‘Values based’ commissioning aims to put users’ views at the heart of reshaping services. By Emma Dent
Commissioning mental health is a complex area. Health, social care and the third sector can all play a part. Care may need to be provided across a range of levels. Although 90 per cent of mental healthcare is provided in primary care, care pathways may involve interaction with a variety of specialist services in secondary care. But these care pathways are far from seamless.
In addition to potentially failing service users, a complex care system that is not fully understood by its commissioners can lead to waste - both economic and of services that are not utilised in the right way. Clinical commissioning groups seeking value for money and good care for their local populations need to get a clear picture of what is happening.
‘Will [CCGs] have the courage to challenge providers on the gatekeeping of services, for example?’
But expertise in mental health commissioning is varied. There has been a widely acknowledged and inevitable loss of organisational memory in the dissolving of primary care trusts and forming of CCGs, and there is no clear national picture of which CCGs actually have mental health leads in place, although around 70 per cent are thought to have one. Those mental health leads that are in place must carry out that work alongside their clinical roles, in a completely new way of working.
“Some places are not getting the support they need, in terms of training about how to commission and in the informatics in what needs to be commissioned, an area where we know mental health falls behind,” says mental health charity Rethink’s associate director of policy, research, campaigns and advice Victoria Bleazard. “There is a chance they could be overwhelmed.”
There are also concerns that the small size of CCGs, compared with that of mental health trusts, many of which cover large geographical areas and population sizes, puts them at a disadvantage.
Sophie Corlett, director of external relations at mental health charity Mind, says many CCGs are simply rolling on contracts as it is too early for them to be in a position to challenge the status quo. “Will [CCGs] have the courage to challenge providers on the gatekeeping of services, for example?” she asks.
Guidance on mental health commissioning is available. The Joint Commissioning Panel on Mental Health (JCPMH) - a collaboration set up two years ago between 17 organisations that is co-chaired by the Royal College of Psychiatrists and the Royal College of General Practitioners - has produced guidance on commissioning specialist areas of mental health including perinatal mental health, rehabilitation services and mental health services for young people.
Values at the core
But ambitions for the future of mental health commissioning go further. What is being taken forward now is a new type of commissioning - which has been dubbed “values based” commissioning (VbC).
VbC aims to challenge the status quo. It takes a step back to see what kind of services should be commissioned and why, with service users and carers working jointly with commissioners to lead commissioning decisions.
Instead of looking only to quantitative, evidence based research and clinical experience as a form of reference for commissioning, a more qualitative approach, making reference to patient and carer experience and perspective, is used.
In prioritising service user values and experience, says its champions, VbC aims to address the whole person. Value therefore follows - services can offer real value to the service user while also being cost effective for the service they use.
“It’s about creating new models of collaborative care, deinstitutionalising patients, and increasing the ability for people to keep their home, their job, their relationship. Rather than focusing on outputs, this is about outcomes. The service should be measured in terms of the wellbeing and quality of life it results in.”
So says Dr Neil Deuchar, VbC architect and champion, JCPMH co-chair and a specialist adviser on commissioning with the Royal College of Psychiatrists, whose day job is as a psychiatrist working in a primary care setting for homeless people in Birmingham.
But for this to happen, commissioners have to change their approach.
“From a commissioning perspective, there needs to be an understanding of the whole of the patient’s needs from the beginning. It sounds like a sensible thing to do but does not necessarily always happen,” says Dr Deuchar.
He acknowledges that this will require a shift in working style.
“Commissioners need not to micromanage. And health and social care professionals need to work differently to stop patients falling between two stools. Why does a psychiatrist only have to see outpatients in an outpatient setting of a mental health hospital when most mental health care is delivered in primary care?
“Many come into a primary care setting to work face-to-face with GPs and service users, and to discuss decisions about their recovery and treatment and physical health needs at the same time.”
What happens currently is variable.
“I often see a lack of integration between all the different services - who are all providing care for the same patient - on a daily basis,” says JCPMH co-chair Dr Liz England, a GP, mental health lead for a locality care group within a CCG, and National Institute for Health Research clinical lecturer at the University of Birmingham.
“We need to move towards a more person-centred model of commissioning. It is about shaping services that are about and for that person and their needs, not just commissioning services as an end point in themselves.”
