Published: 29/07/2004, Volume II4, No. 5916 Page 28

New services must not overshadow existing ones, say Paul Mullin and Margaret McArthur

Boosting primary mental healthcare, setting up new teams and implementing the national service framework - mental health providers and commissioners have a tough agenda ahead of them.

How can new services be introduced while existing teams are supported and developed at the same time?

Meanwhile, designing and implementing a development path for existing services is a challenge in itself, not least when these are known and loved by the people who have built and sustained them.

Any new teams will rely on there being other services in place to support the many clients who do not meet their tight eligibility criteria. But even if you have the resources to simply bolt on new teams without disinvesting in current services, staff may migrate to glamorous new projects, leaving established teams with practical problems and an identity crisis.

At Bedfordshire and Luton community trust, our patch spans two local authorities and three primary care trusts. There is some significant deprivation, particularly in Luton and also more rural and affluent areas.

The resource base is very low, with the Bedfordshire PCTs being the second furthest from capitation funding in the whole country. A recent audit showed the county spent 27 per cent below the national average.

The community trust itself has had a difficult history: two years ago it was a no-star organisation with a bad local press, a 5.3 per cent overspend, a Commission for Health Improvement investigation pending and a public interest report into the collapse of its finance function.

When the Centre for Mental Health Services Development (now part of the Health and Social Care Advisory Service, or HASCAS) was called in 18 months ago to help develop a model for mental health services, the local view was that a merger with a neighbouring trust was virtually inevitable.

With a new management team, however, the trust has gathered strength, is in financial balance and poised for partnership trust formation. Arriving at the vision and the detailed development strategy behind it has taken a considerable investment of time and energy.

Sallying forth with PIG in hand (That is Department of Health policy implementation guidance to the uninitiated) only takes you so far.

Its emphasis is on new services, and even then there has been little attempt to advise on what approach to take in areas that may have less need for new assertive outreach or crisis intervention services. It was necessary to understand local starting points in some detail to find the best fit between national policy and local needs.

Finding a positive development path for the existing community teams was paramount. Staff felt that new teams were being set up at the expense of existing services.

At the same time, community mental health teams were accurately perceived as thinly spread and struggling to offer the support needed by users and primary care colleagues.

While common sense dictated that the presence of so many new services must reduce the workload of the existing teams, this was not easy to quantify.At the same time the difficult financial context meant that commissioners were struggling to find resources to fund the list of 'must do's'. Surely it would be possible to reinvest resources from the older-style services to the new?

HASCAS reviewed community teams to offer staff clarity on the future direction for their services and to ground the issues of reinvestment. A survey of care coordinator caseloads quantified the likely level of needs for different types of service.

One unexpected outcome was to highlight a group of service users who could benefit from an assertive outreach approach in one of the more affluent and rural PCTs, helping to lay to rest commissioning concerns about how to establish services appropriate to this area.

Next we needed a detailed account of existing resources.

Once these were pinned down it became possible to review their size and skill mix in relation to indicators of future workload and policy guidance.

We also had to consider the roles and functions of community teams.Was there a gap in the market they could still legitimately fill? DoH guidance proposed three main functions:

enhanced support to primary care, shorter-term and acute interventions and longer-term support for clients with more enduring illness but who engage straightforwardly with services.

Staff workshops confirmed these broad functions as relevant and legitimate.

There was a keenness from many to do more of their work in the less stigmatising setting of primary care while remaining part of CMHTs, although it remains to work out the detail of how this will dovetail with plans to develop primary mental healthcare within PCTs. The challenge will be to ensure that each of the three broad team functions are complementary and not competitive.

Another challenge is establishing the best team configuration to provide effective support towards recovery for clients with longerterm needs. Rehabilitation and recovery has featured little in the guidance and is an area where we must plan in the dark.

But a significant number of clients locally will continue to need this type of support, so the preference is to try to resolve this within CMHTs.

Whole-system change of this magnitude in a complex care arena has no simple endpoint. A planned survey of all service users will provide a much more detailed and person-centred view of needs.

There is still a lot to do, but reviewing the way the whole mental health system functions rather than simply bolting on new teams offers the prospect of service transformation.

Paul Mullin is chief executive of Bedfordshire and Luton Community trust.Margaret McArthur is a senior consultant at HASCAS and an independent consultant.