NHS Listening Exercise (England):
Initial results from a survey of College Members

What is the NHS Listening Exercise?

• In April 2011, the Government began its 'Listening Exercise' on the NHS reforms in England. This 'Listening Exercise' was organised by the Future Forum, a "group of clinicians, patient representatives voluntary sector representatives and others from the health field, including frontline staff."
• The College made its views known to the Future Forum and also sent a letter spelling out its concerns directly to Andrew Lansley.
• The Future Forum made its recommendations to David Cameron, Nick Clegg, and Andrew Lansley at the end of May 2011.

What has the College done?

• On the 28th of April, we invited the 9,352 English College members^* to air their views on the NHS reforms.
• 1108 English members completed the online College survey.

What were the results?

• 90% of respondents agreed with the College's position on clinician involvement (below):

1. The College welcomes clinicians leading the NHS but strongly believe this must include psychiatrists and other specialist doctors as well as GPs.
2. A psychiatrist should sit on every GP Consortium Board to ensure parity is given to physical and mental health problems, as well as Consortia seeking advice from psychiatrists more generally.
3. The College is working with the RCGP and others in a Joint Commissioning Panel for Mental Health to set out a best practice framework for mental health commissioning.

A selection of quotes from respondents to the survey:

• “Involve psychiatrists in the commissioning decisions. We have dedicated trained specialist psychiatric services with a wealth of experience. It seems absurd not to involve them in commissioning decisions. It seems clear to me that there should be a large representation of psychiatrists at meetings and other key panels” (respondent no. 118)
• “Given that mental health has been given same priority as physical health, I think it should be mandatory that a psychiatrist is on commissioning board” (respondent no. 139)
• “Psychiatrists need to be partners in the process: GP consortia should be required to involved clinicians with expertise and experience in managing mental health conditions, especially high risk and complexity, so that both research evidence, epidemiology etc and practical knowledge of what works (and what has no hope of helping)and what is requires to safely provide a quality service.” (respondent no. 206)

• 91% agreed with the College's position on choice and competition (below):
  

1. The College welcomes increased patient choice (including those detained under the Mental Health Act) in treatment/services.
2. Despite Government reassurances, the College still has concerns that Monitor 'enforcing competition' rules could lead to the fragmentation of care. An 'Any Willing/Qualified Provider' model could result in different providers offering different parts of the pathway and a disjointed service.
3. We are also concerned that local providers getting together to set out best practice may be challenged as 'anticompetitive' by providers not involved in these.

A selection of quotes from respondents to the survey:

• “I feel that continuity of care is vital for patients with complex mental health needs and would be concerned that there might be a tendency to switch providers each time a cheaper one could be found leading to a lack of continuity.  The cheapest available service may well be one with low levels of input from doctors and this may put patients at risk as medical aspects of their health which may be contributing to their mental state may be missed.  I have received patients admitted to psychiatric wards by crisis team workers who are not doctors and have therefore not identified serious organic pathology.  These patients generally have then to be transferred to general hospitals for treatment.  This is an avoidable delay in them receiving appropriate care.  Locally we have had patients admitted to psychiatry with new subdural haematomas, diabetic emergencies and acute renal failure who were thought mistakenly to be confused or agitated due to functional mental illness.” (respondent no. 145)
• “As we all know, you can make anyone look as if they are a 'qualified provider' and maybe they are after a fashion- but some qualifications are just not good enough!! I have a ward where 'qualified' nurses actually believe they are achieving results, 99% in Star Wards challenge,they have the charts, and certificates to 'PROVE' it-these just have nothing to do with patient care/wellbeing and however they are made to look like they are benefiting pts- they are not.” (respondent no. 282)
• “look what has happened to LD services patients stay forever ,are overmedicated, rarely have access to proper psychology-frequently there is no psychologist-it all spirals down as patients get bored/disaffected/then aggressive leading to more restrictios more aggression etc” (respondent no. 315)
• Continuity of care is vital in mental health services. The "any qualified provider" model fits best for episodic care (eg elective operations) but could cause dreadful discontinuity in services that deal with long term conditions, especially psychiatry where relationships are even more important than in other long-term specialties. This is not to argue against innovative models of provision, only to say that comprehensive services should be commissioned mostly from a single provider. (respondent no. 420)

