Mind > Information > Factsheets and booklets by subject > Community care > Community care 4

Copyright note for Mind factsheets: Both individuals and organisations are welcome to print and photocopy any complete factsheet from the 'Information' section of Mind's website. Organisations are free to distribute them to service users and colleagues, but must ensure they always use the latest version of the factsheet, as available on the website, at the time of distribution.

The factsheet attempts to give an overview of how, and some of the reasons why, health and social services are working together to plan, purchase, pool resources and provide services for the health needs of their local population - a process known as 'joint commissioning'. A fuller explanation is beyond the scope of this factsheet. This factsheet is targeted at students and mental health professionals.

Before the NHS and Community Care Act 1990, most health and public services were planned, as well as directly provided, by health authorities and local authorities. This Act split the role of health authorities and local authorities by changing their internal structure. For more information on the NHS and Community Care Act 1990 see #2 - Systems for delivering mental health services.

This change in structure meant that local authority departments took on responsibility for assessing the needs of the local population and then purchasing the necessary services from providers (either their own departments or other organisations in the voluntary and/or independent sectors). Some health and social services authorities chose not to compete with other providers and work together by involving other sections of the community e.g. voluntary groups and housing associations.

To do this, the purchasing agency draws up a service specification and then invites providers to tender for the contract to provide those services. This change was introduced to create what the last government described as a 'mixed economy of care'. Local authorities were expected to make maximum use of the independent sector and to purchase 85 per cent of services from voluntary or independent sector providers.

The introduction of 'a mixed economy of care' and the 'purchaser - provider split' was intended to give service users more choice. However, some local authorities chose to purchase services as part of a 'block contract' (where a certain service is provided for a fixed price and a fixed length of time). Purchasing services in this way may actually reduce choice for the individual, as frequently no alternatives (outside those provided by the block contract) are made available.

Mind's policy on community care states that where an individual requires a service outside a local authority's block contract, individual contracts should be encouraged.

Note: At the time of writing this factsheet, Mind's policy on Community Care is being updated.

In theory, the 'purchaser - provider split' has some clear advantages over direct service provision. Contracts drawn up between purchasers and providers should include a clear specification of how the agreed service will operate, what it will provide, and how it will be monitored. However, its success depends upon whether there are real opportunities for individual choice, and whether effective ways of ensuring quality are in place.

The advisability of an 'internal market' system within the NHS has long been the subject of debate. Cost is undoubtedly a driving force when service providers compete for contracts, which must have an impact on the quality of care being provided.

Commissioning local mental health services should be consistent with standards set out in the individual National Service Frameworks for England (1999) and Wales (2002).

A 1998 Department of Health report identified a number of more specialised services, including medium and high secure psychiatric services, services for severe eating disorder, early dementia and gender dysphoria, and mother and baby units. These services will continue to be provided within specialist mental NHS trusts; high security services will remain within the three high security hospitals [1].

The Framework [2] states that health and social care services will need to agree their arrangements for commissioning with the Directorates of Health and Social Care. These arrangements have slowly evolved as local health and social care communities make use of the new 'flexibilities' between health and local authorities, which allow budgets to be pooled, integrated provision, and the identification of lead commissioning roles.

Whichever option is selected, long term service agreements, which will replace contracts, should be consistent with Health Improvement and Modernisation Plans (HIMPS). HIMPS are explained later on.

Where NHS patients are treated under contract in the private and voluntary health care sector, the responsible NHS commissioning body should ensure that its contracts apply the same clinical governance principles, including the use of the National Service Frameworks.

Standard 5 of the National Health Service Framework for Adult Mental Health for Wales [3] states that effective services must be jointly planned, commissioned and delivered in an efficient coordinated manner in order to provide responsive, seamless care. This will require:

The Welsh Assembly Government, a Strategy Implementation Team, NHS and Local Authorities are responsible for ensuring that the NSF is implemented, progress monitored and targets achieved.

