Download full-text PDF

Integrated mental health services in England: A policy paradox

Article (PDF Available) inInternational journal of integrated care 5(4):e24 · February 2005with28 Reads
DOI: 10.5334/ijic.140 · Source: PubMed
Abstract
The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health services in England. Drawing largely from a narrative review of the literature on adult mental health services published between January 1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary care and across the primary/secondary interface for people with serious mental illness. We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration rhetoric/reality gap in practice. This has particular implications for people with serious mental health problems. We conclude with suggestions for strategies that may facilitate more integrated working.
1This article is published in a peer reviewed section of the International Journal of Integrated Care
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
Integrated mental health services in England: a policy
paradox?
Elizabeth England, Dr., Clinical research fellow, Department of Primary Care, University of Birmingham, Edgbaston,
England, UK
Helen Lester, Dr., Reader in Primary Mental Health Care, Department of Primary Care, University of Birmingham,
Edgbaston, England, UK
Correspondence to: Helen Lester, Phone: q 0121 414 2684, Fax: q 0121 414 6571, E-mail: h.e.lester@bham.ac.uk
Abstract
Purpose: The purpose of this paper is to examine the effects of health care policy on the development of integrated mental health
services in England.
Data sources: Drawing largely from a narrative review of the literature on adult mental health services published between January
1997 and February 2003 undertaken by the authors, we discuss three case studies of integrated care within primary care, secondary
care and across the primaryysecondary interface for people with serious mental illness.
Conclusion: We suggest that while the central thrust of a raft of recent Government policies in England has been towards integration
of different parts of the health care system, policy waterfalls and implementation failures, the adoption of ideas before they have been
thoroughly tried and tested, a lack of clarity over roles and responsibilities and poor communication have led to an integration
rhetoricyreality gap in practice. This has particular implications for people with serious mental health problems.
Discussion: We conclude with suggestions for strategies that may facilitate more integrated working.
Keywords
mental health, integration, health policy
Introduction
Health care services in England have been subject to
a series of significant policy imperatives in the past
decade. There has been a shift in the theoretical
debate around the ways in which healthcare organi-
sations should deliver services to improve quality of
care through extending patient choice and access to
care and a particular focus on issues of partnership
working and integrated care. The debates around the
value of integrated care have been rehearsed in many
other countries
w
1,2
x
as a model for transforming
health care systems, improving efficiency and
responding to the multiple needs of patients both
within and beyond the field of mental health
w
3
x
.
This paper explores policy developments around serv-
ice integration within and between primary care and
secondary mental health services in England, and
reflects on how far current services have moved
beyond policy rhetoric towards the reality of integrated
services. We focus on integrated care for people with
serious mental illness, a group for whom continuity of
care is particularly important
w
4
x
and who have limited
options and choice to seek care elsewhere if dissat-
isfied. A seamless, co-ordinated accessible pathway
to care is, therefore, arguably more important for
mental health service users than many other patients.
The evidence base sources quoted in this paper are
largely drawn from a narrative review of the literature
on adult mental health services published between
January 1997 and February 2003 undertaken by the
authors
w
5
x
. This has been supplemented by discus-
sions with clinical leaders in the field of adult mental
health, particularly in Early Intervention Services
where the authors are involved with a national evalu-
ation of services.
The importance of mental health
Serious mental health problems are relatively com-
mon. Recent statistics suggest that an estimated one
in two hundred people have experienced a psychotic
disorder in the past year in the United Kingdom
w
6
x
and that approximately three per cent of the population
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
2This article is published in a peer reviewed section of the International Journal of Integrated Care
have some form of serious mental illness such as
bipolar affective disorder, schizophrenia or severe
depression
w
7
x
. The financial costs of mental illness in
England have been estimated at over 77 billion
pounds
w
8
x
, and this figure doubles once quality of
life is included alongside costs of care and lost
productivity. Indeed, the total cost to the economy of
mental health problems is greater than ischemic heart
disease, breast cancer and diabetes combined. Men-
tal illness also has a significant impact on the families
of those with mental health problems, many of whom
act as unpaid carers. Whilst harder to quantify, it has
also been argued that mental illness impacts on a
nation’s social capital through the medium of poverty
and social exclusion
w
9
x
.
