The Original National Enhanced Services (NES) Specification
The aim of the original NES was the early recognition & treatment of depression. One major way of achieving this aim was through improved training and awareness in primary care. The recommendations of the NES were:
- Depression should be diagnosed using a combination of evidence based diagnostic tools and specialist clinical judgement
- That quality care depended on effective clinical record keeping (including the development of registers)
- Personal health plans were required as part of a structured approach to care
The original NES also highlighted the importance of linking practice level commissioning to the mental health commissioning of primary/intermediate & specialist mental health services.
However, some of the recommendations were based on the Defeat Depression campaign of the 1990s, and did not reflect the current evidence base and the forthcoming guidance from the National Institute of Clinical Excellence. There were also a number of unanswered questions. Which patients would qualify for this service? How would practices claim for this activity? How could it be monitored?
PCTs and practices may prefer to commission and provide an enhanced level of service on a block contract basis. Practices would be commissioned to adopt a way of working based on current best evidence. This block contract would be for the practice component of a wider system of care for all patients with depression. PCTs, practices and Local Medical Committees would need to agree a basis for funding this service. Funding may be based on a combination of retainer fee and a payment per patient. The payment per patient may be based on the number of patients on a practice list and expected workload or the payment per patient may be commensurate with the nationally specified annual payment per patient and be based on expected numbers of patients with an agreed level of depression. PCTs and practices would need to agree their preferred audit and monitoring arrangements. Enhanced service funding would be needed to cover increased GP consultation time; increased practice nurse time; training and education for primary care staff; and audit and service monitoring.
This guidebook describes an enhanced service specification which points towards an ideal model of care based on current best evidence. It is recognised that PCTs and practices are at different stages of development along the journey towards this model of care.
Implementation issues will vary from place to place and will reflect local circumstances. For example, access to psychological therapies within primary care may be a particular challenge for mental health commissioners. However such challenges should not preclude the commissioning of the practice level component and indeed the engagement with practices may well assist in the wider development of mental health services.
It is recognised that the full implementation of this model of care may take time. Commissioners may be required to take a staged approach to implementation depending on local circumstances. This service specification is not intended to be rigid, and is designed to function as a framework for local service development. This guidance will be updated to keep abreast of current developments, and may be usefully linked with other available guidance on mental health topics.1-3