NSUN network for mental health is an independent, service-user-led charity that connects people with experience of mental health issues to give us a stronger voice in shaping policy and services.

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NSUN is supporting Manchester Users Network (MUN) to challenge local practice.

For people who have a diagnosis that is severe and enduring the 'stepping down' process is having serious consequences that must be acknowledge and addressed. 

Although different areas will have varying target figures, the aim to shift significant numbers of people from secondary (specialist) mental health care to primary care (GP) is the same.

If you have similar experiences or concerns, please email or telephone 020 78208982.

MUN have been collating case studies on these effects of this process and consequences.

RE: The Shifting Settings of Care Agenda 

This agenda has been a growing concern over the last five years. Not in the ideology of the policy but in the lack of transparency and stealth-like implementation, without adequate consideration of service development and transformation within primary care and no appeal system to challenge decisions (see appendix 1).

Shifting settings of care is a programme which helps people with ongoing but stable mental illness to be supported by their GP and a mental health worker in the community rather than by specialist mental health services (West London Mental Health Trust)

Model of Care for Mental Health Long Term Conditions intends reduction in usage of secondary care by managing patients’ long term mental health conditions more actively within primary care setting with improvement in quality and outcomes of care (Kings Fund)

Since 2011 there have been a number of ‘pilots’ across the country aiming to ‘shift’ or ‘step down’ people from secondary care to primary care (For example, 1000 secondary care patients to 10 GP practices in one London borough).

The development of community-based alternatives to hospital care has been a long standing policy objective since the closure of large institutions in the 1980s - which had much support for change. Our members tell us, that where possible they would rather be supported and treated in the community than in hospital, but there are times when more specialist support is needed.

The model of multi-disciplinary teams supporting people in the community with access to specialist hospitals was supported by the introduction of the Care Planning Approach. This framework was intended to create greater degrees of co-ordination between practitioners and agencies, particularly for people who have long term and complex conditions.

Similar to the concerns about ‘Community Care’; the capacity and capability of generic community mental health teams to manage people with complex mental health needs or in crisis, in the 1990s, there is now concern that primary care has inadequate access to specialist support and diagnostics, the length of appointments are not sufficient and it’s hard to provide continuity of care.

If this is current policy and practice then there needs to be greater transparency.

It is vital that practitioners are honest about the reasons for ‘step down’ and there are appropriate alternatives for support available. This needs to be alongside planned change in primary care to support the ‘Shifting Settings of Care’ agenda. Such as: Wrapping community services, mental health services and social care around groups of practices; giving those practices access to specialists and diagnostics; creating more systematic approaches to working collaboratively would provide continuity or rapid access to treatment depending on their patients’ needs.(Kings Fund)

Below is a summary of some of the most frequently asked questions. It would be extremely helpful if you would consider all the questions below and provide a response.

  • Is the ‘stepping down’ from secondary care to primary care for the benefit of the patient or is a based on a financial incentive or target?
  • Do circumstances need to have changed for an individual to be ‘stepped down’?
  • What assessment process is in place?
  • Are Primary Care Mental Health workers employed in local surgeries?
  • How does ‘stepping down’ affect welfare benefits and access to personal budgets?
  • What implications on existing support and benefits does this have?
  • Do all GP practices receive full training and support?
  • Are there any GP incentive schemes to encourage and recognise additional work from primary care?
  • Is there any navigator and/or peer support involvement with voluntary sector or service user-led groups?
  • Are Home Treatment Teams are fully engaged in the process?
  • Are CPA registers aligned between primary care and providers?

Yours sincerely

Sarah Yiannoullou

Managing Director