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Mental health needs must get the same attention and treatment choice that other acute services do

World class commissioning is the new buzz word in the department of health (DH) and underpins all hopes of delivering Lord Darzi's vision for the NHS. In a marketised NHS, where payment by results is set to reign, it stands to reason that the buyers (the PCTs) know what they want and how much they want. However, a recent report in the Health Service Journal suggests that we are a long way off a world class commissioning framework.

Many PCTs are struggling with any credible data defining where they are in commissioning services and, without knowing that, it is pretty impossible for them to know their ultimate destination. PCTs are key to reshaping services and getting a better fix on measurable outcomes, yet many are nowhere near even discussing this. As Gary Belfield, the DH commissioning director, recently asked at a conference: "Would the board of Tesco manage to get through a meeting without discussing food?"

PCTs in many parts of England are expressing plenty of vague notions about improving sexual health, reducing obesity and so on, yet very few have any clear view on how such things are to be achieved.

Acute services also dominate the commissioning agenda, probably because things like operations and diagnostic interventions are easier to count and measure. But even here there are some PCTs who are far from clear about what they are buying, how much of it they are buying, and the quality of what they are buying. This presents a grim picture indeed, but things get much worse when we consider the provision of care to mental health patients.

In specialist areas of mental health, eg forensic and medium secure services, PCTs and SHAs in some parts of the country really have their act together. NHS North West, ably led by Carol Jobbins, has a well thought out strategy for knowing what they are buying, controlling the costs and keeping an eye on quality. Regrettably, not all health economies are as well organised as the North West.

In acute care the commissioning agenda is designed to increase choice for patients. GPs now have to offer patients a range of providers, including private sector providers for elective surgery and a range of diagnostic services.

For the mentally ill, choice is extremely limited. With few large Mental Health Trusts, the concept of choice is not available in most parts of the country. If you are mentally ill in most large cities, your local NHS Mental Health Trust is the only show in town and you have to put up with it. Even within a large Mental Health Trust, the empire will be divided up into geographical patches for general mental health services and most patients will not be able to access services outside their patch.

The newly elected president of the Royal College of Psychiatrists recently interviewed by the Observer suggested that he would not want his family members admitted to many acute inpatient units in the NHS. This is a pretty damning indictment of the state of acute services and would create a national scandal if the same was said of cancer services.

So what is the problem in mental health? The real problem is that in many PCTs commissioning of bread and butter services is delegated to mental health providers. The PCT simply gives a huge envelope of money to NHS providers and leaves them to spend it as they see fit. In these circumstances there is no incentive for the NHS Trust to seek clinically acceptable alternatives outside the NHS. This leads to inefficient spot purchasing of individual beds in the independent sector. It also means that very distressed patients needing inpatient care are shunted around the system and that the only factor determining their care is financial, with little or no consideration given to the views of patients or their individual needs.

In these circumstances the PCT abrogates virtually all responsibilities to NHS providers, which is also dishonest because the provider has no incentive to change behaviours. I have spoken to many independent sector mental health providers who tell pretty damning stories of patients being let down badly by a system that treats them as no more than a number, where their rights and views on service options are not even asked for. They are voiceless consumers with no choice of any kind.

In situations where the PCT actually commissions mental health services, it is often the case that commissioning is led at sub-director level in the organisation. Public health and acute activity will be led at a much higher level, with many more staff devoted to the commissioning process. In mental health commissioning you will be lucky to find anyone at the top of the pile who takes any real ownership of mental health issues and certainly few champions. Regrettably this lack of senior clout is too often repeated at the SHA level.

There is a real need for every PCT and SHA to identify a director level mental health lead who has the status and the authority to ensure that world class commissioning starts to have a real impact on services for the mentally ill. Nothing less will do.

No voice
Apart from commissioning, mental health has other choice-related problems. In acute mental illness there is evidence from reports from the Healthcare Commission, the Mental Health Act Commission and various voluntary organisations like MIND that people are offered little real choice or voice in their treatment options.

An acute episode of mental illness will too often involve being given hefty doses of anti-psychotic medication and little else by way of planned therapeutic intervention. Medication is, of course, an important arm of treatment, but we should still be able to discuss with patients options and choices around the medication being offered, including providing good information about the medication and its potential risks and benefits. This is not happening in many services and users deeply resent this.

Beyond medication we know that a holistic approach to care is vital in offering hope and recovery. Housing, leisure opportunities, paid and unpaid work opportunities, psychological therapies and other aspects all assist in the recovery process. Despite this, users often complain that their experiences of services fail to offer this wider range of options, especially when detained against their will under a section of the Mental Health Act.

We have made significant progress in shifting services out of an institutional environment and undoubtedly improved timely community-based interventions. We can now offer better medicines with fewer damaging side effects and at least there is more therapeutic optimism in mental health than a decade ago.

Yet despite these improvements, we still have a long way to go. If world class commissioning is meant to drive up the quality of services to patients through increased choice and a stronger voice for the patient, then so be it. There has to be equal drivers in all NHS services, including mental health, where patients and families living with mental illness can expect the same rights as people with cancer or diabetes.

Regrettably the social stigma associated with mental illness remains a blight in modern Britain. If services fail children or patients with heart disease there is rightly a huge public outcry. When it comes to services failing the mentally ill, people with learning disabilities or older people with dementias, there is little public interest and no real priority in the realm of policy-makers to be bold or challenging. In short, mental health is not politically sexy.

An alliance of mental health charities recently called for a minister at cabinet level to be designated for mental health, with the power to roam freely across Whitehall and champion the needs of people with mental health needs. Not a bad idea but, without real change in how services are actually commissioned and a real strategy to challenge the appalling stigma associated with mental illness, I suspect a minister in Whitehall would make little difference.

If world class commissioning is the answer to driving up quality in the NHS, then let's simply ensure that people with mental health needs get the same attention as all other users of the NHS from those charged with commissioning services in the future. We might then witness real change and progress in the provision of services and see real choice being exercised across a more diverse range of services, not dominated by a monopolistic and monolithic NHS structure.

The Author:
Ray Rowden is a health policy analyst

31st October 2008


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