Will a new NHS structure in England help recovery from the pandemic?BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n248 (Published 03 February 2021) Cite this as: BMJ 2021;372:n248
All rapid responses
During the Covid19 lockdown, NHS England (NHSE) submitted proposals for transforming how community mental health is delivered in England1, alongside a white paper proposing community integration between health and social services2. NHS services will now to be overseen by ‘Integrated Care Systems’ (ICS’s) typically covering the old health authority regions, with Clinical Commissioning Groups (CCG’s) being dismantled. Instead of CCG’s, local accountability would be through Primary Care Networks (PCN’s) covering around 30,000 people, typically involving 5 GP practices.
Secondary mental health services have been emerging from Covid19 restrictions with extended waiting lists and some exhausted staff 3 through redeployment to unfamiliar roles, getting used to remote working and from moral injury accrued by being unable to provide the usual quality of care. On governance, it is likely that this proposed transformation will be put in place before the ‘lessons to be learnt’ inquiry as to how NHSE dealt with the pandemic; especially in relation to marginalised groups such as elderly in care homes, non-Caucasians in low pay jobs and women at risk of domestic violence.
Regards funding to cover transformation, 12 ICS (all in the south of England apart from Humberside) will receive £70 million each as pathway projects4, with remaining ICS’s expected to commence transformation based on funding already allocated; i.e., no ‘new’ funding in the short term. In the longer term, £1 billion per year is to be allocated and ‘spent by’ 2023/24 across the whole of England; compared to the £37 billion spent on NHS test and trace programme to alleviate the pandemic5.
Practicalities of transforming community mental health care
1. Senior nurses (typically Band 7) working in adult and older adult community mental health teams (CMHT’s) are already being redeployed to large general practices as triage nurses. Their purpose would be to scrutinise referrals (for example ‘frequent attenders’) and signpost to appropriate agencies including the third sector. Furthermore, they would be expected to coordinate physical healthcare of patients with Severe Mental Illness (SMI) on practice case registers in keeping with objectives of transformation4. It is anticipated that this will reduce the burden of excess referrals to secondary care and to assist GP’s with psychosomatic patients and with SMI physical healthcare.
However, lessons from a similar undertaking in the late 1990’s (via the Sainsbury Centre for Mental Health) seems to have been forgotten. The basic problems then were General Practitioners (GPs) dropping their ‘gatekeeping’ role and forwarding many more referrals for triage, coupled with the lack of supervision and access to peer support for the triage nurses. This led to triage nurses being overwhelmed by referrals, not having time for documentation and, typically between 12 – 18 months, seeking other posts due to becoming burnt out. In the meantime, CMHT’s remained short of experienced nurses to oversee complex patients under the care programme approach (CPA).
2. It is anticipated that the supervisory and support roles for Triage Nurses will be picked up by consultant community psychiatrists in addition to responding to calls from General Practitioners (GP’s); via an electronic systems such as Consultant Connect. The likelihood is that Band 7 requests for advice from consultants would entail prolonged discussions involving diagnostic / risk / capacity formulations as well as decisions whether to proceed to referral to secondary care. Previously GP’s referred 5-10% of people with mental health issues, but with ready availability of practice based mental health nurses, a band 7 could receive 15 – 20 referrals per day. Consequently, the time an adult or old age consultant would require responding to GP and Band 7 calls could rapidly escalate, limiting time required for more complex (and risky) patients in the community with psychoses, complex trauma, and dementias.
White Paper Integrating Health and Social Care
1. The white paper essentially has 2 components. The first gives permission for the secretary of state to ‘direct’ how secondary mental health services work with social services, acute hospitals and third sector (including for profit providers). Although this might be an efficient ‘command and control’ system, there is reduced opportunity for local flexibility based on experience of consultant staff; often carriers of ‘organisational memory’.
2. The second aspect of the white paper is the comprehensive collection of data (both process and outcome) of all providers of health and social care. This data will be collated by NHS Digital and passed on to university researchers as well as to the Cabinet Office, Communications and possibly to security services through the ‘Prevent’ and hate speech initiatives. This might cause both psychiatrists and their patients’ difficulties with potential loss of mutual trust.
3. Machine learning will be used to analyse data to assist the ‘directives’ of the Secretary of State. It is proposed that the ‘opt out’ clause allowed to each NHS user will be withdrawn to gather data on Covid delirium, Long Covid and effects of vaccines. Data analysis would also identify ‘failing’ departments and community services, allowing competition from other local (possibly commercial) providers, as contracted by each ICS. Examples include services managing treatment resistant depression, early onset psychoses and personality disorders.
4. Furthermore, the white paper does not place restraints on the emerging phenomenon of large general practices being sold to health insurance companies based in North America. Currently, London and the West Midlands have seen this type of ‘privatisation’. Essentially, this is a return to ‘GP Fundholding’ also seen in mid to late 1990’s, which created inequity in provision of secondary care services, with patients covered by big fund holders having rapid access to consultants. It is unlikely that ICS managers will be able to withstand the corporate and legal firepower of these entities.
In essence, transformation involves community psychiatrists moving from working in to CMHT’s to working in to Primary Care teams, without the necessary basic trust being in place. It feels as if lessons from 20 years ago have not been learned specifically relating to placement of triage nurses in primary care without supervision and support. This coupled with transfer to remote working and the ever-increasing demand from an aging population will cause major workload pressures for community psychiatrists, who might, in effect, have to work from a call centres (called hubs) for substantial proportions of their clinical time.
My overall concern is on the rapid implementation of another transformation without pump priming finance or much consultation with community psychiatrists. Potential pitfalls of rapid transformation need consideration, based on previous experience. The second danger is consequences of primary care privatisation (quasi fundholding) leading to issues of quality and equity. Finally, I have serious concerns of ‘data transparency’ to funding organisations, as this has implications on what patients are prepared to disclose to their psychiatrist, and what the doctor decides in return.
1. NHS Improvement. Transforming Community Mental Health Services for Adults and Older Adults. https://www.england.nhs.uk >adults>cmhs
2. The health and social care white paper explained. https://www.kingsfund.org.uk>publications
3. Liberati, E., Richards, N., Willars, J. et al. A qualitative study of experiences of NHS mental healthcare workers during the Covid-19 pandemic. BMC Psychiatry 21, 250 (2021).
4. NHS England>> community mental health services. https://www.england.nhs.uk>cmhs
5. Wise, J. Covid-19: NHS Test and Trace made no difference to the pandemic, says report. BMJ 202; 372: n 663
Competing interests: No competing interests