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Community mental health care

Royal College of PsychiatristsLondonApproved by Council: April 2004Due for review: 2006

Council Report CR124February 2005

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Contents

Membership of the Working Group 4Acknowledgements 5Executive summary 6Introduction 81. Era of partnership 102. Sector-based community mental health teams 153. Modernisation teams 234. Social care 315. Essential partners 37

6. Local variation and diversity 45References and further reading 55

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Membership of the Working Group

Professor Tom Burns (Chairman) Professor of Social Psychiatry, Universityof Oxford

Dr Sarah Davenport Chair of Faculty of Rehabilitation and Social Psychiatryand Lead Consultant for Womens Secure Services, Lancashire Care Trust,Preston, Lancashire

Mike Firn Service Manager, Adult Intensive Outreach Services, SW, Londonand St Georges Hospital, London

Jenny Fisher Rethink and member of the Royal College of PsychiatristsSpecial Committee of Patients and Carers

Dr Keron Fletcher Consultant Psychiatrist at Shelton Hospital New HouseDrug and Alcohol Unit, Shrewsbury, ShropshireProfessor Anthony Maden Professor of Forensic Psychiatry, Imperial

College, LondonMelanie Walker Director of Social Care, South West London and St

Georges Mental Health NHS Trust, LondonAgnes Wheatcroft Parliamentary and Policy Officer, Royal College of

Psychiatrists, London

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Acknowledgements

Internal consultation day held on 18 February 2004

The following either attended or sent written comments:

Child and Adolescent Faculty Professor Sue Bailey (Chair of Faculty),Gardener Unit, Prestwich, Manchester

Forensic Psychiatry Faculty Dr Aideen O Halloran, Ashworth Hospital,Leeds

General and Community Psychiatry Faculty Dr Suresh Joseph, NewcastleFaculty of Liaison Psychiatry Dr Andrew Hodgkiss, St Thomas Hospital,

LondonOld Age Faculty Dr Roger Bullock, Victoria Hospital, Swindon

External consultation held on 17 March 2004

The following either attended or sent written comments:Dr Alan Cohen Royal College of General PractitionersMargaret Edwards SANEDr Andrew Fairbairn Registrar, Royal College of PsychiatristsSally Feaver College of Occupational Therapists, London

Liz Garrod MacaSally Hughes MindValerie Imms BASW British Association of Social Workers, LondonMike Took Rethink

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Executive summary

This is the third edition of the College s policy on community care for individualsof working age (18 65 years) with mental health problems. It is produced at atime of unprecedented change as the modernisation teams prescribed in theNHS Plan are being introduced. Community care seems still a meaningfulconcept in psychiatry, and has been retained. This document emphasises therange of partnerships that define modern community mental health practice.Despite this, the role of the psychiatrist is proposed as prominent and crucial forthe development and delivery of high-quality, humane services.

The document is clinically led and aimed at practitioners, local service planners

and managers. Concrete figures have been quoted where there is adequateconsensus. These figures are guides, not prescriptions, and aim to promoteconstructive dialogue, not replace it. The report was written by a group thatincluded non-psychiatrists. The psychiatric members were drawn from withinthe College for their known expertise (rather than as representatives of faculties,which is the usual case). Consultations took place with all faculties and with arange of external stakeholders.

Chapter 1 outlines the vital partnerships, in particular those beyond themultidisciplinary team. These crucially involve partnerships with patients andtheir carers, but also voluntary and other, non-health care statutory services.

Partnership is as much a state of mind as a series of managerial structures.Chapter 2 outlines the functioning of the sector-based community mental health

team (CMHT), which is identified as the backbone of the service. We see no realsigns of its replacement (rather than augmentation) by the modernisation teams.CMHTs have, however, benefited from the advent of these modernisation teamsand are increasingly more specific about their functions and procedures.

Chapter 3 deals with the modernisation teams (assertive outreach, crisisresolution/home treatment and early-intervention services for psychosis). Itacknowledges the variation in their development nationally and also thedeviations from the prescribed models that have been developed within the very

real staffing constraints under which they have been introduced.Chapter 4 discusses the crucial issue of social care, both the role of the social

worker within CMHTs and the wider aspects of social care accommodation,occupation and childcare. The rapidly rising significance of social inclusion andthe move to combined health and social care trusts has sharpened the focus onthis area while reducing certainties.

Chapter 5 deals with the essential clinical partners in community care primary care, substance misuse services, rehabilitation and forensic services.There is far greater variation in the forms of service provision within thesespecialties than in general adult CMHTs. General principles of collaboration andcommon configurations are addressed, rather than detailed prescriptions.