Conceptualising integrated health
care
Integrated care is, of itself, a nebulous and often
poorly defined concept, with different authors empha-
sising different aspects. Kodner and Spreeuwenberg
w
10
x
in this journal have usefully proposed that
integration is a coherent set of methods and models
on the funding, administrative, organisational, service
delivery and clinical levels designed to create connec-
tivity, alignment and collaboration within and between
the cure and care sector « to enhance quality of care
and quality of life, consumer satisfaction and system
efficiency for patients with complex, long-term problems
cutting across multiple services, providers and settings.
Rhodes
w
11
x
describes integrated working as a meth-
od of overcoming the complexity associated with wel-
fare care, and is characterised by dynamic, flexible
and evolving methods of working that rely on horizon-
tal self-governing networks. Notions of horizontal and
vertical integration are also important in conceptualis-
ing and understanding policy and practice. Horizontal
integration refers to the bringing together of profes-
sions, services and organisations that operate at sim-
ilar levels in the care hierarchy. Vertical integration
refers to the bringing together of different levels in the
one hierarchy.
The conditions required for an integrated approach
to mental health can be conceptualised as ways of
working that acknowledge the importance of creating
a seamless pathway for the patient as they make their
way through different parts of the mental health sys-
tem. From a structural perspective, integrated care
goes one step beyond collaboration to co-ordination
and often co-location of care. To be sustainable, an
integrated approach needs to be underpinned by
opportunities for health professionals from different
backgrounds to train and learn together. It also
depends on good communication across the interface,
particularly around criteria for referral and discharge.
The importance of integrated mental
health services
As the Kodner and Spreeuwenberg
w
10
x
definition of
integrated care suggests, the potential benefits of
generic integrated approaches are significant for both
patients and providers. In the specific context of
primary care mental health, Blount
w
12
x
suggests there
is evidence that an integrated approach to care can
improve adherence to medication because it provides
a better fit with the often undifferentiated way patients
present, increase satisfaction with care and, because
of transfer of expertise among team members, can
improve providers’ skills base in dealing with psycho-
social aspects of care. A number of commentators
have also suggested that integrated care can be more
cost effective
w
12,13
x
.
There is also an increasing evidence base for both
the central importance of continuity of care for people
with serious mental illness
w
4
x
and of the misinterpre-
tations and consequences of being lost to follow up
w
14
x
which add weight to the arguments for a more
integrated approach to mental health care.
People with serious mental health problems are also
among the most socially excluded within any society,
subject to the interlocking and mutually compounding
problems of impairment, discrimination, diminished
social roles, unemployment and lack of social net-
works
w
15
x
. They have fewer options and resources
than most and many find it problematic to negotiate
the complex bureaucracies and range of different
agencies involved in mental health. They, therefore,
need services that are well integrated at the point of
contact and a health care system that makes sense
from their perspective, that fits their differing needs at
different points in their journey and that adopts a
holistic approach to care
w
16
x
.
The consequences of poorly integrated
services
There are a number of costs of poor integration.
Perhaps the most extreme cost was reinforced by a
series of enquiries into murder cases involving people
with mental health problems. The Ritchie report
w
17
x
,
which was the culmination of the inquiry into the killing
of Jonathan Zito by Christopher Clunis, who was
diagnosed as having schizophrenia, at a London
underground station in 1992, highlighted the difficulties
inherent in joint working between services, the dupli-
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
3This article is published in a peer reviewed section of the International Journal of Integrated Care
December 1997 The New NHS: Modern, Dependable
December 1998 Modernising Mental Health Services:
Safe, Sound and Supportive
October 1999 NSF for Mental Health
July 2000 NHS Plan
July 2001 Shifting the Balance of Power
August 2001 The Health and Social Care Act
January 2002 Shifting the Balance of Power—
the Next Steps
April 2002 PCTs go live across England
June 2002 NHS Reform and Health Care
Professionals Act
April 2004 New GP contract came into force
Figure 1. Policy time line from 1997.
cation of effort and indeed the potential for no-one
taking ultimate responsibility. The Ritchie Report did
not, on the whole, blame individuals and indeed noted
that Christopher Clunis was in some sense a victim
of the health and social care system since he had
spent over 5 years being sent between different facets
of the health and welfare service, between hospital,
hostels and prison with no overall plan for his care
and inadequate supervision for many aspects of the
health and social services.
