[Arj Subanandan]

First of all GPs aren't often mental health aware. Last year or the year before the World Mental Health Foundation (or whoever started World Mental Health Day) did a policy report all about getting them some psychiatric training.

Secondly they know very little about policy. They don't read the documents. Healthcare is changing at such a pace and they need to keep up with that as well as running their practice. Now they're going to be commissioning local services as well? Ask any GP how many policy reports they've read. I've asked a few and the answer is usually somewhere between zero and nil. So a deacde's worth or more of policy work goes out of the window unless GPs are going to stop keeping up with medicine and start reading these documents. I'd rather they keep up with medicine. A lot of the ones I'd spoken too didn't know about the dangers of antipsychotics in people with dementia. The 1,800 unnecessary deaths a year figure was new to them as was the research that showed they reduced life expectancy by half in very old people.

The BMA, Pulse or GP magazine are campaigning for the debt left over from PCTs to be wiped out before the consortia's start. Think it's Pulse. That's not going to happen. So they're going to start with a lot of problems and they dont have the training or awareness to know how to deal with them. Few have any business training.

The change is estimated to cost about a billion but the money's not being set aside to pay for it so it's going to come out of other budgets.

The Civitas report Does size matter? that was recently published showed that, in fact, it does matter. (damn! ;~)) The UK is one of the only countries in the EU (think spain was the other one) which is going down this route. The rest are going the other way. So this isn't evidence based.

This is going to contribute to ever greater health inequalities and the postcode lottery is going to get worse.

Basically this is possible the most silly thing ever. Put it this way - would you want PCT commissioners doing the job of a GP?

Oh, and in a Facebook chat with one of the management consultants they'd brought in in the past to sort out the NHS he said the best thing to do in the near future is go private....

alienpresence, on 09 November 2010 - 05:37 PM, said:

Given the agenda is already set this is a public relations afterthought isn't it? Those opinions that coincide with the agenda will be amplified and doubts or deep concerns will be sidelined. I'd rather not give my opinion after a decision is made....but I don't feel happy that my medical regime is likely to be decided by someone with no significant mental health training along with a budget to watch.

Spot on.

Ditko, on 09 November 2010 - 06:33 PM, said:

My GP says this reform will be a disaster. He is yet to speak to another GP who thinks it is a good idea. He's a doctor, not an accountant. It's a clever way to shift blame from central government to the doctors surgery' as is most of their policies, shift responsibilty. I think the government like to refer to it as empowerment...

So what does it mean for us? GP surgeries will be run like a business and the private sector involvment will make the NHS even more of postcode lottery. My GP is top quality, it took me years to fins a good doctor, but i'm not sure about his accountancy skills... It stinks to high heaven and it will be those with the quietest voices who will be hit the hardest - just like welfare reform. This government's whole phillosophy is 'the strongest will survive'. Andrew Lansley can kiss my arse.

Ditko
x

:~) Beautifully said. LOL. He can kiss mine too.

[celticchickadee]

Antonia - Rethink, on 25 November 2010 - 12:44 PM, said:

Hi alienpresence You commented that opinions are being sought after the agenda being set. We know that these plans are quite firm because the coalition government went straight into announcing the reforms, consulting only on the detail of this. However, the details of the changes are yet to be determined, and the changes to health law to allow the reforms will go through Parliament in the Spring. It is therefore more important than ever that we all engage at local and national levels to ensure that new NHS structures work effectively for mental health. It's imrportant to raise mental health up the agenda now with key players so ensure we don't get sidelined in the new NHS.

would like to endorse that - the absolute failure to consult in development stage is abysmal practice and should be challenged - loudly - and the statutory consultation was equally poor. However it would be a dangerous mistke to sit back and say ' nothing we can do'. There is still scope to influence and the more of us who try to do it the more impact it will have. Most MPs are as confused as the public it seems to me, just spouting rhetoric, and if you are more informed than they are about the issues and problems - it can do nothing but good to talk or write to them about your concerns.

[Arj Subanandan]

Another 2 cents from me. Psychiatrists still aren't good enough when it comes to mental health because of their biomedical training. GPs are even worse. Already they're overburdened with needing to know a very wide spectrum of medicine. Mental health is often beyond them.

[Antonia - Rethink]

Hi You commented on how GPs feel about these reforms. GP’s are likely to be quite mixed in their attitudes towards the changes. The Royal College of GPs has been critical in the press about the fast pace of change, and the government is ‘passing the buck’ to GPs. And a recent BBC survey of 800 GPs found that less than a quarter than that the reforms would lead to improvement in care. However, some GPs we have spoken to have some experience of budget holding and are confident that their new role will lead to more emphasis on the services and treatments that they know their patients want. The key thing is to ensure that those GPs who are not so confident in the area of mental health are supported with tools and resources to skill up and assess need properly.

