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Many in the mental health sector had been eagerly awaiting NHS England’s implementation plan proposing how the Mental Health Taskforce report, The five year forward view for mental health, will be put into practice. If successful, the significance of the plan could extend well beyond the mental health sector: some of the most important opportunities relate to the way in which people with mental health problems could be supported in general acute hospitals and in general practice.
One of the main proposals in the Taskforce report is that mental health care should be integrated more closely with the rest of the health system, so that mental and physical health are considered together. The King’s Fund strongly endorses this principle, and we are working to support it through our ongoing research projects and learning network.
The implementation plan includes some welcome detail on how integrating mental and physical health care can be achieved in secondary care, for example, through expanding liaison mental health services in general acute hospitals, and by improving mental health support during the perinatal period. For the first few years, these approaches will be partially paid for from the Sustainability and Transformation Fund.
However, the vision for integration in primary care is less well-articulated. Our report, Bringing together physical and mental health, argued that some of the biggest opportunities for integration lie in developing new approaches towards mental health care in general practice settings, as part of wider moves to redesign models for primary and out-of-hospital care – a recommendation also made by our research on pressures in general practice. Improving this aspect of care is particularly important given that 90 per cent of adults with mental health problems are supported in general practice.
The implementation plan does include some important measures in general practice. The headline goal is for 3,000 new mental health therapists located in GP practices, as previously announced in the General practice forward view. The plan states that part of the rationale for this is to help relieve the pressure on general practice resulting from unmet mental health needs – something that is certainly required. And while this extra capacity may help, I have two concerns.
The first is that co-location does not necessarily equal integration – an observation that is often made but still worth repeating. Our research on specialists working in out-of-hospital settings shows that ‘drag and drop’ approaches are not the most powerful way of bringing about change. Mental health professionals working in general practice will be in a stronger position to improve the quality of care and alleviate pressures if they are unambiguously part of the primary care team, with an active exchange of information, knowledge and skills between mental health workers, GPs and other team members. Without this, there is a risk of missing an important opportunity to increase the ability and confidence of primary care professionals to both manage mental health issues within general practice, and ensure that the physical health needs of people with mental health problems are met.
The second consideration is getting the training and supervision arrangements right for mental health therapists working in general practice. The implementation plan explains that much of the new capacity will be targeted at people with co-existing mental and physical health conditions or other complex, overlapping symptoms. Working in this area takes a high level of skill, and it is not clear whether the ‘top-up training’ envisaged in the plan will be sufficient. The most evidence-based models for working with these patient groups tend to involve ongoing supervision from mental health specialists with specific expertise in the area. A key task for the ‘early implementer’ sites described in the plan will be testing different approaches to this.
General practice is entering a period of change, in part triggered by the intense pressures many GPs are encountering. The proposals in the General practice forward view build on the ongoing trend of GPs coming together with other professionals, in practice groups, federations and the new care models being tested in the vanguard sites. Given the high levels of unmet or poorly met mental health care need among people using GP services – and the impact of this on both patients and staff – it is important that new approaches towards joining up primary care and mental health care are integral to efforts to strengthen general practice.
The five year forward view for mental health implementation plan places responsibility for bringing about many of the planned changes at the feet of those leading the 44 sustainability and transformation plan (STP) footprints across England. The plan is right to identify STPs as a critical lever for change – but there is a clear danger that both general practice and mental health care are overshadowed as STPs focus on the challenges facing the acute hospital sector. While these challenges cannot be ignored, STPs also need to serve as a stimulus for transformation of services outside hospital. And in bringing about this transformation, we need to think about the future of general practice and the future of mental health care as being part of the same conversation.