Earlier today, I saw a link on Twitter for an article in the Health Service Journal entitled “Fears over mental health gap in commissioning knowledge.” The piece argues that despite revisions, the Health Bill will be problematic for the provision of mental health services – something I’ve been worrying about for a while now.
For those who are not familiar with the commissioning process in health, until the coalition Government took power, each local area had a body called a Primary Care Trust (PCT). PCTs represented all the providers of primary care (the first level of care we usually access – community based care such as GPs and practice nurses) but was independent of them. It was the PCTs’ job to review the health needs of the specific local communities they served, and commission and fund secondary care services (hospital in-patient and out-patient services, usually under a Consultant) and tertiary care services (highly specialised services, e.g. a regional cancer centre).
The main thrust of the Government’s health reforms is the removal of commissioning from PCTs – which were abruptly disbanded shortly after the election – and placing it in the hands of consortia of GPs. Who knows patients and local needs better, the logic runs, than GPs? As soon as this sweeping change was announced, I was concerned about the impact on mental health service commissioning. GPs by their nature have to be generalists, and few have in-depth knowledge of mental health issues. My own GP is endlessly patient and supportive, but recognises that her expertise in the are of mental health and specialist prescribing is limited. She’s not alone; the mental health charity Rethink undertook a survey of GPs towards the end of last year and found that “over half of GPs (54%) said they found people with severe mental illness hardest to engage with, while more than four in ten (42%) said they lacked knowledge about specialist services for people with severe mental illnesses such as schizophrenia and bipolar disorder.”
Let’s look at that again. These are the people who are being made responsible for commissioning services for people with mental health difficulties, but more than half of them struggle to engage with people experiencing serious mental illness. Nearly half don’t know enough about the kind of services available or needed for severe or enduring mental illness, but they are being asked to commission them anyway. A survey conducted in the mid-nineties found that only 35% of GPs had undertaken any course on mental health in the last three years, and another found that only half of all GP trainees had completed a placement in psychiatry during their training (more details here), and this unlikely to have improved much in recent years, with psychiatry become a less and less popular option for qualifying doctors.
GPs may be dedicated, caring, and hard-working, but they are human. Individual doctors, and indeed GPs as a group, sometimes display prejudices about certain patient choices or lifestyles; for example, having mostly attended only deliveries requiring intervention, many are vehemently anti-homebirth even for uncomplicated pregnancies. Drug misusing clients sometimes complain to me that their GP does not want to be involved in their treatment or recovery, and the UK Drug Policy Commission agrees that negative GP attitudes towards substance misusers can be a hindrance to treatment. Given that there is so much stigma surrounding mental health, it would be surprising if negative attitudes towards mental health users were not found among GPs. A survey conducted by the Royal College of Psychiatrists in 2001 found that 40% of people approaching their GP felt stigmatised and discriminated against, and the Royal College’s guidance states, “we doctors need to admit to any stigmatising attitudes, and to check our thoughts and behaviour repeatedly – just as we do with other areas of discrimination.”
Following its “listening exercise”, the Government has acknowledged to need to have other healthcare professionals such as nurses and hospital doctors on consortium boards, but as yet there is no mental health trust representation. Specialist mental health provision will be commissioned without the input of psychiatrists, psychiatric nurses, Approved Mental Health Practitioners – or service users. I participated in Mind’s service user consultation exercise expressing my exactly these concerns about GP commissioning. Mental health care is patchy and under-funded enough as it is; mental health care commissioned by people who are uncomfortable with mental health service users and aren’t sure what services they need is a recipe for disaster.