The NSF for Mental Health

The NSF for Mental Health sets out quite clearly, among other priorities, that it is the role of the specialist mental health trusts to prioritise people with severe mental illnesses (which GPs perceive as almost always meaning psychotic illness). It is not appropriate to discuss here the definition of severe mental illness, nor the appropriate ness of the priority placed on specialist mental health trusts; it is, however, appropriate to consider the consequences of this decision and how it has affected clinical services.

The National Service Framework: a barrier to referral…

The clear priority placed on severe mental illness caused CMHTs, and the subsequent ‘functional’ teams, to set up clear access criteria for referrals made from primary care. Although the rationale for such criteria seemed clear to those delivering the care, the perspective from general practice was that specialist mental health services were withdrawing services, becoming less accessible and less part of mainstream care.

The Policy Implementation Guide for Community Mental Health Teams (Department of Health, 2000a ) made clear the role that they should play in working with primary care services, and how CMHTs should provide a consultation service to general practice. Nevertheless, the experience of GPs was that the shift to functional teams was carried out at the expense of CMHTs, as staff were moved from the generic teams into the new units. General practitioners felt that the personal relationship built up with individual psychiatrists and practice-attached community psychiatric nurses was being undermined, as CMHTs attempted to manage larger and larger areas. The CMHTs became smaller as the new functional teams started up; GPs had to relate not only to the CMHT, but to the crisis resolution team, and the assertive outreach team and the rehabilitation team, and to learn which team was responsible for which type of patient. It seemed to GPs that people whom they were not confident to manage were being denied a specialist opinion.

… and a barrier to treatment

In so far as depression and anxiety were concerned, it was clear that psychological therapy services were an important evidence-based intervention. Access to these services, run by specialist mental health trusts, was via referral to CMHTs, yet patients with anxiety and depression did not meet the newly described access criteria for the CMHTs or the functional teams. Thus, a direct consequence of the NSF setting out so clearly the priority that specialist mental health trusts should provide care to people with severe mental illness was that other mentally ill patients were denied reasonable access to a service that primary care could not provide.

At the time, primary care services did not have alternatives: GP fundholding was being abolished and practice-based commissioning (discussed below) had not yet been introduced. From a primary care perspective, people who needed an evidence-based intervention – psychological therapy – were being denied it because they were not ill enough. General practitioners felt that they were being accused either of making many inappropriate referrals to specialist services, or prescribing too many antidepressants inappropriately. They found them selves between a rock and a hard place – there were patients that they knew they could not manage with confidence in primary care, yet they were unable to refer for a specialist opinion. And whatever clinical line they chose, it would be likely not to provide the best out come for the patient, and neither would it improve relationships between primary and secondary care. This really had to be the most unplanned consequence of a clear and, at first sight, appropriate policy decision.

Graduate primary care mental health workers

In an effort to address what was becoming a significant problem for primary care, and more so for the vast number of people being denied access to evidence-based care, the concept of the graduate primary care mental health worker (Box 1) was introduced in the National Health Service (NHS) Plan (Department of Health, 2000b ) and subsequently supported by best-practice guidance (Department of Health, 2003).

The outcomes of this initiative have been reviewed by Reference Harkness, Bower and GaskHarkness et al (2005), who found that:

1. • fewer mental health workers than planned were employed, although the distribution across the country was variable; 40% of those interviewed reported that they intended to seek work elsewhere in the NHS;

2. • about two-thirds managed patients, but access was often restricted (half of patients were reviewed by a mental health professional);

3. • types of patients seen, and interventions provided, were generally in line with current guidelines;

4. • the degree of integration into primary care settings of individuals trained in mental health environments was a significant predictor of their success.

The management frameworks

Stepped care

The evidence collated in the NICE depression guidelines informed the development of a stepped care model to guide management of the disorder (Fig. 1). This framework represents a major advance: it clearly states who should provide what sort of care to treat depression presenting at different levels of severity and risk.

Fig. 1 The stepped care model (National Collaborating Centre for Mental Health, 2004: p. 52).

A mixed message?

One of the criticisms that I heard levelled at the guidelines is that clinical experience, supported by Office for National Statistics data, indicates that the most common presentation is a combination of anxiety and depression: having separate frameworks for the management of these conditions serves only to confuse clinicians and patients alike.

