Commissioning stepped care for people with common mental health disorders

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg41

6 Service specification for common mental health disorder services

Commissioners should collaborate with clinicians, local stakeholders, and service users when determining what is needed from common mental health disorder services in order to meet local needs. The care pathway should be person-centred and integrated with other elements of care for people with common mental health disorders.

Commissioners may wish to consider commissioning services in a number of different ways, and local mixed models of provision are likely to be appropriate. Commissioners may wish to take action to stimulate the local market if there are identified shortages of providers at any point in the pathway and should note that any qualified providers may include health, local authority, other statutory partners, or private or third sector organisations.

Commissioners should ensure that providers implement the recommendations stipulated in NICE guidance and that providers are taking steps to achieve the standards set out in NICE quality standard for depression in adults.

Commissioners should ensure the services they commission represent value for money and offer the best possible outcomes for their service users. Commissioners should refer to NICE quality standards when commissioning services and should include quality statements and measures within the service specification element of the standard contract where appropriate. If poor performance is identified, commissioners can discuss the level of performance with their providers and address any issues and concerns before introducing more formal contractual remedies.

Commissioners may use NICE quality standards to ensure that high-quality care is being commissioned through the contracting process, to establish key performance indicators as part of a tendering process and/or to incentivise provider performance by using the indicators in association with incentive payments such as Commissioning for Quality and Innovation (CQUIN).

Commissioners should ensure that they consider both the clinical and cost effectiveness of the service, and any related services, and take into account clinicians' and service users' views and those of other stakeholders when making commissioning decisions.

Table 18 includes considerations for commissioners when developing a contract specification for common mental health disorder services.

Table 18 Considerations for contract specification

Contract section	Contract sub-section	To specified in contract specification
Purpose	Policy context	National policy drivers. Evidence base, for example NICE guidance, Quality standards, NHS Evidence accredited sources, national strategies.
	Local strategic context	Local commissioning drivers (for example reducing inappropriate admissions to community mental health teams, improving the quality of referrals, reducing inappropriate prescribing of antidepressants, reducing worklessness, QIPP, CQUIN). Invest to save. Results of joint strategic needs assessment (JSNA).
	Aims and objectives of service	The expected outcomes of the service(s) The partnership's vision for the service(s)
Service scope	Define service user groups	Demographic profile of the local population (age, gender, ethnicity, socioeconomic status, socially-excluded groups, ex-service personnel, persons in contact with the criminal justice system). Evidence of inequalities in outcomes between specific groups. Local recorded and expected prevalence of depression, generalised anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, phobias, social anxiety disorder (social phobia). Estimated prevalence of comorbidities (for example long term conditions, other mental health disorders, drug and alcohol misuse, pregnancy, learning disabilities, cognitive impairment). Number of people currently being treated in community-based psychological therapy services or specialist community mental health teams, and other relevant services. Number of people who see their GP and have a recorded incidence of one or more common mental health disorders. Population-groups that will be targeted.
	Exclusion criteria	Define exclusion criteria in accordance with NICE guidance and locally determined criteria. Services should be as inclusive as possible.
	Geographical population	Proportion of people living in urban and/or rural areas. Areas of higher-than-average need (for example, areas of deprivation and areas with a high population of older people). Population coverage required or geographical boundaries.
	Service description / care package	Mapping existing services for people with common mental health disorders. Commissioning of core service components. Interface with other local services including social care, residential and nursing care, community mental health services, welfare and debt advice, employment services.
Service delivery	Location	Service location(s), defining accessibility requirements and discreet location(s). Integration with other health and social care services for people with common mental health disorders.
	Days/hours	Expected hours of operation, including days, evenings and weekends. Expected number of people for assessment, interventions, prescribing, care coordination, case management, collaborative care and aftercare and relapse prevention, taking into account potential increased flow through the system over defined periods.
	Referral processes	Referral criteria and processes for people with common mental health disorders. Management of 'unable to attend' (UTAs) and 'did not attends' (DNAs).
	Response times	This should be needs-based and outcomes-based. Setting specific times, particularly for accessing psychological interventions
	Care pathways	Agreed clinical protocols or guidelines to support decision-making in the service-user pathway. Pathways for people with complex needs and comorbidities. Care coordination.
	Discharge Processes	Process for discharge from services for people with common mental health disorders, including aftercare and relapse prevention and communication with GPs and other relevant services.
	Staffing	Profile of existing health, social care and welfare workforce. Staffing levels to be funded: minimum band or levels of experience and competency and expected skill mix. Skill mix and competencies of staff for specific areas of care, for example low and high intensity psychological interventions.
	Information sharing	Define information-sharing, confidentiality and audit requirements, including IT support and infrastructure. Raising awareness of services for people with common mental health disorders among relevant health, social care and welfare professionals.
Quality assurance and clinical governance	Patient and public involvement	Processes to understand service-user experience of common mental health disorder services, in order to develop and monitor services. Expectations of how service-user opinion, preference and experience will be used to inform service delivery for example, focus groups, representation on working groups, and surveys. Monitoring of complaints and complements and how used to inform service.
	Quality indicators	Use NICE quality standards to define high-quality care. Service-user satisfaction surveys and access to treatment. Define outcomes measures.
	Performance monitoring	Local need and demand for treatment. Impact of service(s) on admissions to community mental health disorder services.
	Equality	Measures to ensure equality of access to services, taking into account the risks of unintentional discrimination against groups who are often under-represented, such as people who do not speak English as a first language. Consider equity of access for people living within residential and nursing homes and those who are housebound; or people within prisons.
	Staff training and competency	Training and competencies on recruitment and for ongoing development. Processes for monitoring clinical practice and competency, including professional registration and clinical supervision arrangements. Skill mix and competencies required across the care pathway, including competencies in: assessment, behavioural change, personalised care planning, management skills. See Skills for Health for examples. Staff development – appraisal and personal development plans, and mandatory training.
	Audit	Specify expectations for audit, which may include assessment, intervention, prescribing practices and successful treatment outcomes.
	Staff and service-user safety	Procedures for risk assessment. Formal procedures for incident reporting and monitoring. Address any safeguarding concerns and promote the welfare of vulnerable adults.
Activity Plan		Long-term impact of increased access to low and high intensity psychological interventions on referrals to other services and prescribing. Long-term impact of improved diagnosis of common mental health disorders on referrals to low and high intensity psychological interventions and on prescribing. Planned service development setting out any productivity improvements.
Cost	Value for money	Likely cost of new or additional services Anticipated set-up costs. Potential for better value for money. Are service-users receiving most appropriate services for the severity of their disorder? Cost of facilities, for example venue hire. Cost of staff travel to services and service-users' homes. QIPP.