Viewpoint: GP approach to commissioning mental health services

NHS Future Forum member Lord Victor Adebowale, head of social enterprise Turning Point, writes exclusively for GPonline.com about GPs and their approach to mental health service commissioning.

Mental health treatment must be ‘different’ and tailored to the needs of the individual, to their values and culture
Mental health treatment must be ‘different’ and tailored to the needs of the individual, to their values and culture

Those with mental health conditions are among the most vulnerable and most misunderstood in our society. They place the greatest demands on health services but feel disenfranchised by the NHS. The Health and Social Care Bill puts GPs at the heart of commissioning which raises the issue of how much expertise they have in the complex area of mental health.

The assumption is that doctors clearly understand the needs of their local communities and that also means people with mental health issues. But patients who access primary care tell a different story, including those who also have drug and alcohol issues. Turning Point polled its own service users and nearly half doubted that GP-led commissioning would give them a greater say in their treatment.

There were several reasons for this pessimistic response. Many complained their doctor did not spend enough time with them and was unaware of their real problems. Others felt their GP was not interested, did not listen to their needs or even understand all of them.

Turning Point Survey
Turning Point also commissioned a separate survey of 250 doctors from ICM. This found that more than a third (38%) of GPs predicted that consortia would need a lot of support to commission mental health services effectively. The vast majority (98%) thought that some level of support would be needed.

These findings are a cause for concern. GPs must engage with residents in their practice areas, not just their own patient lists. I believe that GP consortia should be certified in work to engage with their local community before they participate in commissioning local services.

Of course, it will be difficult for doctors to get these services right. A history of incarceration and over-use of medication means there is still widespread mistrust among patients towards treatment. The days of the Victorian asylums are long gone but we must not forget the case of Jean Gambell, sectioned in 1937 after being wrongly accused of stealing two shillings. For 70 years, she was ‘lost’ in the system - and to her family - until her brothers tracked her down to a care home in 2007.

The public's view of mental health
GPs will not only be up against hostile patients but also a fearful public. To suffer from depression or a psychiatric illness still carries massive stigma. A YouGov poll (2007) revealed that less than one in five people (19%) would be comfortable living next door to someone with a mental health problem. And doctors will have to get accustomed to being blamed if someone diagnosed as mentally ill kills. Editors rarely acknowledge the challenges of managing a complex psychiatric illness. Instead, they focus on the sensational details of such cases where a psychiatric patient murders someone or commits manslaughter.

The right treatment
The mental health sector has made progress in making services ‘people-centred.’ In many cases, doctors now realise a prescription alone is not enough to improve the health of someone with depression or an anxiety disorder. Yet some sections of the community still feel disenfranchised, especially black and minority ethnic populations (BME).

There is even evidence the mental health system is systematically racist, a concern highlighted by reports including Breaking the Circles of Fear (Sainsbury Trust, 2002), Inside Outside (DoH, 2003) and the inquiry into the death of David Bennett. The Count Me In census presents a consistently bleak picture year in, year out. In 2010, it confirmed that black and white/black mixed groups were more likely to be detained under the Mental Health Act compared with the average for all inpatients (CQC, 2011).

Breaking the cycle
The UK’s complex ethnic mix will only increase and mental health services will have to respond to this trend. An effective system should address the needs of many, not just a few. Whitehall is beginning to realise the importance of equality of access. Breaking the Cycle, the recent government criminal justice green paper, acknowledges the findings of the Bradley review and the importance of diverting those with mental health difficulties away from the criminal justice system where appropriate.

There have been other promising steps forward. These include a drive to increase the accessibility of talking therapies for younger and older people, and access to support for the BME population which builds on the gains achieved by the Improving Access to Psychological Therapies programme.

Treatment and services
‘Equal’ treatment is not the answer. Treatment and services must be ‘different’ and tailored to the needs of the individual, to their values and culture. Mental health needs should be treated in the same way as disability, from the viewpoint that patients are individuals living with multiple-problems.

Turning Point’s surveys highlight two fundamental issues. Our service-users question the ability of GPs to understand their needs and GPs themselves believe consortia will need support in commissioning mental health services.

Commissioning is the means by which we understand the needs of an individual and/or community and so build a platform for procurement. This means commissioning consortia must make understanding the needs of service-users central to their actions. It is only this which will ensure that our mental health services are accessible for the least engaged in the community.

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