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Chapter 6 focuses on the issues of local variation and diversity. Hardly anylocality in the UK now is typical . Ethnic diversity challenges almost all urbanservices to ensure cultural sensitivity and, in some settings, highly specific serviceconfigurations. Diversity includes the consistent differences found in all localities(e.g. gender, specific diagnostic groups which may demand different approachessuch as acquired brain injury and personality disorder), as well a local highconcentrations of specific groups (e.g. the homeless, refugees).

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Introduction

This is the second revision of the College s community care document, firstpublished in 1995 and reviewed in 2000. The past 50 years have witnessed aprofound change in the delivery of mental health care that has been trulyinternational. The decline of the mental hospital has been mirrored by thedevelopment of a community-based model of care. This development has,however, been patchy and there are only a few examples of well-coordinatedand comprehensive reprovisions. Despite this, the evidence is overwhelmingthat patients (and indeed their families and carers) prefer care to be outsideinstitutions wherever possible and (as demonstrated in the TAPS Project) that

good-quality community care can be provided.The College has long emphasised the need for a clear statement on its approachto community mental health care to guide practice and help in local planning:hence this Council Report. However, this revision comes out at a time of intensechange, driven by the implementation of the NHS Plan and the activities of theModernisation Agency and the National Institute for Mental Health in England(National Institute for Mental Health in England, 2003). Given this, we haveopted in our report to focus on current practice and developments in theimmediate future. This should not be read to indicate that the College is resistantto change in community care. Nothing could be further from the truth.

In producing this revision we have tried to shorten the report and make itmore user-friendly and less academic in tone. Inevitably, this has involved somecompromise on comprehensiveness.

We have emphasised key issues, and avoided dwelling too much oncontroversy and differences of opinion. We have striven to present the consensusviews of psychiatrists who are active in community mental health care. For thisreason, we have not produced specific appendices for Scotland, Wales andNorthern Ireland as in previous documents. We anticipate that everything in thisdocument will be subject to local judgement and adaptation. College documentshave sometimes been hampered by their need to reflect the internal politics of

the faculties and that this can blunt their message to the outside world. Thisview resulted in a different approach to selecting the Working Group for thedocument. Rather than compose it from faculty representatives the memberswere selected for their known expertise in the area, not as representatives ordelegates. We think that this has been successful in keeping the document focused.

We also had to decide whether the document should be aspirational(describing a gold standard for services to aim for) or a description of currentagreed practice. We have chosen to describe good current practice such as canalready be found in different parts of the country and can serve as a model toaim for. Little is gained by describing model services that are completelyunattainable. Our choice also reflects the current rapid pace of change in mental

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health services (as exemplified in the shifting policies around the modernisation teams). The past few years have shown that things can, and do, change quickly.Projecting our thoughts too much into the future runs the risk of the document becoming almost instantly redundant.

This document (like its predecessors) has been subject to a day s consultationwithin the College, on 18 February 2004; all the faculties were invited to eitherattended or send comments. An external consultation day was held on 17 March2004. We believe that it should be reviewed sooner rather than later as this is anarea of practice very vulnerable to policy changes. The report recognises theinevitability of many of these policy guidances (indeed welcomes many of them), but does question and reject some.

This is our profession s view of the way forward, but it is developed in closecollaboration with partners outside the profession. It emphasises throughout thevital importance of such partnership partnership with other members of themultidisciplinary team, partnership with other involved agencies (both statutoryand voluntary) and, most important of all, partnership with patients and theirfamilies and carers. Its aim is to support and advise College Members and Fellowsin their daily practice and in negotiating service delivery. We hope that it proveshelpful.

This revision comes out at a time of intense change driven by theimplementation of the NHS Plan and the activities of the Modernisation Agencyand the National Institute for Mental Health in England (National Institute forMental Health in England, 2003). Given this, we have opted to emphasise currentpractice and developments in the immediate future. This should not be read toindicate that the Royal College of Psychiatrists is resistant to change in communitycare. Nothing could be further from the truth.

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1 Era of partnership

Modern community-focused mental health care is characterised by its partnerships.As practice has moved from behind the walls of psychiatric hospitals, the isolatedhegemony of the psychiatrist has been exchanged for a place in a series of functional networks. In these, he or she plays a key role, sometimes the lead role, but almost never a solitary role. The needs of more severely mentally illindividuals almost invariably demand inputs that no one individual, or oneprofession, can meet.

Most psychiatrists working now have always been team-players to someextent. What has changed is the centrality of this teamwork and the different

players in the partnership. And a partnership is exactly what it has to be agenuine collaboration between members with equal respect and authority withintheir respective spheres, not always a team with the same leader and with thesame agenda. For most of us these changes are welcome, yet challenging andunsettling. Even if we wanted to, however, there is no going back. The worldaround us is changing. The rise of consumerism, managerialism, accountabilityand choice across the spectrum of health and social care will continue to pushmental health practice forward for the foreseeable future.