You can read the article about the views of the Royal College of GPs here: http://www.guardian....-unrest-reforms

[Arj Subanandan]

celticchickadee, on 25 November 2010 - 12:50 PM, said:

would like to endorse that - the absolute failure to consult in development stage is abysmal practice and should be challenged - loudly - and the statutory consultation was equally poor. However it would be a dangerous mistke to sit back and say ' nothing we can do'. There is still scope to influence and the more of us who try to do it the more impact it will have. Most MPs are as confused as the public it seems to me, just spouting rhetoric, and if you are more informed than they are about the issues and problems - it can do nothing but good to talk or write to them about your concerns.

Totally. You should have heard Andrew Lansgley in the Department of Health web chat. He avoided a lot of the important questions. For example the UK is still overdiagnosising black men with schizophrenia, over-sectioning them and overusing the CTO on them (which is already overused by 900% om everyone).

He want sto move away from top down measures but that's a step back 50 years. I used to work in perfomance management in children's social care and the national framework of measures was essential. There was a whole set of measures just around the Victoria Climbe tragedy.

I fear a national disaster for physical healthcare and it's going to be worse for mental healthcare, especially as more people will be accessing services. With 1 million people out of work (at least - CSR cuts to public sector plus 500,000 cuts in private sector as a direct result according to Price Waterhose Coopers) in the next 4 years the mental health of the nation will spiral downwards. More people will be accessing a poor welfare system. More people experiencing poverty for the first time and bad debt problems. More homelessness and misery for everyone. GPs just won't know what to do because they're not mental health aware. They're trained primarily as physical doctors. Few do psychiatric rotations when training.

[Antonia - Rethink]

Good to see a few people getting stuck on now. Please bear with my technical skills - I'm a bit new to writing on web forums (although I do read them)so I'm not so good at linking to things!

, I also wanted to agree with you about how absolutely essential it is that the 'quietest voices' are not forgotten in all these changes. The most important thing in this new NHS is that decision makers must be accountable for their actions.

Local people must be supported to engage meaningfully with local needs assessment, and that includes people with mental illness who may be more vulnerable or lack the confidence to speak out. This will be a major message from Rethink both nationally and locally, especially with the move towards the Bog Society. We feel this issue is particularly thin on commitment, aside from plans to develop links into HealthWatch, which we fear may continue to favour more confident, outspoken patient groups.

[celticchickadee]

Antonia - Rethink, on 25 November 2010 - 12:53 PM, said:

Hi You commented on how GPs feel about these reforms. GP’s are likely to be quite mixed in their attitudes towards the changes. The Royal College of GPs has been critical in the press about the fast pace of change, and the government is ‘passing the buck’ to GPs. And a recent BBC survey of 800 GPs found that less than a quarter than that the reforms would lead to improvement in care. However, some GPs we have spoken to have some experience of budget holding and are confident that their new role will lead to more emphasis on the services and treatments that they know their patients want. The key thing is to ensure that those GPs who are not so confident in the area of mental health are supported with tools and resources to skill up and assess need properly.

You can see the [post='http://www.guardian.co.uk/society/2010/nov/19/doctors-warned-expect-unrest-reforms']article[/post]about the views of the Royal College of GPs.

It's not just about experience of budget holding though, is it, and in any case, the limited number of GPs who have experience of it is not very comforting, especially as they are generally not very good at it, lots of issues around overspending.

Practice based commissioning is very revealing; it has been, at best, a patchy 'successs'. Even those enthusiastic about it would admit that in many places it is very poor, or mediocre, limited, slow to develop proposals, subject to issues that are of personal interest to the GPs involved, lacks objectivity and, from my experience, many GPs are quite resistant to the input of patients in commissioning and to issues around equalities. It's hardly an encouraging picture to look at then envisage the massive scaling up that the government reforms require.

There's a very simple reason why PBC not a success. Most GPs are not interested, and if they are, only some are competent and informed enough to make a success of it.

There is a massive degree of change needed, not only in skills and knowlege base, but in attitude and culture. Changes like that cannot be imposed, which is what Lansley is trying to do.

None of this bodes well for patients.

