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The Health and Social Care Act 2012: what will it mean for mental health services in England?

  • Frank Holloway (a1)
Summary

The Health and Social Care Act 2012 brings in profound changes to the organisation of healthcare in England. These changes are briefly described and their implications for mental health services are explored. They occur as the National Health Service (NHS) and social care are experiencing significant financial cuts, the payment by results regime is being introduced for mental health and the NHS is pursuing the personalisation agenda. Psychiatrists have an opportunity to influence the commissioning of mental health services if they understand the organisational changes and work within the new commissioning structures.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Frank Holloway (f.holloway1@gmail.com)
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Declaration of interest

F.H. is a member of the NHS Consultants' Association.

Footnotes
References
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1 Bailey, S. The Health Bill passes. Royal College of Psychiatrists, 2012 (http://www.rcpsych.ac.uk/members/thepresidentsblog/thehealthbillpasses.aspx).
2 Ham, C. What will the Health and Social Care Bill mean for the NHS in England? BMJ 2012; 344: e2159.
3 NHS Commissioning Board. Clinical Commissioning Group Authorisation: Draft Guide for Applicants. NHS Commissioning Board, 2012.
4 NHS Commissioning Board. Clinical commissioning groups: proposed configurations agreed. NHS Commissioning Board, 2012 (http://www.commissioningboard.nhs.uk/2012/05/31/ccg-configs-agreed/).
5 NHS Commissioning Board. Developing Commissioning Support. Towards Service Excellence. NHS Commissioning Board, 2012.
6 Department of Health Payment by Results Team. Mental Health Clustering Booklet (V2.03) (2012/13) Gateway Reference 17250. Department of Health, 2012.
7 NHS Confederation. Mental Health Payment by Results Readiness Review. NHS Confederation, 2011 (http://www.nhsconfed.org/Publications/Documents/PbR_241111.pdf).
8 Mason, A, Goddard, M, Myers, L, Verzulli, R. Navigating uncharted waters? How international experience can inform the funding of mental health care in England. J Ment Health 2011; 20: 234–48.
9 BMA Parliamentary Unit. What We Know So Far… Health and Social Care Act 2012 at a Glance. BMA, 2012.
10 National Institute for Health and Clinical Excellence. Service for the Treatment and Management of Schizophrenia in Adults. Commissioning Guide. NICE, 2009 (http://www.nice.org.uk/media/243/B9/AdultSchizophreniaCommissioningGuide.pdf).
11 Cameron, A. Getting it Together for Mental Health Care: Payment by Results, Personalisation and Whole System Working. National Development Team for Inclusion, 2012 (http://www.ndti.org.uk/uploads/files/Pbr_and_pers_Final_v2.pdf).
12 Ryan, T, Davies, G, Bennett, A, Meier, R, Killaspy, H. In Sight and In Mind: A Toolkit to Reduce the Use of Out of Area Mental Health Services. National Mental Health Development Unit, 2011 (http://www.rcpsych.ac.uk/pdf/insightandinmind.pdf).
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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The Health and Social Care Act 2012: what will it mean for mental health services in England?

  • Frank Holloway (a1)
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eLetters

Needless complexity in commissioning

Prasanna N. de Silva, Consultant Old Age Psychiatrist
15 November 2012

Having attended a local Third sector and service user conference and then having read the editorial by Holloway (1), I wonder if the following needs more consideration.

Firstly, it strikes me that dividing mental health commissioning responsibilities locally between the Clinical Commissioning Groups (mentalillness treatments) and Local Authorities (suicide and substance misuse prevention, mental health promotion) poses unnecessary complexity and bureaucratic waste. Despite clinical commissioning groups (CCGs) having lay representation, there is no democratic accountability similar to that offered through local councillors and local authority scrutiny committees - which can call providers to attend a public meting to account for their priorities in using public funds. Perhaps local elections might be more popular if electors realise that councillors could be voted out if they are not active in championing mental health issues such as dementia care. Furthermore, local authorities (LAs) already have experienced procurement teams with ready access to performance management and audit functions.

Therefore, I wonder if CCGs should be relieved of all mental health commissioning responsibilities, with this function carried out entirely byLAs. This would allow CCGs to concentrate on acute and chronic medical diseases (which contribute to most of the cost via hospital bed usage and new technology). The added benefit of mental health being commissioned by LAs would be integration of social and health care budgets for the benefitof people with severe mental illness such as psychosis and dementia. As a practicing clinician, I find it difficult to separate social and health interventions in providing a good outcome for an individual patient, usually there is a synergistic effect.

The other main issue discussed by Holloway is 'Personalisation'. It is hoped that by April 2013, that 70% of eligible mental health service users (mainly with severe chronic illness) will have a personal budget with an allocated broker to help clarify and achieve their choices in interventions. The above rationalising of commissioning would lend itself to a combined health and social care budget which can be spent pragmatically. A CHIP and PIN charge card could be utilised to carry a combined budget with grater accountability and freedom from having to collect receipts.

The third issue highlighted at the above meting was an increasing body of evidence suggesting that active collaborations between statutory mental health providers and third sector organisations result in better outcomes and lower bed days in psychiatric hospitals. Perhaps this should be considered an essential requirement for mental health trusts when submitting bids for a service.

Reference1.Holloway, F. The Health and Social care Act 2012: what will it mean formental health services in England? The Psychiatrist (2012) 36: 401-403

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Conflict of interest: Thease views are not those of my employer

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The impact of the Health and Social Care Act 2012 on forensic psychiatry

Muzaffar Husain, Consultant Forensic Psychiatrist
15 November 2012

As a National Health Service forensic psychiatrist working on a newly commissioned low secure ward, the statement: "it is all too predictable that yet more patients will be pushed down forensic care pathways from which return to mainstream care will be difficult," in Holloway’s excellent article (1), struck a firm chord with me.In the past year, I have overseen an expansion of both the low secure forensic estate and the Out of Area patient placements. While there was some clinical and commissioning intent to introduce the low secure estate to allow transition out of the medium secure estate (and indeed this has happened to some extent), there has been quite a surge of patients coming from the general acute services and the community. We also receive some prison transfers; these include general adult community patients with no prior forensic history who were missed in the community due to (poorly resourced) service lapses. Such patients become “forensic” due to a lack of adequate community psychiatric services rather than being appropriate referrals to the service. In any case, we are expanding.Good news for forensic staff, but not so good for patient care. Earlier psychiatric intervention for them may have even averted the need for them to be locked up in prison. This is developing world psychiatry in a developed country.At a recent presentation by some Californian psychiatrists, I was very impressed by the vigour with which they grapple with often very difficult legal circumstances of psychiatric care in their jurisdiction. They noted most of their state hospital beds were occupied by their forensic patients. There was very little available for non-forensic patients, either in hospital or in the community. I really wonder whether here in England we are also heading in the same direction. Finally, it appears that in this evolving risk-focused, forensic-heavy psychiatric care environment, the “forensic” patient today is not the same forensic patient from twenty years ago. These days, not every “forensic” patient is a high-secure step down patient. Why is it then more difficult to discharge forensic patients into the community these days, and return them to mainstream services? At the very least, the expanding low secure estate ought to provide an easier interface within the psychiatric services than was the case in the past. This way we will have done our best for our patients whilst contending with the difficult care environment being planned for us by this government. Indeed, who else will?

References:(1)The Health and Social Care Act 2012: what will it mean for mental health services in England? Holloway, F., The Psychiatrist 2012; 36: 401-403

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Conflict of interest: None declared

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