Four equally important and overlapping spheres of partnership can bedistinguished: multidisciplinary team-working; partnership beyond the mental

health team; partnership with families and carers; and the therapeutic relationshipas partnership.

Multidisciplinary team-working

Effective care of severely mentally ill individuals requires a close workingrelationship between psychiatrists, social workers and nurses. Without thesethree professions working together, it is simply not possible to provide safe care.Their relationships were established in the Mental Health Act 1959, and all threehave essential, unsubstitutable roles. At its most basic, this three-way partnership

provides assessment, treatment and the capacity to use the provisions of theMental Health Act 1983. Over the years, community mental health teams (CMHTs)have welded these three disciplines into a flexible, supportive unit that addressessimultaneously the health and social care needs of patients. This team structurehas been a distinguishing feature of UK mental health practice for 40 years, and by the 1980s over 80% of the population had access to such a therapeuticpartnership (Johnson & Thornicroft, 1993).

Multidisciplinary working in CMHTs has grown beyond the modest trinityinitiated by the Mental Health Act 1959. There are now more community mentalhealth nurses than there are psychiatrists; partnership working has been

strengthened as both they and social workers are fully integrated into the team.

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While a partnership between these three disciplines is essential for care, it is notsufficient for optimal care. CMHTs have extended their membership to includeclinical psychologists, occupational therapists and, in some, mental health supportworkers, vocational counsellors and more. In many such teams, the consultantpsychiatrist is identified as the team leader, but this role is complex and farremoved from the asymmetric autocracy of the old psychiatric hospital.

Partnership beyond the mental health team

The balance of modern mental health care has increasingly shifted to the longerperiods of care outside hospital, with a focus on supporting the often precarioussurvival of vulnerable individuals. This has extended the range of partnershipsrequired and significantly altered their relative importance. Effective and closeworking relationships with primary care are essential. Social care is no longer a junior partner. Housing, occupation, finances, personal safety and durable supportnetworks are essentials for a stable, dignified existence. The enhanced role thatsocial services now have is augmented by a range of voluntary services,community and self-help groups. This wide range of partnerships, includingrepresentatives of minority ethnic and faith communities and marginalised groupssuch as asylum-seekers, the homeless and prisoners, has undoubtedlystrengthened and focused community care practice.

This extended partnership presents challenges to psychiatrists. The care team is no longer the traditional and predictable CMHT. It varies between patientsand varies over time for the same patient according to needs. As a result, itsdynamics can be difficult and uncertain. Assumptions about common trainingcannot be made, and long-established ethical guidelines about who should beprivy to what information or included in clinical decision-making have to beconstantly reviewed. For one individual, close collaboration with the housingdepartment may be the make or break issue, for another effective police liaison.We currently lack a well-established and consensual understanding of theserelationships in the way that we have, for instance, well-entrenched and respectedworking relationships with the primary care team. Updated guidance is availablein Council Report CR85, Good Psychiatric Practice: Confidentiality (Royal College of

Psychiatrists, 2000). Disagreements and differences need to be viewed as growthpoints in a developing relationship, rather than conflicts to be settled.

Part nership w i t h fami l i es and carers

The relationship between mental health staff and patients families (who comprisethe vast majority of carers) is, arguably, the most dramatically changingpartnership of this era. The move to the community has shifted a significant burden of care to families. Most families members welcome their role in lookingafter and supporting one another. In the first, optimistic wave of deinstit-

utionalisation, their contribution was taken for granted and essentially ignored.

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Sadly, that neglect persisted even when it was becoming increasingly obviousthat the demands on them were often excessive.

Families asked for their voices to be heard, but were not given the status of essential partners in the undertaking. Although older ideas implicating familiesin the origin of mental illnesses have been overwhelmingly discredited andabandoned, mutual suspicions lingered on. The involvement of families wasalso hindered by a recognition that most adult patients wanted to be treated asindependent adults and many refused contact with their families. Informationneeds to be shared with families to enable them to care effectively, subject toissues of confidentiality.

Family groups have had to fight hard for recognition. UK psychiatry has beenslow to acknowledge the rights for support that families commitment to patientswarrants. We have been even slower to embrace their potential as colleaguesand allies in the task of supporting patients. We need to accept that familieshave often been called upon to shoulder an excessive burden when patientshave been managed in the community, without the recognition or support theydeserve. Social services have always had a duty to assess at the request of thenearest relative. The requirement of the National Service Framework for MentalHealth that carers needs must also be assessed is a landmark step in rightingthis historical wrong (Department of Health, 1999). We should anticipate, andaccept, a difficult transitional period when some of the justified resentment felt by carers and users groups is worked through.