From the patients’ perspective, although relatively little
has been published on users’ views of integrated
services, Preston
w
14
x
found that many patients felt
they had been left in limbo, with poor communication
and co-ordination across the interface often to blame.
As one of the people interviewed in his study
commented:
Separate clinics don’t talk to each other or ring each
other. I find the whole thing incredible, the length of
time it takes: it’s just been horrendous, waiting weeks
to see a consultant to be told ‘I don’t know why you’ve
been referred to me’«It can make you feel very insig-
nificant (1999, p.19).
Case studies of integrated care
Policy background
When New Labour formed the Government in the
United Kingdom in 1997, one its main policy focuses
was on the ‘modernisation’ of all sectors of Govern-
ment. This encompassed the promotion of partnership
working between different areas of Government and
with the voluntary and private sectors, and consulta-
tion with patients. Giddens
w
18
x
described this new
way of working as a ‘third way’ in the delivery of
welfare and health care between centralised, bureau-
cratic planning and marketised, consumerist liberal-
ism. The concept of the ‘third way’ took on particular
meaning at this time as it also became associated
with the politics of the New Democrats led by Bill
Clinton in the United States.
Echoing third way ideals, the Government’s first sub-
stantive health service White Paper The New NHS:
Modern and Dependable
w
19
x
stated:
The Government is committed to building on what has
worked but discarding what has failed. There will be
no return to the old centralised command and control
of the 1970s « but nor will there be a continuation of
the divisive internal market system of the 1990’s «
Instead there will be a third way of running the NHS—
a system based on partnership (Secretary of State for
Health, 1997, p. 10).
However, as the following case studies will demon-
strate, there is evidence to suggest that the speed of
change and number of significant often paradoxical
policy directives are in many ways responsible for the
failure of fully integrated services across health care
(see Figure 1). We will now examine these policy
paradoxes from three different perspectives: integra-
tion of services for people with serious mental illness
within primary care, secondary care and finally, across
the interface between primary and secondary care.
Case study 1: horizontal integration in
primary care for people with serious
mental illness
One of the main changes heralded in The New NHS
w
19
x
was that commissioning would be in the hands
of Primary Care Trusts, that is, a new basic organi-
sational unit of the National Health Service covering
an average of 100,000 patients set up to manage,
commission and also to some extent provide primary
care services, instead of fund holding General Practi-
tioners and Health Authorities. However, the policy
document on Primary Care Trust formation, Shifting
the Balance of Power
w
20
x
in 2001 dramatically accel-
erated the timeframe for their formation. Twelve
months later, Shifting the Balance of Power—the next
steps
w
21
x
gave Primary Care Trusts additional
responsibility for commissioning all mental health serv-
ices. There are now over 300 Primary Care Trusts in
England, controlling 75% of the health budget. They
have, in effect, become substitute Health Authorities
for their geographical areas, but operate from primary
care rather than acute care platforms. However,
almost as soon as Primary Care Trusts had started to
function as independent bodies, the introduction of the
new General Medical Services Contract, effective from
April 2004
w
22
x
and of practice based commissioning
in 2005
w
23
x
, led to a further series of fundamental
changes in the way in which primary care is delivered
(see Figure 2).
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
4This article is published in a peer reviewed section of the International Journal of Integrated Care
Central Regional Strategic NHS Trusts: Foundation Primary
Management Management Health NHS (Acute) Trusts Care
Authorities Trusts, Trusts
(SHAs) and Ambulance (PCTs)
Special Trusts,
Health Mental Health
Authorities Trusts
(MHTs),
Care Trusts
(Provide
services in
more than one
sector)
Secretary Regional 28 SHAs c. 280 NHS c. 31 c. 300 PCTs
of State for Public (the link (Acute) Trusts Foundation
Health Health between the c. 33 Trusts
answerable Teams DOH and Ambulance
to the NHS) Trusts
Parliament. c. 80 MHTs
Department
of Health
(DOH).
