morbidity in England, 2007: Results of a household survey. Leeds: NHS Information Centre; 2007.
3. NHS Confederation Mental Health Network. E-mental health: what’s all the fuss about? London: NHS Confederation; 2013. http://www.nhsconfed.org/Publications/discussion-paper/Pages/E-mental-health.aspx