The therapeutic relationship as partnershipRelationships between health care professionals and their patients haveundergone massive changes across the world. A traditional paternalisticapproach where doctor knows best and patients are passive and obedientsubjects is fast disappearing in the industrialised West. The reasons for thischange are complex, but two obvious forces are at work. First, there is thegeneral questioning of authority as the public become better educated and ableto judge the quality of their care. This reflects a widespread reduction in thestatus hierarchies in developed countries and affects all professional

relationships. Second, there is the demographic shift to an older population,with the rising importance of long-term disabling disorders compared to acute,life threatening illnesses. In these long-term disorders the evidence isoverwhelming that patients do much better if they are informed collaboratorsin treatment than if they simply receive and follow instructions. Emphasisingthe patients role in managing their own health is now routine in much of general medicine.

Psychiatry has always had an ambiguous position on this issue. Like the rest of the medical profession, psychiatrists are increasingly concerned with managinglong-term disorders rather than with short episodes of illness. Unlike the rest of

the profession, however, we have the power to override patients wishes and force

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treatment. This facility to insist on treatment in those serious situations wherepatients are not able to make sound decisions must be retained in psychiatry if weare to offer our patients and society a safe service. However, this is not incompatiblewith an increasing shift to a partnership relationship. Even with patients who aredetained under the Mental Health Act 1983, there remain wide areas of involvementwhere a genuinely collaborative approach should be the aim, and is both possibleand welcome.

This partnership with patients goes beyond the simple shift from complianceto concordance. It recognises the importance of providing detailed andcomprehensive information about illnesses and treatments so that patients cancontribute effectively to the joint effort. The training of staff in cognitive behavioural therapy (CBT) has often contributed a recognition of the value of collaborative empiricism in mental health care that extends far beyond the impactof the CBT treatments themselves.

A real partnership, extending beyond tokenism, requires a sharing of areas of uncertainty and openness about the importance of personal values. Decisionsabout what to do will not simply be dictated by knowledge of which treatmentswork, but also by the patients own priorities. Patients of mental health careservices vary in their attitudes towards their illnesses, just as do those withhypertension or diabetes. Some will want tight pharmacological control of theillness irrespective of side-effects, whereas others will insist on a lighter touch,accepting a higher risk of relapse. This is likely to be an uneasy time forpsychiatrists, required to offer evidence-based practice and simultaneously acceptthe status of patient choice. Few would deny, however, that in the long term thisis a healthier therapeutic relationship, in tune with society s values and likely tolead to better outcomes.

The structure of services

Psychiatry is a discipline with a highly evolved understanding of, and respectfor, relationships. Jaspers wrote nearly 100 years ago that psychiatrists functionprimarily as living, comprehending and acting persons in their relations withpatients. Psychiatry has traditionally been a trailblazer in multidisciplinary health

care. We have already stressed the overwhelming importance of partnerships asthe emerging characteristic of current community mental health care. However,this does not mean that psychiatrists are just a cog in the wheel or that we do nothave a unique and specific viewpoint to offer.

This document is based on the premise that psychiatrists will remain centralfigures in most of the care of mentally ill people in the community for theforeseeable future. Although working in teams, they will more often than notexercise essential leadership roles in those teams. This leadership stems not onlyfrom societal and legal recognition of their special position, but also from thenature of their wide and extensive training. Valuing partnerships does not absolve

us of responsibilities.

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This report also reflects a widely held view within the College that secondarycare generic CMHTs will remain a core feature of UK mental health services. Insome respects, this is at variance with recent policy in the NHS Plan (Departmentof Health, 2000 a) and the National Service Framework for Mental Health, whichpropose that CMHTs will be replaced by a range of specialised secondary teams.We consider this neither feasible, nor necessarily wise, although we recognisethat there are several developments proposed at the margins of primary andsecondary care that will undoubtedly alter the current balance. Rather we endorsethe view of the World Health Organization that development of mental healthservices should be a step-by-step process (Thornicroft & Tansella, 2004). Onlywhen there are well-functioning generic secondary mental health services shouldinvestment be made in specialised teams that serve rather than replace them.

The failings of some CMHTs have received much publicity without a balancedrecognition of their merits. This report redresses the balance, and focuses onthese core teams. This does not imply any lack of respect for the essentialcontributions of other specialists, such as those in rehabilitation, forensic andsubstance misuse services. Similarly, our concentration on secondary servicesshould not be taken as a dismissal of the vital contribution of primary care.

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2 Sector-based community mental health teams

The sector-based CMHT

The shift in emphasis from institutional to community-based care for people withsevere mental illnesses in the UK over the past 40 years has been marked by thedevelopment of highly evolved multidisciplinary teamwork. Patients needsdemand input from a range of professionals. Initially these were mainly medicalprofessionals, nurses and social workers, but soon involved clinical psychologistsand occupational therapists and, more recently, members specialising in such fieldsas vocational rehabilitation and substance misuse. The Mental Health Act 1959 andits development in the Mental Health Act 1983 required collaboration betweenpsychiatry and social work, which has increasingly been manifest in co-locationand in the establishment of health and social care trusts.