Figure 2. The NHS structure in England.
The new General Medical Services Contract, which
directly affects the 36,000 General Practitioners in the
United Kingdom and their patients, is a practice-based
contract between the Primary Care Trust and the
practice. There are far more centrally driven targets
which may theoretically encourage a better quality
core service with, for example, points (meaning mon-
ey) related to the delivery of specific services. It may
also help to ensure greater consistency in standards
and services. General Practitioners can now decide
to offer services at one of three levels: essential
services for people with acute and chronic illnesses
and which have to be provided by all practices;
additional services including maternity and contracep-
tive services which are being offered by most practic-
es, and enhanced services (which are optional)
including specialised care for people with depression.
From the perspective of patients with mental health
problems such as severe depression, the new contract
means that they may be able to see their regular
General Practitioner for the sore throat, but have to
go to a different health care setting to discuss their
depression if the Primary Care Trust has set up
specialised enhanced services for people with depres-
sion as part of the enhanced services scheme. Poten-
tial outcomes of this new way of providing services
include poorer continuity of care, an important part of
integrated care, particularly for people with serious
mental illness. This policy imperative also reinforces
the Cartesian notion of seeing people as having either
a physical or a mental health problem.
The advent of primary care practice based commis-
sioning from April 2005 poses an additional potential
threat to integrated mental health care. In 1997, when
New Labour abolished fund holding, the Government
made it clear that that it was keen to see practices
given the opportunity to hold indicative budgets to
commission a full range of services
w
19
x
. The NHS
Improvement Plan
w
24
x
stated that practices would be
able to hold an indicative budget from April 2005 to
commission services including community health team
assessments, psychological therapies and services
from specialised functionalised teams such as early
intervention and assertive outreach teams. Potential
benefits cited in support of practice based commis-
sioning include an opportunity to offer ’seamless’
health and social care. However, drawbacks highlight-
ed by Craig et al.
w
25
x
include the tension that may
be created between the need for strategic planning to
underpin sustainable commissioning and the frag-
mented nature of devolved commissioning to individ-
uals or groups of practice. Unlike many other areas
of the National Health Service, it is additionally difficult
to attach a price tag to mental health services (indeed
mental health services are excluded from the Payment
by Results scheme introduced in April 2005 precisely
because of this reason). Practice based commission-
ing also requires consistent quality of service delivery
and good quality information about services to be able
to offer patients a meaningful choice. Neither of these
is as far advanced in mental health services as in
other parts of the National Health Service. Whilst the
formation of Primary Care Trusts could be seen as a
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
5This article is published in a peer reviewed section of the International Journal of Integrated Care
strong driver towards integrated care, the new GP
contract and subsequent devolution of commissioning
back to individual practices and localities threatens to
significantly fragment services particularly for patients
with serious mental illness.
Case study 2: horizontal integration—
the effect of functionalised mental
health teams on integrated secondary
care mental health services
Since the 1980s, multi-disciplinary generic Community
Mental Health Teams have been the main vehicle for
delivering co-ordinated comprehensive community
based mental health services
w
26
x
. Recently, however,
this notion of a generic community mental health team
responsible for all aspects of care for people with
common mental health problems referred from primary
care and also people with serious mental illness and
more complex needs has been reassessed. Evidence
from evaluations of service models in North America
w
27
x
and Australia
w
28
x
and successful remodelling of
the community mental health services in North Bir-
mingham in the United Kingdom have been influential
in the thinking and development of functionalised
mental health teams, that is, specialist teams organi-
sed to provide for the needs of particular patient
groups. This approach has been reinforced by the
NSF for Mental Health
w
29
x
, The NHS Plan
w
30
x
and
a series of Mental Health Policy Implementation
Guides
w
31
x
describing the more detailed team struc-
ture and functions.