In 1997, the White Paper The New NHS: modern, dependable first set out the government's intention to modernise the structure of the NHS in England.

The White Paper Putting Patients First (1998) did the same thing in Wales. The New NHS outlined plans to abolish the worst of the so-called 'internal market', whilst retaining the best elements of commissioning.

Both NHS White Papers for England and Wales, as well as Modernising Social Services (1998) and Building for the Future (1999) (the White Paper on social services for Wales) have emphasised the need for more co-operation between health and social care agencies if service provision is to be improved. Primary Care Trusts (previously Primary Care Groups), Local Health Boards (to be established in 2003 to replace Local Health Groups) and NHS Trusts all have a part to play in establishing better joint working between the different service agencies, as well as local authorities. In July 2000, the government published The NHS Plan which is a radical plan for the next ten years, which sets out the measures to put patients and people at the heart of the health service.

The NHS Plan states that all these bodies will work within the Health Improvement and Modernisation Plan (previously Health Improvement Programme) which will require them to co-ordinate their efforts.

New roles and responsibilities for NHS England and NHS Wales (in alphabetical order)

The NHS Plan first proposed the creation of Mental Health and Social Care Trusts "to ensure that mental health and social care provision can be properly integrated locally". The Health and Social Care Act 2001 provides the legal framework for the establishments of Care Trusts, including Mental Health and Social Care Trusts.

Since 2001, if Primary Care Trusts and National Health Services Trusts can show that there is a significant level of integration between health and social care services, they can successfully apply to the Secretary of State in England for Health for Mental Health and Social Care Trusts status. Primary Care Trusts and National Health Services in Wales can apply to the Welsh Assembly.

Mental Health and Social Care Trusts could manage a range of services which include adult mental health services, care of older people, substance misuse; working with people with learning difficulties and mental health problems.

In a response to a consultation document on the development of a recent Mental Health and Social Care Trust, Mind welcomed the integration of health and social care. Mind also believes that this can lead to "improved joint working and therefore improved service provision for people with mental health problems."

"Although care trusts should have 'jointly agreed and managed services' to provide a good model of mental health care; it is important that when budgets are set, the levels of needs in delivering services are taken into account."
Melba Wilson, Mind Policy Director, 2002

"It is important that the range of needs of mental health service users are understood, assessed and provided in a comprehensive manner. This includes care and support needs, including housing." Melba Wilson, Mind Policy Director 2002

It is envisaged that Specialist Mental Health Care Trusts will be service providers only; they will not commission services. There will be joint working between the Care Trusts, Primary Care Trusts and the local authorities.

At the time of writing this factsheet there are only a small number of Care Trusts in development, though is expected that more will be set up in the future.

Health Improvement Programmes (HIPs) have been renamed Health Improvement and Modernisation Plans (HIMPs). This is because they are expected to plan and provide the vision on how the local NHS, with its partners, will modernise services to tackle ill health as well as the causes of ill health. HIMPs will set out the three year vision to (a) improve local health (b)include all key partners in planning of services and (c)tackle the root causes of ill health and modernise services.

Strategic Health Authorities (discussed later on) currently have lead responsibility for bringing partners together to develop the HIMPs and ensuring the necessary involvement, from the outset of local organisations including NHS Trusts, Primary Care Trusts, Local Authorities, the voluntary sector and local communities. HIMPs should provide the basis for all other planning across the local system, with details of specific activities like the National Service Frameworks and Joint Investment Plans. These will be drawn up between health and social services to provide for groups where a coordinated service is particularly important.

From October 2002, it is expected that once the necessary legislation is in place that the development of HIMPs will be the responsibility of the Primary Care Trusts.

Under the guidance of Putting Patients First 1998, Local Health Groups (LHGs) were originally established. These brought together GP practices, other health care professionals and, more explicitly than in Primary Care Groups (PCGs), social services departments and voluntary organisations. LHG boundaries coincide with those of unitary health authorities. Like former PCGs, Local Health Groups are expected to be given the opportunity to achieve Primary Care Trust status subject to National Assembly for Wales approval.