The requirements of the Mental Health Act 1959 also fostered continuity of careacross the in-patient/community boundary. As a consequence, the model of carethat has evolved in the UK is of a geographically defined team. By the early 1990s,over 85% of the population of England and Wales were served by such teams(Johnson & Thornicroft, 1993), albeit at differing levels of comprehensiveness andintegration with social services. While much of this report may be considered relevantacross the age spectrum, it is targeted on provision of care for adults of working age.We are well aware of the importance and complexities of the transition from childand adolescent to adult services. For what follows, adult teams will be consideredalways to take responsibility for individuals aged 18 64. Local and nationalnegotiations are currently underway to refine practice (see Council Report CR106(Royal College of Psychiatrists, 2002)) and clinical judgements can, and will, determineindividual care.

Functions of the generic CMHT

The generic CMHT is a secondary care team. It is responsible for the assessmentand care of people with complex mental health problems who cannot be adequatelydealt with in general practice or generic social work services. Most, if not all,referrals to the CMHT come from other professionals predominantly generalpractitioners, other medical staff (particularly accident and emergencydepartments) and social services.

It has three distinct functions:1. assessment and advice on management for patients treated in primary

care;2. to provide treatment and care for time-limited disorders which are more

complex or severe than those treatable in primary care;

3. to provide treatment and care for those with severe and enduring needs

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(adapted from the Mental Health Policy Implementation Guide: Community Mental Health Teams (MHPIG for CMHTs; Department of Health, 2002 a).

When patients are taken on for care, they are subject to the care programme

approach (Department of Health, 1990). When patients require in-patient care, theyare usually admitted to a ward whose nursing team work collaboratively with theCMHT staff, and they remain under the care of the CMHT consultant. CMHT staff take an active role in decisions about admission and discharge of their patients.

Staffing and organisation

Sector size in CMHTs varies considerably (from 20 000 to 60 000), reflecting localmorbidity, resources and traditions (e.g. joint CMHTs). The College srecommendation is for maximum catchment areas of 30 000, but considerably

less in teaching units and areas of particularly high morbidity. The modelrecommended here is for:a single team that includes social care staff working from the samelocation, preferably under the same management and using a single set of clinical notesstaff who are full-time members of the team, or at least predominantly soconsultant psychiatrists fully integrated into the teama clearly defined sector population and links to identified primary care teams.

The size of a teamThe size of a team is important for its efficient functioning. The value of multidisciplinary team-working is that most team members know something aboutmost of the long-term patients, and can therefore offer sensible insights and becomeeasily involved in care. Similarly, the administrative demands of the team mustalso leave adequate time for informal reflection and discussion about care. Allthese are dependent on a manageable case load for their efficient functioning.

Experience suggests that it is hard to sustain high-quality work with fewerthan 6 full-time employed staff. Below this it is difficult to achieve an adequatespread of skills or to allow for annual leave, sickness, training days, etc. On theother hand, if teams are too large (e.g. above 15 staff) the clinical work becomesswamped by organisational and information transfer tasks; cliques and factionscan form and the lines of responsibility can become complex and confused.

Staff numbers and professions

The MHPIG for CMHTs (Department of Health, 2002 a) outlines optimal currentstaffing for a standard CMHT. With a medical staffing of 1 full-time consultantand 1 1.5 non-consultant psychiatrists they recommend 8 whole-time equivalentcare coordinators, of whom:

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34 are community psychiatric nurses (CPNs)23 are social workers (including approved social workers (ASWs))11.5 are occupational therapists11.5 are clinical psychologists13 are mental health support workers11.5 are administrative assistants/secretaries

Also, there should be information technology (IT) support and reception staff.

Team leadership and management

Consensual functioning is to be aimed at in CMHTs. There are, however (quiterightly), differing priorities within a team and sometimes a need to arbitrate instuck situations. Time is not always available to discuss thoroughly who can

best respond to pressing situations.The role of maintaining the clinical focus of the team and resolving disputesover clinical priorities requires clinical oversight of the whole team s functioningand the authority for operational management. In current NHS practice, this roleof clinical team leader is best discharged by the consultant psychiatrist.

Teams also need a member who takes responsibility for day-to-day managerialtasks. Usually the team manager is an experienced, non-medical team member,who carries a reduced clinical load but is responsible for the routine managementof the team and much of the supervision of non-medical staff. The clinical teamleader and the manager need to work closely together.