[Antonia - Rethink]

ramboghettouk, on 10 November 2010 - 04:09 PM, said:

My inner city gp will be given a sum of money to buy serevices, he'll have to spend it on a big no of needy people, my gp doesn't have many patients in good health not needing help like in the rich areas

My gp will have to invest in admin staff, as a small surgery he'll have problems, the admin staff will concentrate on the procedures they know well and use a lot, any procedure that would help weirdo me as a minority of one will be ignored

Hi ramboghettouk, have worked out how to quote now! It will be up to the new National Commissioning Board to allocate money to GP Consortia. There isn't any detail on how this will be done, but presumably there will be some accounting for population size and demographic, and hopefully on some level, according to need. Individual GP practices will of course need admin staff, but they won't be directly responsible for the management of commissioning and spending. A smaller number of GPs within a Consortia will lead on this, and will employ various staff to carry out the management. As you say, we need to ensure that decisions aren't based on what they already know - they will have to start from scratch to assess local need, and engage properly with all patient groups.

[Antonia - Rethink]

Hello CaptSpaceBat. I hear what you are saying about not being able to get the help you need. It's entirely unacceptable that this is the experience of so many people with mental illness, and is the basis of our Fair Treatment Now campaign. It's incredible that GPs continue to refer to services which don't exist - and thinking optimistically about this at least - this is perhaps less likely to happen if GPs have to become more aware of what specialist services are being provided.

We often hear that psychological therapies for psychosis and other mental illness in particular lose funding because non-clinical PCT commissioners don't understand why this treatment is so crucial for many. That's not to say that GPs are as knowledgeable as they should be about mental health, but perhaps they could be in a better position to see why psychological therapy, or indeed other forms of treatment, are important.

[Admin - Rethink]

Arj Subanandan, on 25 November 2010 - 12:57 PM, said:

...the UK is still overdiagnosising black men with schizophrenia, over-sectioning them and overusing the CTO on them (which is already overused by 900% om everyone).

Interesting edition of All In The Mind on Radio 4 that has a fairly heated debate about CTOs - well worth a listen.

[Arj Subanandan]

And what about all the old policy stuff? Dual diagnosis patients still get awful treatment. There's still no joined up thinking.

GPs already work a long week. I know because I rarely seen my dad when I was growing up. They don't have the time to read all the stuff they need to and keep up with medical advances.

[celticchickadee]

they will have to start from scratch to assess local need, and engage properly with all patient groups.


- Antonia - another worry - more evidence of poorly thought through proposals - how are consortia going to make use of statistical data on geographical or politically defined areas that will quite possibly not be co-terminus with consortia population and area? They are certainly not going to have the money to collect their own and in any case that is undesirable duplication.

Moreover - patient organisations are very familiar with reluctance or even hostility to patient involvement at primar care level - that, and the early casualties in NHS of posts such as PPI and Equalities signal that these areas still seen by many as a soft and not very useful area of work. I am not convinced that 'patients being at the heart of the system' will translate into reality - and if the white paper consultation is anything to go by, there will be no attempt to reach seldom heard groups.

[Antonia - Rethink]

ebonycat, on 18 November 2010 - 07:42 PM, said:

What will happen to direct payments they come from the Mental Health budgets

Will GPs value home help and alternitive therapies or holidays for service users?

Hello ebonycat. Your question about direct payments is a good one. The government's 'vision' for social care (which came out just this week) emphasises the importance of direct payments, and names mental health as a specific are for greater support for take up. They also eventually want to see the pooling of health and social care individual budgets (direct payments in health are being trialled at the moment). But of course, availability of direct payments is dependent on eligibility for free social care, which is in turn dependent on local budgets. Rethink is planning to get information about local authority spending plans for 2011-12 to find out whether mental health is being disproportionaly targeted for cuts, as we fear, so that we can get high level attention for any unfair decisions.

With regard to GP views on alternative therapies and respite, local decisions about service types will be down to good quality assessment of need. And then involvement of mental health service users and carers in decision about addressing that need! We have to ensure that GP Consortia planning is properly accountable to local people so that it is clear where involvement has not been carried out well. We have raised this with several MPs already, many of whom agree strongly with us, so we are building a network of people who can make this argument both nationally in Parliament, and locally in their constituencies.

[Antonia - Rethink]

firemonkey, on 19 November 2010 - 03:50 AM, said:

I can't see my gp being that helpful when it comes to buying services for mental health problems. If i go about a mental health issue he passes the buck, but if i go about a physical problem he invariably says it's to do with my being mentally ill.
I have not seen him for 5 years and he has not asked to see me to see how i am in that time.

