Practice based commissioning may not work for mental health
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《英国医生杂志》
Plans to allow general practitioners to commission a wider range of mental health treatments will result in substandard care, a report published by the Sainsbury Centre for Mental Health has said.
The charity, which works to improve the quality of life for people with severe mental health problems, has condemned the UK government抯 plans to expand the practice based commissioning scheme under which individual practices, rather than primary care trusts (PCTs), are responsible for directing secondary treatment into specialised areas such as mental health.
The government wishes to extend the scheme to include a greater variety of secondary care services. Community mental health teams, psychological treatments, and other talking cures could all potentially be commissioned directly by GPs.
The centre sees some benefits in allowing practices to take responsibility for a limited range of services, such as cognitive behaviour therapy and "talking therapy" for somatisation disorder and depression. But it questions the wisdom of having individual practices direct more complex and extended care.
Practice based commissioning bears some similarities to the general practice fundholding scheme, which Labour abolished in 1998. General practice fundholding gave practices actual budgets to commission services on behalf of their patients, but in 1998 primary care trusts were given responsibility for commissioning care collectively to establish national standards of quality and care.
Last month the government announced that, from April 2005, it is going to devolve budgets back to individual practices again (BMJ 2004;329:819, 9 Oct). It hopes that the introduction of the national service frameworks and payment by results (the scheme whereby the government sets a national tariff for health treatments to ensure that commissioning bodies pay the same price for the same service) can ensure that cost and quality continue to conform to a national standard.
Although the Sainsbury Centre is confident that the National Service Framework for Mental Health (1999) has brought about significant improvements in the treatment of disorders, there are concerns that confusions over cost may make it difficult for GPs to commission services in an informed way.
The complicated and often extended nature of treatment means that so far the scheme of payment by results has been unable to establish a national tariff for the services provided by mental health trusts. The Sainsbury Centre points to the effects of the general practice fundholding scheme, which led to practitioners tending to focus on common mental health problems, such as depression rather than patients with a severe and enduring illness.
A number of other concerns are also highlighted. There appears to be no obligation on practices to consult patients about their commissioning policy. Also, the financial aspects of the arrangement may pose risks. Although the scheme could bring about a potential decrease in the number of fruitless referrals to outside specialists, there seem to be no obligation for practices to warn primary care trusts of potential changes in their commissioning, and primary care trusts will bear the brunt of any overspending.
Alan Cohen, director of primary care at the Sainsbury Centre, said, "Practice based commissioning is the logical conclusion of the government抯 NHS reforms. But it will not work for patients unless we can be sure that all services are of sufficient quality, that choices are supported by good information, and that cost considerations do not distort decision making. None of these conditions yet apply to mental health services in England."
"GPs have been frustrated by the lack of responsive commissioning by PCTs ," countered Mayar Lakhani, chair of the Royal College of General Practitioners. "And as such we welcome any initiative which improves support for GPs in giving high quality care to their mentally ill patients."(London Madeleine Bretting)
The charity, which works to improve the quality of life for people with severe mental health problems, has condemned the UK government抯 plans to expand the practice based commissioning scheme under which individual practices, rather than primary care trusts (PCTs), are responsible for directing secondary treatment into specialised areas such as mental health.
The government wishes to extend the scheme to include a greater variety of secondary care services. Community mental health teams, psychological treatments, and other talking cures could all potentially be commissioned directly by GPs.
The centre sees some benefits in allowing practices to take responsibility for a limited range of services, such as cognitive behaviour therapy and "talking therapy" for somatisation disorder and depression. But it questions the wisdom of having individual practices direct more complex and extended care.
Practice based commissioning bears some similarities to the general practice fundholding scheme, which Labour abolished in 1998. General practice fundholding gave practices actual budgets to commission services on behalf of their patients, but in 1998 primary care trusts were given responsibility for commissioning care collectively to establish national standards of quality and care.
Last month the government announced that, from April 2005, it is going to devolve budgets back to individual practices again (BMJ 2004;329:819, 9 Oct). It hopes that the introduction of the national service frameworks and payment by results (the scheme whereby the government sets a national tariff for health treatments to ensure that commissioning bodies pay the same price for the same service) can ensure that cost and quality continue to conform to a national standard.
Although the Sainsbury Centre is confident that the National Service Framework for Mental Health (1999) has brought about significant improvements in the treatment of disorders, there are concerns that confusions over cost may make it difficult for GPs to commission services in an informed way.
The complicated and often extended nature of treatment means that so far the scheme of payment by results has been unable to establish a national tariff for the services provided by mental health trusts. The Sainsbury Centre points to the effects of the general practice fundholding scheme, which led to practitioners tending to focus on common mental health problems, such as depression rather than patients with a severe and enduring illness.
A number of other concerns are also highlighted. There appears to be no obligation on practices to consult patients about their commissioning policy. Also, the financial aspects of the arrangement may pose risks. Although the scheme could bring about a potential decrease in the number of fruitless referrals to outside specialists, there seem to be no obligation for practices to warn primary care trusts of potential changes in their commissioning, and primary care trusts will bear the brunt of any overspending.
Alan Cohen, director of primary care at the Sainsbury Centre, said, "Practice based commissioning is the logical conclusion of the government抯 NHS reforms. But it will not work for patients unless we can be sure that all services are of sufficient quality, that choices are supported by good information, and that cost considerations do not distort decision making. None of these conditions yet apply to mental health services in England."
"GPs have been frustrated by the lack of responsive commissioning by PCTs ," countered Mayar Lakhani, chair of the Royal College of General Practitioners. "And as such we welcome any initiative which improves support for GPs in giving high quality care to their mentally ill patients."(London Madeleine Bretting)