The Guidance on community mental health teams
states that ‘Community Mental Health Teams will
continue to be the mainstay of the system. Community
mental health teams have an important and indeed
integral role to play in supporting service users and
families in community settings. They should provide
the core around which newer service elements are
developed’ (2002, p. 3). Although the guidance is not
prescriptive about the relationships between Commu-
nity Mental Health Teams and the newer functionali-
sed teams, it suggests that ‘mutually agreed and
documented responsibilities, liaison procedures and in
particular transfer procedures need to be in place
when crisis resolution, home treatment teams, asser-
tive outreach teams and early intervention teams are
being established’ (2002, p. 17). Community Mental
Health Teams in future are, therefore, envisaged as
the central hub of mental health care, liaising with the
more specialised teams as well as with primary care.
These policy pledges, which led to the formation of a
series of functionalised teams, look on the surface to
encourage more appropriate and focussed care with-
out threatening the horizontal integration of mental
health services. However, in practice, they appear to
be having a number of paradoxical effects. Emerging
evidence from national evaluations of some of the
functionalised teams suggest that one unexpected
consequence of their introduction is a disintegration
of services from the patient’s perspective. There are,
for example, concerns about the speed with which
Early Intervention Services are being developed
w
32
x
and commissioned and, indeed, the need for a sepa-
rate Early Intervention Services at all
w
33
x
. Within
some Early Intervention Services, evidence from the
EDEN study suggests that variable ‘buy in’ to the
concept at Primary Care Trust commissioning level
has led to problems with releasing funds to develop
new teams and downward financial pressures on
existing ones. This is turn has led to staff shortages
and time constraints and resulted in some teams
deciding to reduce the age criteria for admission to
services. There has also been insufficient time to
develop links with teams who provide out of hours
care (between 6 pm and 9 am) and liaise with teams
who feed into early intervention services and take over
care once the initial period of care by the Early
Intervention Service is complete, all of which pose
significant threats to patient continuity of care (EDEN
early intervention services evaluation project team,
personal communication). Effective integrated care
requires new teams to have clear lines of communi-
cation with existing teams and adequate financial
resources, not redistribution of existing monies from
more established teams.
Case study 3: vertical integration across
the interface
In the United Kingdom, integrated mental health care
is most commonly represented as a system of shared
care between the primary health care team and sec-
ondary care mental health services
w
34
x
. In the early
1990s, it was estimated that, at any one time, between
20 and 30 people per 1,000 of the United Kingdom
population were being referred to out-patients or to
Community Mental Health Teams for further care, and
were, therefore, in receipt of shared care
w
35
x
. There
is little to suggest that the numbers are much different
today.
From a policy perspective, shared care has been
increasingly mandated since the advent of the New
Labour Government in 1997, reflecting the partnership
approach within the wider modernisation agenda. Pri-
mary care, for example, has specific responsibility for
delivering standards two and three of the National
Service Framework for Mental Health
w
29
x
and is also
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
6This article is published in a peer reviewed section of the International Journal of Integrated Care
1. Community mental health teams provide increased liaison with primary care and crisis intervention, although communication can be slow
and laborious and Community Mental Health Teams can find themselves swamped with people with common mental health problems
2. Shifted outpatient clinics enable psychiatrists to operate clinics within primary care health centres although may lead to a deskilling of
General Practitioners
3. Attached trained mental health workers, usually community psychiatric nurses work with people with mental health problems in a primary
care setting although this can lead to confusion over roles and responsibilities
4. The consultation liaison model enables primary care teams access to advice and skills from specialist mental health services although
studies of changes to patient outcomes are usually limited to patients under the direct care of the mental health worker
5. Integrated working models create seamless patient pathways through the health system, going one step beyond collaboration, to co-
ordination and often co-location of care.
Figure 3. Models of mental health care at the primaryysecondary interface.
integrally involved in the delivery of the other five
standards with secondary care mental health services.
The NHS Plan
w
30
x
further underpinned this with over
£300 million of investment to help implementation,
included specific pledges to create 1,000 new gradu-
ate mental health workers to work in primary care and
encourage a shared care approach across the inter-
face. There are also negotiations at a national level
around formally extending the role of General Practi-
tioners with a special clinical interest, including mental
health, who will play a key role in managing people
with depression and serious mental illness within
appropriate shared care arrangements with secondary
care
w
36
x
. A range of secondary care policy initiatives
are also encouraging shared care. The recent National
Institute of Clinical Excellence guidance on schizo-
phrenia includes a series of clinical practice recom-
mendations from developing primary care practice
registers for people with schizophrenia, the develop-
ment of advance directives placed in both primary and
secondary care and the development of referral guide-
lines from primary to secondary care
w
37
x
.