• 86% agreed with the College's position on education and training below:
  

1. The College believes that tariffs that fairly reflect the work done in teaching/training are welcome but (a) lessons learned from Modernising Medical Careers must be drawn upon and (b) changes are implemented after careful modelling, piloting and consultation.
2. The expertise of postgraduate deaneries in quality assuring postgraduate education should be preserved.
3. If local provider networks are used to deliver education, there must be an oversight system to protect less vocal mental health services.

Other findings

Re: involvement of psychiatrists in commissioning

• 96% of respondents agreed that psychiatrists, as well as General Practitioners, should be involved in the commissioning process for mental health.

Re: proposed introduction of 'any qualified provider'

• 88% did not agree that the proposed 'any qualified provider' model would improve patient care.

Those responding to a free-text question asking “Why do you think the 'any qualified provider' model will not improve patient care?” gave the following views:

31% (n=310) were of the view that:

• quality will suffer as costs reduced/profit motive works against patient-centredness
• the ‘any qualified provider’ model doesn't promote recovery as private companies will try to retain patients
• private companies will put their share-holders' interests above those of patients

20% (n=197) were of the view that:

• the ‘any qualified provider’ will lead to a fragmentation of services/lack of joined up care/two-tier system

14% (n=146) were of the view that:

• the ‘any qualified provider’ model will lead to the cherry-picking of most profitable groups
• the ‘any qualified provider’ model will leave the NHS to deal with most complex cases

Quotes from respondents to the survey:

• “The private sector is a poor provider of mental health services, as it is an area with few quick, cost-effective profits to be made. It already creams off many of the patients with private health insurance with mild to moderate illnesses, and dumps back to the NHS those with more complex problems when the money runs out” (respondent no. 512).

• “This will allow other providers to cherry pick the easiest type of cases to manage.  The rump of the NHS will be left to manage only the most complex psychiatric cases, with fewer resources since many of them will have been redirected to other providers” (respondent no. 601).

• “Countries with privatised health systems do not often have better patient care. The NHS has traditionally been publicly provided and generally ranks well internationally. I worry that this change will lead to the breakup of services and gradual privatisation of the NHS as we know it. The public service ethos will be lost and profit will be the driving factor. This will likely have an adverse effect on therapeutic relationships and quality of care.” (respondent no. 830)

• “Having worked both in the NHS, in a private health company, and as an independent private practitioner, I have seen for myself the corrupting effect private profit-driven provision has upon clinical practice, and consequent deleterious effects upon patient care.” (respondent no. 1000)

Re: proposal to abolish postgraduate deaneries

• 90% did not believe that abolishing postgraduate deaneries and replacing them with local networks of trusts would improve the planning and delivery of high quality postgraduate medical education.

Further information

• Please contact Richard Meier (rmeier@rcpsych.ac.uk) or Chris Fitch (cfitch@rcpsych.ac.uk).

• An invitation was sent to the 9,352 English members with a registered email address.  Not all email addresses were valid, nor were all members still in post/available to participate.

• Respondents were asked 19 questions divided into three sections: (i) clinical involvement; (ii) choice, accountability and ‘Any Qualified Provider; and (iii) education and training.  In each section, respondents were asked for their general thoughts on the issue being addressed. They were (a) then shown the College’s policy position on each of these three issues and asked whether they agreed/disagreed with this, and (b) then invited to explain why they agreed/disagreed.

• The findings are not based on a random sample.  The rationale for (i) not employing a random sample and (ii) only inviting those with an email address was that we wanted to invite all eligible College members to participate – it had a consultative objective. As a non-probability sample with a sampling bias towards members with email addresses, the results are not statistically representative of the wider College membership. However, the results provide important insights into the views and opinions of a comparatively large number of the College membership.