Dr England acknowledges this may be something of a culture shift for some professionals who have spent their working lives fixing, rather than preventing, problems.
She believes some GPs, who have become increasingly au fait with commissioning, may deal with the changes reasonably comfortably. But, for many, seismic culture changes will still be needed.
“Even in primary care, we often have little to do with social care. When we try and get in touch with non health services, half the time we do not know who to talk to. This creates barriers to integrated care,” says Dr England.
“I have good relationships with some local psychiatrists and our local crisis resolution team but that is after a lot of hard work on both our parts. It is not the standard thing GPs do; traditionally we have been trained differently and we have worked differently. Patient-centred, integrated care based on VbC will be a new way of working.”
So how to achieve such change? Though there are significant challenges in putting service users and commissioners on an equal footing, all those involved stress that working with service users and carers - through contacts with local groups, focus groups and workshops - is vital in getting VbC to have any kind of success.
“Any commissioning is at its most effective - when applied at a local level -when local groups and people work with the commissioners and mental health trusts about what works,” says Rethink’s Victoria Bleazard.
VbC takes this a step further, aiming to put into place services suggested, commissioned and perhaps even run, by service users and carers. The extent to which VbC work in the West Midlands has involved service users has been evaluated.
“Patient power is key,” says Dr Deuchar. “There might not be scientific evidence that a patient run respite service will work but if that is what they want, a commissioner should try to make that happen.
“Co-production between patient and carer groups, clinicians and commissioners is vital at each stage of the commissioning cycle. There is evidence to suggest the more involved they are, the more likely it is they will go for a less intensive approach than a professional would opt for. So it’s important the values of the patient and the professional are affiliated.”
However, Dr England believes there is still often a reluctance at senior board level to take on board patient involvement in service development.
“Prioritising the concept of co-production and co-commissioning, using a VbC approach is key,” she says. “In the next two to three years VbC is going to be the ‘normalised’ or embedded way of commissioning.”
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Values based commissioning - what do service users think?
Work done so far on values based commissioning in the West Midlands has been evaluated by the National Survivor User Network for Mental Health.
“We were aiming to identify both good practice and barriers in increasing service user participation, and asking service users what impact they wanted VbC to have,” says Emma Perry, lead researcher on VbC for NSUN and co-author of a review of the programme.
The review found that, although service users wanted to be equal partners in services - and there was a lot of rhetoric around that participation - in reality this did not often happen, and when it did happen there was a lack of coherence about how.
“It was clear that this kind of co-production and power sharing would require a culture shift,” says Ms Perry.
“If there is just one service user on a commissioning panel, they are at risk of isolation; it is not an equal partnership. There also has to be allowances made for the possibility of someone becoming unwell and unable to attend meetings, so more than one service user needs to be on a panel. Ideally carers should be on panels too.”
Service users identified issues such as the need for early diagnosis and intervention, swift referral to the appropriate person or place, clear communication, continuity of care and co-care versus a paternalistic attitude by health professionals, as key to a values based system. Overall, they said, service users should be at its heart.
Other barriers to such co-production work taking place included the use of jargon.
“Language was key. However familiar the service users we spoke to were with the process, does the average person actually know what the term commissioning means? It needs to be demystified. Language can also be used to exclude. The use of acronyms was often mentioned when people for our research said they did not know what was being talked about in meetings,” says Ms Perry. “Although VbC meant more jargon, they were overall pleased about the direction of travel; at least they were being asked their opinion.”
* The NSUN review of VbC was launched at the end of April (available at www.nsun.org.uk). It includes recommendations on how VbC can be applied to the major areas of prevention and provision within mental health and learning disabilities, including addictions, compulsory treatment, dementia and long term conditions.
How NHS London carried out a mental health commissioning training programme
Before it was dissolved earlier this year, strategic health authority NHS London realised it had an issue regarding levels of expertise in mental health commissioning across the emerging 32 clinical commissioning groups in the capital. In response, it decided to invite the CCG mental health leads to an intensive training programme on commissioning, in a bid to create a London-wide mental health commissioning network.