However, despite this plethora of guidance and new
roles to encourage horizontal integration, there is little
consistency between Primary Care Trusts in terms of
the type of care commissioned between primary care
and secondary care mental health services and the
advent of Practice Based Commissioning is likely to
lead to an even more disparate approaches.
There are currently at least five different models of
interface working and little consensus over how inte-
grated care could best be achieved
w
38
x
. Each model
involves different players and degrees of commitment
to the concept of integration. Each attempts to enable
communication across the interface and has its own
particular strengths and weaknesses (see Figure 3).
Other barriers to more integrated care across the
primaryysecondary care interface include the paucity
of formal training in mental health for General Practi-
tioners. A recent survey found that only one third of
General Practitioners had received any mental health
training in the last 5 years, while 10% expressed
concerns about their training or skills needs in mental
health
w
38
x
. From a secondary care perspective, bar-
riers to greater integration are less those of training,
but more of a lack of understanding of the culture of
primary care, defensive attitudes and a lack of certain-
ty over roles and responsibilities
w
39
x
. Poor commu-
nication across the interface is also an important
barrier to integrated working. There appear to partic-
ular issues created by poor communication between
psychiatrists and General Practitioners about non
attendance by follow-up patients, who are often more
unwell and harder to engage than new patients
w
40
x
.
General Practitioners have also reported that they
don’t know the mental health consultant well enough
to telephone them for advice and very few Community
Mental Health Teams had a clear strategy for com-
munication with primary care
w
41
x
.
Conclusion
This paper has suggested that while the central thrust
of a raft of recent Government policies in England has
been towards integration of different parts of the health
care system, policy waterfalls and implementation
failures, the adoption of ideas before they have been
thoroughly tried and tested, a lack of clarity over roles
and responsibilities and poor communication have led
to an integration rhetoricyreality gap in practice.
Whilst the paper has focussed on the English context,
similar barriers to integration are being experienced in
other health care systems and the arguments
rehearsed here are applicable to many other national
settings
w
1,2
x
. Whilst policy may provide leverage for
organisational restructure and reform, it does not
necessarily provide the essential ingredients for pro-
fessional collaboration. Relatively immature organisa-
tions have had to respond to a series of policy
initiatives where there is often limited management
expertise or organisational memory. Surveys have
suggested problems with management capacity and
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
7This article is published in a peer reviewed section of the International Journal of Integrated Care
expertise in commissioning services including mental
health
w
42
x
. Some Primary Care Trusts and Mental
Health Trusts have also inherited debts from the old
Health Authorities making it more difficult to plan and
provide new services. Inefficient interagency collabo-
ration particularly where different parts of the system
have different ideologies and priorities, inadequate
mechanisms for enabling the shift of finance from
hospitals to community care have also created
problems.
Despite the increasing attention given to mental health
policy in England, tensions remain between the plan-
ning and development of well-informed policy, under-
pinned by consistent and robust frameworks and the
actual delivery and implementation of such policies,
particularly in mental health. This paper has highlight-
ed some of the social and political challenges involved
in the implementation of mental health policy in Eng-
land. These issues are by no means unique to the
English situation and reflect experiences throughout
Europe in implementing mental health policy.
There are no easy solutions. To facilitate integrated
working, increased attention needs to be focussed on
overcoming inter-organisational divides and inter-pro-
fessional differences with the aim of fostering and
maintaining commitment and enthusiasm for joint
working. Knowledge sharing, respect for the autonomy
of the different groups involved, the surrender of
professional territory where necessary are key to the
development and the effective sharing of values and
goals
w
43,44
x
. These can be encouraged by inter-
professional education which enables practitioners to
learn about each other’s settings and strengths and
encourage a culture of collaboration and mutual
respect. Above all, however, a ‘policy amnesty’ to
enable time and space for Primary Care Trusts, local-
ity commissioning groups in primary care and Mental
Health Trusts to catch up and rationalise their strate-
gies is required to reduce the ‘push-me pull-you’ policy
paradox of integrated mental health care.