Hello firemonkey. GP understanding of mental illness is a major issue for Rethink. A poll of 500 GPs we conducted in the Summer this year found that:

- 42% say that they are worried about providing mental health services, because of their lack of knowledge about services for severe mental illness, and 23% about their general knowledge about severe mental illness.
- 54% of GPs had difficulties dealing with patients with severe mental illness.
Only patients with drug and alcohol problems were reportedly more difficult for GPs, with 57% reporting problems.
- Almost two thirds of GPs (63%) think it’s vitally important that every GP consortia has a mental health lead, and over half (53%) want special commissioning guidance on severe mental illness.
- 40% of GPs say there should be additional funding for specific commissioning support on mental health.
- 37% of GPs want NICE Standards on severe mental illness to be prioritised

This is very telling indeed. Rethink is arguing for extra funding to be provided to the Consortia to help them buy in the advice to assess need, plan services or engage directly with patients specifically in the area of mental health. We are pleased to see that NICE is about to start developing new Quality Standards for adult mental health services, which GP Consortia will have to demonstrate they are adhering to - but they will need support to develop competency in this health area.

[Antonia - Rethink]

Hello celticchickadee! It's taken a little while for me to catch up with previous questions but I've been reading your comments as I go along. Ultimately, more than anything, local decisions about how resources are allocated are what really matter. National policy affects this - but perhaps our biggest challenge is fighting disproportionate cuts. The Rethink campaigns team is keen to hear any local intelligence about cuts and closures so we know which authorities are guilty of this. Info can be submitted at [post='http://www/rethink.org/cutswatch']Cutswatch[/post].

The next phase of Fair Treatment Now is locally focused - and our message to commissioners (apart from doing the right thing) is that the best way to save money in mental health is to invest in the right services and treatments. They will only ever generate more costs if they don't support recovery. A classic example of this is the national commitment to psychological therapies, and the local, short-sighted decision to cut these very services. We have our work cut out, but now is the time to do it.

Sorry I'm struggling to post links properly. The url for Cutswatch is http://www.rethink.org/cutswatch

[Antonia - Rethink]

And hello to you, Arj Subanandan! Thanks for your comments. GP awareness of some of the major issues around mental health is indeed low. We will have to see whether the Consortia are able to have PCT debt wiped, but even so we believe that allocations of resource from the National Commissioning Board should take into account the complexity of mental health as a new area for GPs. We would ideally like to see GP Consortia have a dedicated mental health lead, to be responsible for development and quality commissioning in this area, though we know the government is reluctant to tell Consortia how they should manage themselves.

I think it's important to bear in mind that GP Consortia will have to show they are providing services in accordance to new NICE Standards for different health areas. So as long as these address some of these key national issues, we will be able to see which Consortia are doing a good job and which are not. There will also be local data on new NHS Health Outcomes, will will include data on indicators such as emergency admissions to hospital for people with mental illness, and early mortality rates for this group. We are arguing that this data should be available broken down by age and ethnicity in particular, so we can see if any groups are not receiving quality care.

[Antonia - Rethink]

celticchickadee, on 25 November 2010 - 02:21 PM, said:

- Antonia - another worry - more evidence of poorly thought through proposals - how are consortia going to make use of statistical data on geographical or politically defined areas that will quite possibly not be co-terminus with consortia population and area? They are certainly not going to have the money to collect their own and in any case that is undesirable duplication.

OK my last post for just now. I shall pop back in occasionally to see any other posts.

It doesn't make any sense to us that GP Consortia could have different geographical boundaries to the local authority. We have heard many other organisations say the same. The analysis of local data, not to mention the planned joint approach to assessment and provision, will be almost impossible without a shared boundary. We will continue to press our concerns on this and find others who are willing to say the same.

[Arj Subanandan]

Chris - Rethink, on 25 November 2010 - 01:14 PM, said:

Interesting edition of All In The Mind on Radio 4 that has a fairly heated debate about CTOs - well worth a listen.

Thanks Chris. I'm stuck in safe mode. : ( No music. No sound. No point watching videos. Can't install software. Just stuck reading stuff.

[Admin - Rethink]

Arj Subanandan, on 25 November 2010 - 02:59 PM, said:

Thanks Chris. I'm stuck in safe mode. : ( No music. No sound. No point watching videos. Can't install software. Just stuck reading stuff.

Sorry to hear it - hope it's only temporary. There is at least a show summary and links on this page.

