The new national service framework for mental health has challenging implications for primary care groups. It states that anyone who contacts their primary healthcare team with a common mental health problem should have their needs identified and assessed and be offered effective treatments, including referral to specialists if required. The framework also requires evidence of the availability of 24-hour services.
But the policy of a primary care-led NHS may lead to conflict with government-led initiatives to focus care on severe and enduring mental illness.
1There is likely to be considerable variation in primary care providers'ability to respond to the expanded role envisaged in the framework, according to the results of a survey we have conducted.
The national evaluation of PCGs and primary care trusts is led by the National Primary Care Research and Development Centre, in conjunction with the King's Fund.
We plan to survey a sample of 72 PCGs every year to determine how they perform their key functions of improving the health of the local population, developing primary and community health services, and commissioning secondary and tertiary services.
The first survey, in September-October 1999, comprised postal questionnaires and interviews with PCG chief officers and chairs, and the PCG lead at the local health authority. Questionnaires were also sent to PCG board members and clinical governance leads. Most of the results presented here were collected in interviews with the PCG chairs.
Provision and policy Almost a third of the PCGs surveyed had identified mental health as a priority for improving the health of the population. Two-thirds had designated an individual with lead responsibility for mental health, commonly a GP.But there was little indication that the organisational and governance arrangements of PCGs and PCTs had started to change the configuration ofmental healthcare provision. In their infancy, PCGs have generally considered the onus to lie with developments outside primary care.
The level of involvement PCGs reported in commissioning specialist services was low.Most (64 per cent) reported no involvement or were only involved in a consultative capacity.Only a minority planned to use prescribing indicators in primary care, develop local prescribing formularies or create practice-based lists of people with severe and enduring mental illness which have now been recommended in the national service framework.
A quarter of PCGs surveyed cited mental health as a priority for the development of community services. But an overwhelming majority reported no intentions to develop general practice-based mental health services.
This is at odds with expectations about community mental health services, which are unlikely to be in a position to provide services for primary care. Indeed the national service framework is quite clear that 'the majority of mental healthcare will remain within primary care as at present'.
The national service framework emphasises the need for links with statutory and voluntary agencies and to involve service users. Most of those PCGs developing or planning indicators of need for services are doing so in partnership with social services and community mental health services. There is less commitment to building partnerships with service users or the voluntary sector.
Our survey suggests that PCGs have a substantial base in primary care counselling and community psychiatric nursing. But less than half the PCGs reported provision in their localities that included practice-based psychology services or any form of practice attachment for psychiatry.
The primary care sector's responsibilities for mental health services stipulated in the national service framework are onerous. Our survey reveals a primary care sector that recognises the need to respond to mental health needs as a priority. But radical re-focusing, and consideration of how mental health service capacity can be expanded and used within primary care, is required if the milestones laid down for implementation are to be achieved.
1 Lee J, Gask L. Past tense, future imperfect. HSJ 1998; 108: 24-25
Anne Rogers is professor of the sociology of health care, Linda Gask is reader in psychiatry and Brenda Leese is senior research fellow, all at Manchester University's national primary care and development centre.
PCG plans for developing indicators of the need for mental health services Number %
Mental health formulary/guidelines 25 35.5
Practice-based lists of people with 18 30.0 severe mental illness
Mental health prescribing indicators 24 34.0
Involvement of voluntary or advocacy services 23 32.0
Partnerships with social services 36 50.0
Partnerships with community mental health services 31 44.5
Practice-based mental health provision reported by PCGs Number %
Primary care counselling 60 81.0
Community psychiatric nurse attachment to practices 47 8.0
Practice-based psychology services 31 44.5
Practice-based liaison psychiatry schemes 15 21.0
Practice-based outreach clinics 19 27.0
Practice-based lists of people with severe mental illness 14 19.5
Mental health prescribing indicators 11 15.5
Mental health formulary/guidelines 3 4.5