Reviewers
Peter F M Verhaak, PhD, Research coordinator for mental
health services research at the NIVEL, Netherlands institute
for health services research, Utrecht, The Netherlands.
Nick Goodwin, Dr, Senior Lecturer in Health Services
Delivery and Organizational Research, Health Services
Research Unit, London School of Hygiene and Tropical
Medicine, London, United Kingdom
Susan Gregory, Dr, Psychiatrist, Scientific Associate,
Department of Health Economics, National School of Public
Health, Athens, Greece.
References
1. Fleury MJ, Mercier C. Integrated local networks as a model for organizing mental health services. Administration and
Policy in Mental Health 2002;30(1):5573.
2. Horner D, Asher K. General practitioners and mental health staff sharing patient care: working model. Australasian
Psychiatry 2005;13(2):17680.
3. Davey B, Levin E., Illife S, Kharicha K. Integrating health and social care: implications for joint and community care
outcomes for older people. Journal of Interprofessional Care 2005;19(1):2234.
4. Freeman G, Weaver T, Low J, de Jonge E. Promoting continuity of care for people with severe mental illness whose
needs span primary, secondary and social care. A report for the NCCSDP. London: SDO; 2002.
5. Glasby J, Lester HE, England E, Clarke M. Cases for change in mental health. Colchester: National Institute for Mental
Health; 2003.
6. Singleton N, Bumpstead R, O’Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households,
2000. London: TSO; 2001.
7. Bird L. The fundamental facts: all the latest facts and figures on mental illness. London: Mental Health Foundation; 1999.
8. Sainsbury Centre for Mental Health. Setting the standard: the new agenda for primary care organisations commissioning
mental health services. London: Sainsbury Centre for Mental Health; 2001.
9. Jenkins R, Ustun T, Bedhiran E. Preventing mental illness: mental health promotion in primary care. Chichester: Wiley;
1998.
10. Kodner DL, Spreeuwenberg C. Integrated care: meaning, logic, applications, and implications a discussion paper.
International Journal of Integrated Care
w
serial online
x
2002 November 14; 2. Available from: URL:http:yywww.ijic.orgy.
w
cited 2004 12 30
x
.
11. Rhodes RAW. Transforming British Government. London: Macmillan; 2000.
12. Blount A. Integrated primary care: the future of medical and mental health collaboration. London: Norton and Co; 1998.
13. Thornicroft G, Tansella M. Co-ordinating primary care with community mental health services. In: M.Tansella and G
Thornicroft, editors. Common mental health disorders in primary care. London: Routledge; 1999. p. 2225.
14. Preston C, Cheater F, Baker R, Hearnshaw H. Left in limbo: patients’ views on care across the primaryysecondary
interface. Quality in Health Care 1999;8:1621.
International Journal of Integrated Care Vol. 5, 3 October 2005 ISSN 1568-4156 http://www.ijic.org/
8This article is published in a peer reviewed section of the International Journal of Integrated Care
15. ODPM. Mental health and social exclusion. Social exclusion unit report. London; 2004.
16. Sainsbury Centre for Mental Health. Taking your partners: using opportunities for inter-agency partnership in mental
health. London: Sainsbury Centre for Mental Health; 2004.
17. Ritchie Report. Report of the inquiry into the care and treatment of Christopher Clunis. London: HMSO; 1994.
18. Giddens A. The third way. A renewal of social democracy. Cambridge: Polity Press; 1998.
19. Department of Health. The new NHS: modern, dependable. London: The Stationary Office; 1997.
20. Department of Health. Shifting the balance of power within the NHS: securing delivery. London: Department of Health;
2001.
21. Department of Health. Shifting the balance of power within the NHS: the next steps. London: Department of Health;
2002.
22. BMAyNHS confederation. Investing in general practice: the new general medical services contract. London: BMAyNHS
confederation; 2003.
23. Sainsbury Centre for Mental Health. Practice based commissioning in the NHS: the implications for mental health.
London: Sainsbury Centre for Mental Health; 2004.
24. Department of Health. The NHS improvement plan: putting people at the heart of public services. London: Department
of Health; 2004.
