3 A stepped-care approach to commissioning high-quality integrated care for people with common mental health disorders

NICE recommends that a stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. In stepped care the least intensive intervention that is appropriate for a person is typically provided first, and people can step up or down the pathway according to changing needs and in response to treatment.

Commissioning services using the stepped-care model is likely to be cost effective because people receive the least intensive intervention for their need. If a less intensive intervention is able to deliver the desired positive service-user outcome, this limits the burden of disease and costs associated with more intensive treatment.

Service users may begin their journey at any step of the pathway, in accordance with their needs. Timely referral to higher or lower steps may be appropriate and cost effective for some people. A study of psychological intervention services shows that services that comply with NICE guidance and provide stepped care have better service-user outcomes and improved recovery rates[4].

Commissioners and their partners should develop integrated care pathways that promote stepped care. Figure 3 shows a stepped-care model for common mental health disorders, covering steps 1 to 4. When commissioning services using the stepped care model, commissioners should ensure that local systems allow for some flexibility in how interventions are provided, with the crucial factors being the patterns of local need and whether a service provider is competent to provide a particular psychological and/or pharmacological intervention.

Figure 3 Stepped-care model showing steps 1 to 4 for people with common mental health disorders

3.1 Working collaboratively

'Common mental health disorders: identification and pathways to care' (NICE clinical guideline 123) recommends that primary and secondary care clinicians, managers and commissioners collaborate to develop local care pathways that promote access to services for people with common mental health disorders. It states that responsibility for the development, management and evaluation of local care pathways should lie with a designated leadership team, which should include primary and secondary care clinicians, managers and commissioners.

Commissioners should develop, or enhance existing, multiagency partnerships to lead on developing and monitoring local care pathways for people with common mental health disorders. Partnerships may include representatives from a range of professional groups and from a variety of statutory, voluntary and private providers. Examples are included in box 1.

Box 1 Possible members of a multiagency common mental health disorder partnership

Primary care representatives including:

  • GPs, including clinical commissioning group leads and/or GPs with a special interest in mental health

  • Practice nurses

  • Practice-based counsellors, mental health or wellbeing workers

Community-based services representatives from:

  • Local psychological intervention and counselling services (primary care psychology services/improving access to psychological therapy [IAPT] services, which typically provide services at steps 2 and 3)

  • Community mental health team (typically provide more specialist care to people at step 4 and above)

  • Social care

  • Local employment and education services

  • Local drug and alcohol services

  • Local debt, welfare or citizens advice or victim support services

  • Local relationship counselling services

  • Physical activity services

  • Occupational therapy

  • Criminal justice

  • Refugee and asylum seeking services

Secondary care representatives including:

  • Psychiatrists, including primary care and/or community psychiatrists

  • Mental health nurses

  • Practitioner psychologists

  • Secondary care physicians and nurse specialists from a range of specialties including musculoskeletal, respiratory, dermatology, diabetes, cardiac, neurology and cancer

  • Accident and emergency staff

Support services, representatives from:

  • Local commissioning organisations

  • Data and performance

  • Finance

Figure 4 outlines a model for the development of stepped-care services using a partnership approach. Commissioners should encourage their local partnership to:

  • Use the partnership as a forum for improving communication between partners, and increasing knowledge of the range of local services for people with common mental health disorders.

  • Agree how to promote flexible, integrated and inclusive care pathways based on the stepped-care model (see section 3.2).

  • Define local service outcomes (see section 3.3).

  • Agree methods to destigmatise common mental health disorder services. This may include using service user feedback to understand barriers to accessing services, exploring language use, public education or local media initiatives, and encouraging services to allow self-referral. A study of psychological intervention services shows that self-referred service-users present with symptoms as severe as those of GP-referred service-users but recover with fewer sessions of treatment, suggesting that services should seek to expand self-referral to improve efficiency, and promote better access for different sectors of the community[4].

Figure 4 A partnership approach to commissioning common mental health disorder services