Both NICE guidelines recognise that the two disorders present in combination, but resolve this problem by recommending that the depressive element be managed first, and once the depression has lifted, that the anxiety be tackled. A review of this approach is overdue, as it is not clear that the evidence points to this as the most effective strategy. It is interesting that neither guideline group reviewed any papers that intentionally compared the different approaches to managing mixed anxiety and depression; the advice was based solely on clinical experience. It is perhaps a failing of research practice that some of the most important questions in clinical practice cannot be easily answered using current research methods.

Recommended interventions

Although the two guideline groups recommend a different organisational approach to the management of depression and of anxiety, the types of intervention recommended are very similar and fall into four main categories: watchful waiting, self-help, psychological therapy, medication.

The GP contract and QOFs

To that end it is worth spending a little time discussing the new GP contract (NHS Employers, 2004). Less than 10% of GPs are salaried – the vast majority are self-employed. In 2004, following 2 years of negotiation, a new contract was introduced for GPs seeing patients within the NHS. This differed from previous contracts in a number of important ways, but so far as this discussion is concerned, the major difference was the introduction of the ‘quality and outcomes framework’ (QOF). The QOF provides GPs with a financial incentive to deliver high-quality, evidenced-based essential care. Essential care – defined for the first time in the 2004 contract – is the care that all general practices are expected to provide. To incentivise the quality of that care a framework was developed that accounts for about 20% of a GP's earnings.

The concept underpinning the QOF is that points are awarded to each practice for the delivery of specified processes or outcomes in four domains: clinical, organisational, patient care experience, and additional services. Each point has a financial value. Outcomes are specified and evidence based, and in view of the fact that the evidence base changes and develops over time, the QOF is reassessed every 2 years to review new research and to make changes where appropriate.

In the clinical domain, outcomes relate to the management of various clinical (mostly long-term) conditions, for each of which a number of indicators are specified. Achieving each indicator is rewarded with points from the total number available for that condition. It should not be forgotten that the new GP contract would be for all GP practices offering services under the NHS, and that remuneration and earnings would be related to aspects of care. It was therefore imperative that the indicators were specific, recordable on practice computer systems and accurately described the care provided, and also that the opportunity for ‘gaming’ (completing the indicators but not completing the intent and purpose of the clinical intervention) was minimised.

Depression was not among the conditions listed in the clinical domain in the first QOF in 2004. However, in the 2006 revision (NHS Employers & General Practitioners Committee, 2006), extensive changes were made to the mental health indicators, and depression was allocated its own share of points. In the 2006/7 QOF, 1000 points were available, of which 655 related to the clinical domain (Box 2).

Box 2 Points summary for the 2006/7 QOF clinical domain

Condition	Points
Coronary heart disease	89
Diabetes mellitus	93
Heart failure	20
Hypertension	83
Smoking indicators	68
Asthma	45
Mental health	39
COPD1	33
Depression	33
Atrial fibrillation	30
Chronic kidney disease	27
Stroke or transient ischaemic attack	24
Dementia	20
Epilepsy	15
Cancer	11
Obesity	8
Hypothyroidism	7
Pallative care	6
Learning disabilities	4
Total	655

The two indicators for depression (Box 3) were drawn directly from the NICE depression guidelines – a good example of the process of moving from research, to the review of evidence (through the NICE guidelines development process), to engagement (by the creation of a specific QOF domain based on the depression guidelines). These indicators are the only two that the expert clinicians, negotiators and administrators involved developing the GP contract believed could accurately be introduced for depression. The experts were unable to develop an indicator that linked the intervention offered to the severity of the depression – although this is a natural next step in the development of the depression QOF.

The impact of the inclusion of depression in the clinical domain is hard to judge, since it has only had a year of implementation. If the depression indicators are accepted by GPs, the UK will be the first country in the world in which primary care clinicians routinely use questionnaires to assess severity of depression and link this to an appropriate intervention.

An interesting by-product of the QOF process is that (in theory) every practice now records the same data, which are downloaded to the PCT, and hence to a central virtual warehouse of data, to provide evidence for payment. This warehouse could provide enormously valuable information about a whole range of clinical conditions, including depression, indicating for example the proportions of people with mild, moderate and severe depression – data that are currently unavailable.