25. Craig N, McGregor S, Drummond N, Fischbacher M, Illiffe S. The primary care led NHS 1: shifts in resources to primary
care for three clinical conditions an empirical study. Report to the NHS Executive North Thames, Department of Public
Health, Glasgow University; 2002.
26. Kingdon, D. Mental Health Services: results of a survey in English district plans. Psychiatric Bulletin 1989;13:778.
27. Stein LI, Test MA. An alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical
evaluation. Archives of General Psychiatry 1980;37:3929.
28. Hoult J. Community care of the acutely mentally ill. British Journal of Psychiatry 1986;149:13744.
29. Department of Health. National Service Framework for Mental Health: modern standards and service models. London:
Department of Health; 1999.
30. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: Department of Health; 2000.
31. Department of Health. Mental health policy implementation guidance: community mental health teams. London: Depart-
ment of Health; 2002.
32. Burns T. Community mental health teams: a guide to current practices. Oxford: Oxford University Press; 2004.
33. Pelosi A, Birchwood M. Is early intervention of psychosis a waste of valuable resources? British Journal of Psychiatry
2003 Mar;182:1968.
34. Goldberg D, Huxley P. Common mental disorders. London: Routledge; 1992.
35. Lester HE, Glasby J, Tylee A. Integrated primary care mental health: threat or opportunity in the new NHS? British
Journal of General Practice 2004;54:28591.
36. Department of Health. Guidelines for the appointment of general practitioners with special interests in the delivery of
clinical services: Mental Health. London: Department of Health; 2003.
37. NICE. Schizophrenia. Full national clinical guidelines on core interventions in primary and secondary care. London: Royal
College of Psychiatrists and the British Psychological Society; 2003.
38. Mental After Care Association. First national GP survey of mental health in primary care. London: MACA; 1999.
39. Nolan P, Dunn L, Badger F. Getting to know you. Nursing Times 1998; 94(39):3436.
40. Killaspy H, Banerjee S, King M, Lloyd M. Non-attendance at psychiatric outpatient clinics: communication and implications
for primary care. British Journal of General Practice 1999; 49:8803.
41. Bindman J, Johnson S, Wright S, Szmukler G, Bebbington P, Kuipers E, et al. Integration between primary and secondary
services in the care of the severely mentally ill: patients’ and general practitioners’ views. British Journal of Psychiatry
1997;171:16974.
42. Lester HE, Sorohan H. Barriers and organisational development needs for effective PCT commissioning of mental health
services. Primary Care Mental Health 2003;1:3744.
43. Freeth D, Reeves S. Evaluation of an interprofessional training ward: pilot phase. In: Glen S, Leiba T, editors. Multi-
professional learning for nurses: Breaking the boundaries. Hampshire: Palgrave; 2002. p. 11638.
44. Hammick M, Barr H, Freeth D, Koppel I, Reeves S. Systematic reviews of inter-professional education: results and work
in progress. Journal of Inter-professional Care 2002;16:804.
Article
    This article explores some of the current issues in providing primary care for people with serious mental illness. In contrast to many patients in the United States, up to half of patients with serious mental illness in the United Kingdom are seen only by the primary care team. However many General Practitioners feel that the care of this patient group is beyond their remit. In the United... [Show full abstract]
    Article
      Primary care mental health workers are a new role recently introduced into primary care in England to help manage patients with common mental health problems. To explore the views of GPs, primary care teams and patients on the value and development of the new role of primary care mental health workers in practice. Qualitative study. The Heart of Birmingham Primary Care Teaching Trust in the... [Show full abstract]
      Article
        This qualitative study explores the experiences of stakeholders in implementing the guidance for early-intervention services (EIS) for first-episode psychosis in England. One important challenge in implementing early-intervention policy is to develop workable, integrated partnership across a number of diverse organizational boundaries, particularly with child and adolescent mental health... [Show full abstract]
        Article
          In this paper, we argue that mental illness touches everyone's lives, and that mental health care is a core activity of primary care. The increasing move towards a primary care-led National Health Service has now created a climate where primary care can move beyond providing a gatekeeper function for secondary care specialist services. Primary care is also sufficiently mature as a discipline... [Show full abstract]
          Discover more