Proper GP provision, proper physical healthcare
A key part of our vision for better care includes the provision for real physical health care. Bizarrely, despite the fact that psychiatrists' role as medical professionals, and consequently their potential to address physical health care needs, is frequently advanced as a reason for their 'clinical primacy' in teams, the physical health of mental health service users is frequently very poor. As we discussed above, therefore, a preferable model might be to look to our GP (primary care) colleagues to deliver this care - and indeed much of the medical aspects of what is currently the province of psychiatry.
That argument was made in Chapter 7, but it is reasonable here to consider the costs of such a change. There are three principal ways to consider this. It could be argued that such care is, or should be, part of the GPs' responsibilities. But we need to consider the resource implications. It could be argued that as GP colleagues adopt this responsibility, resources currently used to employ and support specialist psychiatrists could be redirected to employ and support additional primary care specialists - perhaps specialised, particularly, in mental health and wellbeing. In essence, this would imply a like-for-like redistribution of costs between primary care and psychiatry, with no net costs. In this sense, our proposals are (again) cost neutral. But it also seems reasonable to estimate the level of resources needed, not least to estimate the challenges involved. It is relatively simple (if hugely contentious) to suggest a like-for-like reduction in psychiatrist numbers and an increase in GP numbers, but what sort of numbers would be involved?
One possible comparison is to look at the costs of providing out-ofhours primary care cover. In the UK (which admittedly may be somewhat unrepresentative) we offer a comprehensive primary care service (delivered by the general practitioners or GPs that are repeatedly mentioned). Many years ago, these medical practitioners were tacitly expected to deliver a service 24 hours a day. More recently (and amid some controversy), plans were laid to establish out-of-hours services. Physical health care for people receiving mental health and well-being services could never be designed on exactly the same basis as out-of-hours GP services, but the scale of resources involved could give an indication of what might be required. Helpfully, this has already been estimated. The UK Department of Health estimates1 2 that GP out-of-hours services cost around ?500 million per year.
Not all of this sum is made up of salary costs, but it allows us a reasonable estimate as to what it might cost to implement our vision for transformed mental health services in the real world. If it costs about ?500 million per year to provide out-of-hours primary care cover, it is reasonable to assume that a similar sum would be more than sufficient to meet the needs of people in receipt of mental health and wellbeing services. But extra expenditure is not really the point. Our vision involves a much clearer location of many of the medical responsibilities associated with mental health care within primary care. This is an argument for redistribution of resources, not extra resources. Since the salary costs of GPs, medical practitioners specialist in primary care, and psychiatrists, medical practitioners specialist in a different branch of medicine, will be fundamentally identical, this resource should be seen not as a net extra cost, but as a redistribution of funds. There are currently around 41,000 GPs working in the UK,13 who would of course also be recipients of extra training. An increase of some 5,000 would therefore represent an increase of some 12%. That is reassuring, as it (again) is close to the overall proportion of healthcare spend dedicated to mental health issues.
Thus far then, in this economic argument, we might expect one-off 'transitional support costs' of ?100 million, extra training costs of ?100 million per annum to permit the re-deployment of nursing and medical staff to support psychosocial approaches, the cost of 2,000 entirely new staff specialising in psychological and psychosocial approaches at perhaps ?100 million per annum, and perhaps ?500 million per annum to provide for additional primary care cover, with this latter figure recouped partially from the existing spend on psychiatry, and partially from other sources.