Case-loads and reviews

Active case-load management is the key to flexible, responsive capacity withinCMHTs. Experience of CMHTs has shown the following:

they should have a maximum of 300 patientseach full-time care coordinator should have no more than 35 patients(with a pro rata reduction for part-time workers): increasingly, servicesare aiming at 25each individual s case-load should be sensitive to the team s skills mixand the patients needsthe distinction between the standard and the enhanced care programmeapproach (CPA) varies greatly from team to team: usually, enhanced CPAis restricted to patients with long-term problems that routinely requireinput from more than one team memberenhanced CPA patients should make up over half of the team s case-loadand each should have a named care coordinatorcare coordinators are usually trained professionals, not medical staff (because of limited availability or the risk of discontinuity of care),support workers or trainees

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a consultant s or staff grade psychiatrist s personal case-load of standardCPA patients whom they manage with GPs should not exceed 50: balancing this with the needs of the CMHT requires ongoing reviewtrainees should hand long-term patients back to trained staff, not on toother trainees; better still, trainees and trained staff should work jointlywith these patientsconsultants should have face-to-face contact with all their long-termpatients at regular scheduled intervals agreed within the teamsome form of structured assessment should be part of the routinemanagement of long-term patients; there are a number of possible scales(e.g. the Brief Psychiatric Rating Scale, Health of the Nation Outcome Scale)and their use helps to track slow changes and alert staff to deteriorationcare coordinators should continue involvement when patients areadmitted to hospital.

Care coordinators are responsible for ensuring that a treatment plan is workedout in collaboration with the individual patient (and involved carers), that it isdelivered, monitored and regularly reviewed. This responsibility also coversmaking sure that back-up arrangements are in place to cover sickness and annualleave, and ensuring that documentation (CPA, risk assessment, contingency plans,carer s assessment, GP letters, etc.) is up to date. The care coordinator is notresponsible for delivering all of this care (although usually the bulk of it), butmust ensure that it is provided.

CMHTs have a regularly scheduled meeting at least once a week, in which

patients can have a multidisciplinary review. Patients on enhanced CPA requireregular scheduled reviews, not driven purely by crises.

Note-keeping and time management

Time management is essential in an acute CMHT, which needs to protect capacityfor emergencies and which is subject to variable demands. High-quality, up-to-date note-keeping and completion of the documentation that is increasingly afeature of modern mental health care requires supervision and monitoring. Italso requires scheduled time in the week.

Staff who book up the whole day seeing patients miss out on multidisciplinaryinput, with the risk of a deterioration of the care they offer. Furthermore, neitherthey nor, as a consequence, the team are effectively available for crises (whetherwith current patients or new referrals). Such staff also risk early burnout. Teamsneed to agree sensible norms for non-contact time.

Hours of operation

Most CMHTs operate 09.00 17.00 h, Monday to Friday, with flexible working(e.g. evening work with family groups managed by taking time back). An

increasing number, however, are providing an extended service (08.00 19.00 h)

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GPs expect 70 80% of assessments of new patients to be by trainedpsychiatrists (consultant, staff grade or specialist registrar, either singly or jointly with other disciplines. Although this would be possible in a teamstaffed as well as that outlined in the MHPIG, it may not be realistic forall teams.There should be a single point of entry for new referrals to the team toestablish consistent thresholds and enable adequate monitoring. Someservices run routine out-patient clinics parallel with CMHTs. There isdivided opinion about this practice and there needs to be careful balancing of resources where it does occur.Community (including both GP surgeries and patients homes) andmultidisciplinary assessments are recommended.New patient assessments should always contain a psychiatric formulationand, where possible, diagnosis and an adequate assessment of risk andsubstance misuse.In many cases an assessment of how the individual is coping with thedemands of daily life and of their strengths is particularly important.Where possible information should be sought from carers and familiesand incorporated into a comprehensive assessment.Maximum waiting times for assessments should be agreed locally. Thereis an increase in patients failure to attend if the delay exceeds 3 weeks(Burns et al, 1993). The MHPIG recommends working towards 1 week as aroutine, but this is generally impractical (for patients as much as forteams) and 4 weeks is more realistic.Urgent assessments should be available within a week.Discharged patients should all be reviewed as soon as possible within thefirst week of discharge.Emergency assessment capacity should be available within the team andsame-day assessment procedures should be agreed locally, includingstipulation about the seniority of the assessor and that the referrer hasseen the patient that day.Where crisis resolution/home treatment teams are established these willusually take on responsibility for most emergency assessments. Access to

assessments by qualified medical staff and social workers must beavailable 24 hours a day, 7 days a week within each local service.

Treatments

This document is predominantly concerned with how services are organised.However it is the treatments that teams provide for their patients that make adifference, not their processes. CMHT staff are expected to keep up to date withcurrent best practice through their own continuing professional development. TheMHPIG for CMHTs has a very useful section entitled What does the service do?

