Primary care led commissioning of mental health services: Lessons from total purchasing

Abstract

Introduction: The aim of this paper is to identify lessons for the National Health Service that can be learnt from previous organisational experiments. The paper draws on an evaluation of the purchasing of mental health services by Total Purchasing and Extended Fundholding sites. These are the closest previous models to the newly emerging Primary Care Groups and Trusts. We aimed to determine what primary care practitioners tried to achieve when given a budget for purchasing secondary care mental health services, and what determined whether or not they were successful in achieving their objectives. Methods: The study involved an initial telephone survey of 40 sites (27 Total Purchasing, 13 Extended Fundholding). Six 'special study sites' were then selected for in-depth study. Follow-up questionnaires were sent to the remaining 34 sites and responses were received from 25 (18 Total Purchasing, seven Extended Fundholding). The overall response rate from the 40 sites was 31 (78%). Findings: Primary care purchasing produced better communication and improved working relationships between primary and secondary care. This was less evident with social services, except where initiatives were jointly funded. Setting budgets was difficult, but holding a budget was seen as important in changing service provision. The main change in service provision was that more mental health staff were located in primary care settings. Detailed contracts were rarely used as the method of producing change. User involvement was notable by its absence. The challenge for PCG/Ts is to roll out perceived benefits achieved in Total Purchasing experiments in mental health to larger populations, balancing the drive for high quality services with equitable distribution of care. This will require clear and effective management of communication between stakeholders at an increasingly complex interface.