Carried out in partnership between NHS London, Lucent Management Consulting and UCL Partners Academic Health Science Partnership, the training took place over 10 days, with five days of self taught study. Trainees “graduated” at the end of April.
‘I now feel much more confident about asking questions [of the mental health trust], and am much better placed as a commissioner’
“All the attending GPs are really passionate about mental health. We wanted to ask, ‘what does good look like?’, and to help commissioners decide what the mental health needs in their areas are,” says Dr Geraldine Strathdee, formerly NHS London associate medical director and now a national clinical director for mental health.
The training covered issues such as personal and strategic leadership, strategic needs assessment, national and international best practice, and evidence bases around conditions and issues such as psychosis, substance misuse and children and young people, value based service improvement, commissioning tools and techniques, partnership and collaboration, and service user and carer engagement.
City and Hackney CCG mental health lead GP Dr Rhiannon England says that, as a relatively small organisation, being in a CCG can feel like being David to the mental health trust’s Goliath. But focused training gave her confidence as a commissioner.
“No one told me how to chair a meeting or go through minutes properly before, so [the training] was fantastic. I didn’t know how to commission, how to analyse data or know which data to ask for before. And it was incredibly valuable to be in the same room as all the other London CCG mental health leads,” she says. “I now feel much more confident about asking questions [of the mental health trust], and am much better placed as a commissioner.”
Each training participant carried out an assignment aimed at tackling a service issue local to them. For Dr Fiona Butler, mental health lead for West London CCG, that was the local urgent care pathway.
“We looked at how to set standards rather than specific services but there were issues around access and response time. We looked at shared communication, assessment response times, communication response times, The training gave us the time and space to push this work forward.”
The CCG then held a co-production workshop including local service users and carers and health professionals to develop new standards.
“An implementation plan should now be in place by mid July,” says Dr Butler.
London-wide, it is hoped the network will be able to carry out further intensive training - subjects requested by participants for further training include dual diagnosis services, autism, and a masterclass in world class primary care.
And Dr Strathdee believes what took place in London could be replicated elsewhere. “There are pockets of good practice around the country around mental health commissioning but generally the picture is mixed,” she says.
Neil Deuchar and Liz England on values
The quality of mental health service commissioning has, in the past, been variable. This often led to inequitable services and care, particularly when compounded by a past commissioning tendency to focus on expensive high cost and low volume services, to base service outcomes on numbers and processes, and to commission “one size fits all” service models.
The new NHS landscape offers opportunities to re-examine mental health commissioning in a way which brings together innovation, clinical expertise and patient values, experience and preferences. Treating people earlier with expert input can prevent or minimise more severe and enduring problems. In addition, the system will need to tackle population health and wellbeing and prevention of mental disorder.
To achieve this change, clinical commissioning groups will need to explore new models of commissioning that involve much broader partnership working than traditional mental health commissioning.
In addition, CCGs will need to re-define traditional targets, performance indicators and outputs to reflect patient-relevant outcomes, and focus on issues such as wellbeing, resilience, social integration and looking at physical and mental health together. Commissioners will then need to find new ways of incentivising all the elements of the system to help each other in pursuit of these new goals.
Since the Joint Commissioning Panel for Mental Health was formed two years ago, the 17 leading mental health organisations that make up its membership have worked to produce guides, resources and tools for commissioners to achieve such an approach.
The three pillars
The panel - co-chaired by the Royal College of Psychiatrists and Royal College of General Practitioners - has produced 19 guides and a suite of tools that describe what excellence looks like and help those commissioning, providing and using mental health services to achieve it.
Critically, all this work has been premised on a “values based” commissioning (VbC) approach. This process rests on the three equal pillars of patient and carer perspectives, clinical expertise, and knowledge derived from scientific or other systematic approaches to evidence. In doing this, VbC aims to ensure users are involved at every stage of commissioning, as well as at every level of decision making.
Developing NHS leaders, practitioners and CCGs to advocate a VbC approach will create the foundations of a commissioning model with the patient at the centre. This will require changing hearts, minds and the existing dynamic between providers and commissioners. Ultimately a VbC approach is about challenging existing processes and instilling the belief that people can change things for the better.
Neil Deuchar and Liz England are co-chairs of the Joint Commissioning Panel for Mental Health