This will not be dealt with in detail here but there are some over-arching principles:

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CMHTs should aim to keep abreast of, and apply, evidence-basedpractice.Psychological therapies should be part of the remit of CMHTs. These areaimed both at reducing symptoms and at increasing coping and resilience(examples include CBT, stress management, brief counselling).The NHS has classified psychological treatments into A (an integralcomponent of routine care), B (eclectic psychological therapy) and C(formal psychotherapy). All CMHTs would be expected to be able toprovide types A and B and some to provide some type C.All staff, not just clinical psychologists, need to be trained inpsychological therapies.Staff should also be trained in current psychosocial interventions (e.g.adherence therapy, relapse signature identification).CMHTs should have the skills and resources to provide optimalpharmacotherapy (e.g. physical health monitoring of patients takingatypical antipsychotics, including blood tests for clozapine and lithium)and structured assessments of drug side-effects.Outcome goals should exceed the purely medical and include socialfunctioning such as work, parenting, study and leisure pursuits.Teams members should also provide: comprehensive assessment and support with substance abuse

management help with survival skills (e.g. housing, budgeting) basic monitoring of physical health care family and carer support and education.

Operational policy and team governance

All of the above makes a daunting list. Multidisciplinary teams need clarityabout roles, responsibilities and policies. These should be encapsulated in awritten operational policy which is reviewed and agreed at least annually and isreadily available. This should cover at a minimum:

internal authority and chain of responsibility

liaison arrangements (primary care, social services, housing etc.)transfer arrangements and protocols for crisis resolution/home treatmentteams, assertive outreach and early-intervention servicesdischarge to referrer and transfer between services protocolssafety policydocumentation (CPA, risk assessments, relapse plans, etc.).

Summary

CMHTs remain the basic model for most of the more specialised teams that have

been identified in the modernisation agenda. Traditionally they have been reactive

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rather than actively managed and their virtues have been overlooked. Happily,this is now changing.

Because of their role in assessing and managing such a wide range of problems,they have a challenging task of balancing access and flexibility with maintainingfocus and prioritisation. They are, however, moving away from the traditionalperception of being a catch-all provision. They also must continuously monitorand balance the relative contributions of generic working and profession specificinterventions. They are likely to experience major changes in their role andrelationships as the modernisation teams evolve and become established. Inmore dispersed populations they are, however, likely to remain the backbone of mental health services for some time to come.

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3 Modernisation teams

Recent years have seen an unparalleled reconfiguration of adult communitymental health services following a centrally determined National ServiceFramework for Mental Health. This established a trinity of discrete teams (assertiveoutreach; crisis resolution and home treatment; and early intervention), to targetextra resources and specialised treatments on high-need populations. Initially, itwas proposed that these teams, plus a primary care liaison team , would replacecommunity mental health teams (CMHTs) as a functionalised adult secondarycare service system. A more sensible, and subsequently acknowledged, model isto retain CMHTs as the core of the service, with modernisation teams

complementing them.Modernisation is not restricted to these three teams, but they represent themain new evidence and policy-driven specialisms. They continue the shifttowards prioritising people with severe mental illnesses and reflect the rise of international research and evidence-based practice, as well as consumerismand public pressure for improvements in health policy and practice (Burns &Firn, 2002).

The newness of these teams is reflected in the lack of consensus onnomenclature. For clarity, Department of Health literature terms are used.

Assertive outreach teams

The NHS Plan target of 220 teams in England has almost been fulfilled. Theassertive outreach model (known as assertive community treatment in the USA),is underpinned by a huge and largely US literature and research base. Assertiveoutreach teams are not just about targeting a specific population of patients whoare hard to engage, chaotic and high users of in-patient services. They aim todeliver a mix of evidence-based psychosocial intervention and intensive practicalsupport from multiskilled and multidisciplinary practitioners. In the UK, teamshave evolved from both acute and rehabilitation services and incorporate best

practice from both traditions.

Funct i on and tr eat ment

The team works intensively, with an assertive approach to maintaining regularcontacts providing both treatment and rehabilitation. There is a tension betweenthis assertive approach and the aspirations of collaborative approaches that focuson recovery and self-determination: in the former, team members takeresponsibility, monitoring and maintaining patients , whereas in the latter theynurture, empower and foster the growth of consumers or service users .

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Features of assertive outreach teams:delivery by a discrete multidisciplinary team able to provide a full rangeof interventionsmost services provided directly by team, not brokered outlow staff-to-client ratios (1:10 1:15)most interventions provided in community settingsemphasis on engagement and maintaining contact with clientscase-loads shared across clinicians, staff know and work with the entirecase-load, although a care programme approach (CPA) care coordinator isallocated and responsiblehighly coordinated intensive service with brief daily handover meetingsand weekly clinical review meetingsextended hours, 7-day-a-week service, with capacity to manage crises andincrease contact to daily if neededtime-unlimited service with continuity of care.