From 1 April 2003 Local Health Groups will be strengthened to become 22 Local Health Boards (LHBs) and become statutory bodies. This will give them the power and status which will be essential for them to discharge their new responsibilities. LHBs, Local Authorities, Trusts and the voluntary sector will work together, to ensure joined up and, where appropriate, integrated commissioning arrangements for community services within local populations [4].

The introduction of The New NHS 1997 has also meant that health authorities and NHS Trusts also made changes. NHS Trusts will continue to have the same functions as before i.e. responsible for running most hospitals, some are attached to universities to help to train health professionals, but they will have to develop new working relationships with Primary Care Trusts, and will be accountable to the 'new' Strategic Health Authorities rather than the Department of Health.

One of the most significant developments to arise from The New NHS 1997 was the introduction of Primary Care Groups (PCGs). PCGs were gradually phased in by 1999 and were seen as a better way of commissioning and delivering services to the local population. PCGs marked the beginning of a more wide-reaching role for primary care and had the freedom to make decisions about how they use their resources, consistent with the then Health Improvement Programme.

From April 1st 2002, Primary Care Groups evolved into Primary Care Trusts (PCTs), one of two important bodies making decisions about health provision. (Strategic Health Authorities being the other) This means that PCTs are free-standing bodies, responsible for commissioning healthcare (including most specialist mental health services) for their local populations. PCTs are seen as the cornerstone of the NHS and will receive 75 per cent of the NHS budget by 2004. At the time of writing this factsheet, there are currently 303 PCTs covering England, each uniquely placed to have an overview of the organisations and bodies providing health and social care services. Each PCT is responsible for planning and securing services; improving the health of the community and integrating health and social care locally.

The Department of Health's 8 regional offices have been abolished and four new Regional Directorates of Health and Social Care will work directly with the NHS and performance manage Strategic Health Authorities.

The National Assembly for Wales is responsible for policy direction and for allocating fund to the NHS in Wales. The Assembly allocates funds annually to each of the five Welsh regional health authorities. The health authorities buy health services from professionals in primary care, such as family doctors, dentists and opticians, and from the NHS Trusts that provide community care.

In April 2002, 95 Health authorities were merged and replaced by 28 new larger Strategic Health Authorities (SHAs). SHAs have responsibility for developing strategy and managing the performance of PCTs and NHS Trusts. They have stronger powers to improve the health of their residents; in effect SHAs manage the NHS on behalf of the Department of Health. The NHS paper Shifting the Balance of Power: The Next Steps 2001 sets out the framework and principles of these changes - but - in line with its own philosophy - it leaves practical arrangements, the how, when and where of working arrangements and service delivery to be decided locally e.g. they don't make the decisions about what services to commission.

Mind has produced a range of Understanding leaflets, factsheets and brief guides addressing different mental health problems which relate to this topic.

#1 The spectrum of mental health services
#2 Systems for delivering mental health services
#3 How to access community mental health services
#5 Charging for services

How to access services - information for carers
Counselling
Crisis services
Crisis services (...list of )
Housing
Supported housing and residential care

Getting the best from ... Your Approved Social Worker
How to assert yourself
How to cope as a carer
How to help someone who is suicidal
How to improve your mental well-being
How to look after yourself
Mind guide to advocacy
Understanding mental illness

1. Civil admission to hospital
2. Mental health and the police
3. Consent to medical treatment
4. Discharge from hospital
5. Mental health and the courts
6. Supervised discharge and supervision registers
7. Managing your finances

These legal advice booklets are designed to help users of mental health services, their relatives and professionals to understand the Mental Health Act 1983 and related law. They should be read in conjunction with the Code of Practice.

antidepressants
cognitive behaviour therapy
ECT
major tranquillizers
minor tranquillizers
sleeping pills
lithium

