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Integrated care – Rethink the American Way?

Up to Additional Mental Health Information
January 21. 2012
Theresa Eynon

A recent Health Service Journal posed the question ‘ can CCGs learn from a Californian healthcare model’? The surfing beaches of west coast America can feel a very long way from West Leicestershire on a cold January day – but the healthcare problems are much the same. In California they have IPAs – independent practice associations. Rather like our clinical commissioning groups – CCGs, they take full budgetary responsibility for patients’ long term care.


In the NHS, GPs have, until recently, been rather cushioned from the financial realities of their clinical decisions. With real budgets on the horizon, West Leicestershire CCG, is looking at how, by being more pro-active, GPs can reduce costs while improving clinical outcomes. Practices are identifying patients with complex needs and at high risk of admission.  Working with community teams, they aim to ensure patients and carers are well-informed and have clear care plans so that every penny spent is maximally effective.

The Californian experience suggests that, if CCGs are going to make the most of this strategy, then they need to integrate and to measure. The authors tells us that

Improved integration between physical and mental health care is necessary to improve overall outcomes for patients and reduce overall cost for commissioners” (Wheelan & Stanton, 2012).

As UK GPs, we would want to say ‘Yes, so?’ The biopsychosocial model is written through every primary care consultation – in theory at least. But the gap between aspiration and patient experience that can make all the financial difference (Butler, Evans, Greaves, & Simpson, 2004).

Diabetes, COPD and cardiovascular disease

A US report suggests that up to 70 percent of primary care visits stem from psychosocial issues (Collins, Hewson, Munger, & Wade, 2010) The UK economic case for greater emphasis on mental health care is already well made (Knapp, McDaid, & Parsonage, 2011). The Department of Health have been championing the idea that there can be ‘No Health Without Mental Health’ for some time now (Department of Health, 2011). All primary care practitioners are rewarded by the Quality and Outcomes Framework if they screen for depression in patients with diabetes, cardiovascular disease and COPD.

 ‘What works’ and ‘How do we know’?

GPs know that depression and anxiety worsen the prognosis of patients with chronic physical ill health. They know it makes such patients more difficult to manage. It has been estimated that depression is associated with a 50% increase in the costs of long term medical care (Lyons, Nixon, & Coren, 2006). Patients with severe mental health problems are at greater risk of CVD (Dollery 2011)


It is not always obvious what we should be doing next. Clearly we could do better, but how would we know if we were moving in the right direction? The Californian model suggests that

Good data collection and measurement of quality indicators enabled purchasers to distinguish between services on a non-cost basis (Wheelan & Stanton, 2012).

What is needed is practical, evidence based approaches that improve overall wellbeing and, critically, if this is to be money well spent, ways of determining if these have been useful. An IAPT stakeholder meeting, discussing the extension of Improving Access to Psychological Therapies  to people with severe mental illness recognised that

New services are beginning that challenge the primary/ secondary care dichotomy (NHS, 2011)

Good Thinking.....

Leicestershire’s Good Thinking Therapy Service has been leading the way in showing how a GP-led approach to mental health works across the conventional boundaries (Eynon, 2011). A partnership between Rethink Mental Illness, Leicestershire Partnerships Trust and the GPs of the West Leicestershire LLP, Good Thinking’s innovative mental health facilitators work in practices to assist GPs as they aim to provide good physical care for people with severe and enduring mental illness.

 MHFs use benchmarkable measures of effectiveness. Patient-centred outcome monitoring, that enables us to see which strategies give us the results we want, is key to improvement (Lyons, Nixon, & Coren, 2006) .

Collaborative working between Rethink Mental Illness and GP practices meant that in 2010-11 95.5% of patients with SMI had a comprehensive review including health promotion. Leicestershire County and Rutland GPs were second only to Cheshire in the 2010/2011 National Quality and Outcome Framework for indicator MH09.


The next phase of the project will see Mental Health Facilitators working with GPs to improve care packages for people with long term conditions who have a mental health problem complicating their presentation. They will assist with shared decision making, personal health planning, supported self care and carer support in order to ensure the take up of appropriate primary care services by people who are often difficult to reach.


Rethink Mental Illness

You may have seen that Rethink Mental Illness has updated its logo. Like the Department of Health, they believe we need to ‘rethink mental illness’. It is not only the Californians who recognise than mental and physical ill health cannot be separated out and dealt with in clinical silos. The ‘full stop’ in the logo is there for a reason. We’ve got to do it, because, if we don’t the economy and the NHS will grind to a halt.



Archer, D., & Cameron, A. (2009). Collaborative Leadership: how to succeed in an interconnected world. Oxford: Butterworth-Heinemann.

Butler, C. C., Evans, M., Greaves, D., & Simpson, S. (2004). Medically unexplained symptoms: the biopsychosocial model found wanting. Journal of the Royal Society of Medicine , 97 (5), 219-222.

Collins, C., Hewson, D. L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Integration in Primary Care. New York: Milbank Memorial Fund.

Department of Health. (2011). No health without mental health: a cross-government mental health outcomes strategy for people of all ages.

Dollery, C. (2011). Patients with mental health illness are at higher risk of CVD. Retrieved January 20, 2012, from eGuidelines: http://www.eguidelines.co.uk/eguidelinesmain/gip/vol_14/dec_11/dollery_mental_health_dec11.php

Eynon, T. (2011). Providing mental healthcare in partnership with the private and voluntary sector. Practical Commissioning .

Knapp, M., McDaid, D., & Parsonage, M. (2011). Mental health promotion and prevention: the economic case. London: Personal Social Services Research Unit, London School of Economics and Political Science.

Lyons, C., Nixon, D., & Coren, A. (2006). Long term conditions and depression: considerations for best practice in practice based commissioning. National Institute for Mental Health in England, Care Services Improvement Partnership. London: Department of Health.

NHS, I. (2011). IAPT severe mental illness SMI stakeholder event. Retrieved January 20, 2012, from http://www.iapt.nhs.uk/silo/files/smi-stakeholder-eventreport--final-version.pdf

Nye, A. (2011). RCGP Annual Conference 2011: D8 Commissioning. Retrieved January 2012, 2012, from Culture disruptors: patient decision aids and prime contractors: http://www.rcgp.org.uk/courses__events/rcgp_annual_conference/past_conferences/liverpool__2011/presentations_2011.aspx

Pennine MSK Partnership. (n.d.). Pennine MSK Partnership. Retrieved January 17, 2012, from http://www.pmskp.org/

SUCRAN. (2011). Mental Health Charter Audit. Leicester: Service User and Carer Research and Audit Network.

Wheelan, B., & Stanton, E. (2012). Can CCGs learn to integrate mental health services from a Californian healthcare model? Health Service Journal (12 January 2012).


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