[Arj Subanandan]

Antonia - Rethink, on 25 November 2010 - 02:09 PM, said:

And hello to you, Arj Subanandan! Thanks for your comments. GP awareness of some of the major issues around mental health is indeed low. We will have to see whether the Consortia are able to have PCT debt wiped, but even so we believe that allocations of resource from the National Commissioning Board should take into account the complexity of mental health as a new area for GPs. We would ideally like to see GP Consortia have a dedicated mental health lead, to be responsible for development and quality commissioning in this area, though we know the government is reluctant to tell Consortia how they should manage themselves.

I think it's important to bear in mind that GP Consortia will have to show they are providing services in accordance to new NICE Standards for different health areas. So as long as these address some of these key national issues, we will be able to see which Consortia are doing a good job and which are not. There will also be local data on new NHS Health Outcomes, will will include data on indicators such as emergency admissions to hospital for people with mental illness, and early mortality rates for this group. We are arguing that this data should be available broken down by age and ethnicity in particular, so we can see if any groups are not receiving quality care.

Thanks Antonia for your response. I'm not sure it's enough for a GP to be simply handed the mental health lead. Think of the inordinate spectrum of disorders. No GPs are educated well in psychosocial stuff. They older ones may not believe in psychological therapies at all.

Breakdown by age and ethnicity makes sense. So does gender. Men are referred to secondary mental health services measureably less than women. It may, perhaps, be because they're less likely to seek help from GPs or because GPs simply aren't recognising symptoms in men. GPs are predominantly male so may treat men different from women.

They also need to drill down to diagnosis level. At the moment there's still real problems with provision of care for the severely mentally ill - as I'm sure you're well aware. IAPT doesn't cater for those with the severest conditions. While funding for IAPT seemed to survive I think psychological therapies for severe mental illness may end up being cut because this wasn't ring-fenced.

The mortality gap is important but it's dangerous. I saw the Baroness who's on the parlimentary mental health group chat about this and go on about how it's all about smoking, so really all they're likely to do is refer people to smoking cessation services without realising that many people smoke as self-medication. Smoking triggers the neurotransmitter that's released by sodium venlaflaxine at high levels. It's guessed that people with sz smoke to help with the negative symptoms. The Baroness didn't seem to know about the 50% reduction in mortality due antipsychotics used in very old people with dementia either.

It's also helping people have a reason to live. I never got any therapy when I tried to get help. They sent me to a drugs and alcohol service which isn't what I wanted then cocked up my referral. I had to get myself better by drinking myself well and something called a paradoxical intervention but I can't really talk about that publicly. Many people with sz aren't getting the sort of support they need to help them want to live long lives. GPs don't understand severe mental illnesses and psychiatrists are barely any better. It's sad to say but perhaps psychiatrists need to have a hand in commissioning because GPs are simply ill-equipped.

There are several GPs in my extended family and network. I do mental health awareness training with them ad hoc and I'm sure they're sick of it but the ones who want to learn are willing to listen. Their qualification barely touches on common mental disorders let alone the complexities of severe psychiatric illness.

As I mentioned somewhere in another post there's a desperate need for a large scale alternative treatment paradigm for first episode psychosis. What I mean is something advanced like the Soteria wards, ones that allow people the choice to be treated without antipsychotic medication and allows them to learn to self-manage. This makes a lot of sense to develop one of these in London. There's a population of something like 7 milion (ONS 2001) and if I remember the details of the AESOP study quoted inthe New Horizons consultation the rate of diagnosis of schizophrenia is twice that of Nottingham and...Bristol I think. This takes capital-wide buy in but the evidence seems to be showing better outcomes in the long term, at least the evidence from countries that seek to have progress in the treatment of severe mental illness.

I have a personal interest in this. When I get psychotic I can't use services. I have to survive alone. The things that happen to me during these periods are horrific. But I refuse to be sectioned again. I refuse to have my right to choice taken away as well as my liberty. UK policy seems focused on more coercion, not less. They're focused on cheap outcomes - this means antipsychotics (which aren't really antipsychotics because they don't really treat the internal experience. They just sedate the person.).

And don't even get me started on dual diagnosis patients. We're fucked. No charity lobbies for us. No one reads the strategy from 2002 and in my experience it's certainly being put into place. We suffer that extraordinarily powerful and untackled stigma: we do it to ourselves. An anorexic with depression is ok but a depressive who becomes an alcohol isn't. Heck - even Time to Change didn't touch dual diagnosis with a barge pole. In fact the stigma is often foisted onto this group of the mentally ill. I very much doubt that the situation will get much better except for the fact that alcohlism is high in GPs. Perhaps that's a sliver of hope that some of them may understand just how hard it is.

Anyway, best of luck. Fight the good fight.