Assertive Community Treatment of Persons with Severe Mental Illness Leonard I. Stein and Alberto B. Santos W.W. Norton, 1998, £19.95

Choice, Information and Dignity - Involving users and carers in care management and mental health John Carpenter and Silvia Sharaini The Policy Press, 1997, £13.95

Community Care: A reader (2nd edition) Eds. Joanna Bornat, Julia Johnson, Charmaine Pereira, David Pilgrim and Fiona Williams Oxford University Press, 1997, £13.99

Dancing with Angels David Crepaz-Keay, Chris Binns and Evelyn Wilson CCETSW, 1997, £8.00

Drug Treatment in Psychiatry: A guide for the community mental health worker Peter Tyrer, Phil Harrison-Read and Elizabeth van Horn Butterworth- Heinemann, 1997, £27.50

Guidelines on Equal Opportunities and Mental Health Jan Wallcraft and Jim Read Mind/UNISON, 1995, £2.50

Housing and Social Exclusion Ed. Fiona E. Spears Jessica Kingsley Publishers, 1999, £16.95

Mental Health Act Manual (7th Edition) Richard Jones (Sweet and Maxwell, 2001) £49.00

Mind the Law: Mind's evidence to the Government's Mental Health Act Review Team Margaret Pedler, (Mind, 1999)

Needs Assessment and Community Care - Clinical practice and policy making Ed. Steve Baldwin Butterworth-Heinemann, 1998, £16.99

Adult Mental Health Services - A National Service Framework for Wales Welsh Assembly Government, 2002

Improving Quality in Primary Care: A Practical Guide to the National Service Framework for Mental Health National Primary Care Research and Development Centre, 2002

National Service Framework for Mental Health - Modern Standards and Service Models. Department of Health, 1999.

Carers UK (previously Carers National Association)
20-25 Glasshouse Yard
London EC1A 4JT
Carers Line 080 8808 7777 (10am-12noon, 2-4pm)email: internet@carersnorth.demon.co.uk
web: www.carersnorth.demon.co.uk
Provides information and support for carers. Branches throughout the UK. Information on subjects such as benefits, residential care, respite care and the Carers Act.

MindinfoLine (Mind's telephone information service)
Mind
PO Box 277
Manchester
M60 3XN
tel. 0845 766 0163 Textphone: 0845 330 1585 (if you are using BT Text direct add the prefix 18001) Mon-Fri 9.15am-5.15pm
email: info@mind.org.uk
web: www.mind.org.uk
Information service includes a database of local Mind services and other organisations. Gives basic information on legal rights.

Mind Legal Advice Line
Mon, Wed and Fri 2.00-4.30pm
tel. 020 8519 2122
Gives legal advice on mental health law and related areas by telephone or in writing, has a network of solicitors who have experience in mental health issues and who specialise in different areas of law.
Write to: Principal Solicitor, Mind's Legal Unit, Mind, Granta House, 15-19 Broadway, London E15 4BQ.

NHS Direct
tel. 0845 4647
web: www.nhsdirect.nhs.uk
24-hour helpline providing healthcare advice and information to the public. Enables callers to speak directly to experienced nurses, assists callers to make the right healthcare choice.

UK Advocacy Network (UKAN)
14-18 West Bar Green, Sheffield S1 2DA
tel. 0114 272 8171
email: ukan@can-online.org.uk
web: www.comcom.org/acorn/ukan/htm
Supports, advises and represents a network of user-run advocacy groups.

References

[1] Commissioning in the new NHS, 1999/2000, HSC ( 98) 198. 1998 Department of Health

[2] National Service Framework for Mental Health - Modern Standards and Services Models (September 1999). Department of Health.

[3] A National Service Framework for Wales - Adult Mental Health Services. April 2002. Welsh Assembly Government.

[4] Improving Health in Wales January 2002 NHS Cymru Wales