Interventions and activities of assertive outreach teams:assertive outreach maintaining regular and frequent contact with patientsengagement developing long-term therapeutic relationships withpatients who are hard to engage with servicesretaining and maximising patients strengthssymptom management (regular monitoring and adjustment of treatments)direct community medication administration, daily when neededclozapine treatment, including home initiation

psychosocial interventions: cognitive behavioural therapy, family workand support for carerspractical assistance and problem-solvingdeveloping daily living and life skills; encouraging the use of normalsocial resourcesvocational rehabilitation.

St ruct ure and var i a t i on

A typical assertive outreach team comprises 6 12 whole-time-equivalent care

coordinators and caters for a case-load of 60 100 patients. National guidancestates a maximum patient-to-staff ratio of 12:1 and this is borne out in practice.Team-working and daily handover ensure that the whole team is familiar withthe case-load and can easily work with any of its patients. The level of teamapproach ranges from efficient and flexible cross-cover and sharing of high-contact patients to a completely shared approach, where all visits are routinelyrotated on a daily basis between staff members.

Li a i son and co l l abora t i on

Teams try to provide the majority of interventions from within their ownexpertise, to reduce the fragmentation of services. Only occasionally would

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highly specialist psychological interventions, forensic or addiction services input be sought. Only a small number of UK teams currently provide a 24-hour crisisfunction purely for their own team case-load with assertive outreach on callstaff. Routine cover into the early evening and over 7 days, however,significantly reduces crisis presentations. Contingency plans are usually leftwith local 24-hour services (either crisis resolution/home treatment teams oron-call duty systems). Ensuring that CMHT referrers are clear about entry orreferral criteria and exit or discharge criteria helps modernisation teamscomplement CMHTs and manage interfaces.

Staff ing

All modernisation teams are multidisciplinary, often with a predominance of nurses and requiring social workers and medical input. Occupational therapyand psychology contribute to a more effective team, as do unqualified supportworkers. Ideally, the psychiatrist should accept consultant responsibility withcontrol over admission and discharge to designated assertive outreach beds. Alltrained staff act as CPA care coordinators, with the exception of medical staff.Psychiatrists concentrate on clinical input across the entire case-load, reviewingpatients with unstable symptoms, risk behaviours or side-effects and participatingin routine CPA reviews.

Conclusion

Assertive outreach is well established in England. The task for the majority of relatively new teams is to develop their clinical and social care skills and retainthe model principles. It is a model that provides both structure and freedom forteams to offer intensive community treatment and flexibility of care.

Crisis resolution and home treatment teams

Crisis resolution and home treatment teams (also known as intensive hometreatment or community treatment teams) have evolved as a response to:

pressure on number of beda requirement for 24-hour access to services in a crisisincreasing recognition that hospital does not always have to be thelocation for intensive multidisciplinary treatment during acuteepisodes.

These teams provide short-term intensive treatment for patients at risk of hospitalisation. These teams offer more than just wards without walls , sincethe community focus means that families and friends as support networks can be involved more effectively, disruption to normal lives is minimised andrestrictive environments are avoided. Some also provide a crisis telephonehelp-line.

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Funct i on and tr eat ment

Home treatment teams operate 24 hours a day, 7 days a week because they dealwith people who would otherwise be in hospital and because they must promptly

assess all acute presentations. Assessing potential admissions is referred to asgatekeeping. Its purpose is to reduce inappropriate admissions, ensuring thateveryone for whom it is safe and sensible to provide a home treatment alternativeis diverted accordingly. Strict gatekeeping for patients already engaged withCMHTs encounters resistance from some professionals, who feel that they knowtheir patients needs and resist the possible fragmentation of care that gatekeepingthis involves.

Components of the home treatment team service include:24 hours a day, 365 day a yeara focus on people who are acutely ill or in crisis and who are at imminent

risk of hospitalisationa main focus on people with severe and enduring mental healthproblems; the teams are not usually appropriate for self-harm in theabsence of psychosis or severe depression, nor for those with the solediagnosis of personality or anxiety disorder although currentexperience indicates that these latter patients do constitute a significantpart of their workloadability to rapidly assess following referralfrequent contact and intensive interventionshort duration of involvement, just until the crisis resolves: treatmentepisodes usually last 1 6 weeksearly discharge of acute patients from in-patient to home treatmentassessment, care and treatment that involves and encourages the existingsupport network of family and friendsassertive outreach approach in terms of engagement and comprehensivehealth and social care inputsecure, appropriate follow-up care once the acute phase of mental illnesshas passedassisting patients and their support networks to learning from the crisis.

Home treatment interventions include:problem-solvingsymptom managementadministration and supervision of medicationmanagement of side-effectspsycho-education brief supportive counsellingroutine reassessment of mental state and risksupporting, maintaining and improving support networks andrelationships

direct assistance with activities of daily living

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direct assistance with housing, benefits and criminal justice issuesestablishing a crisis planstress management.

St ructure and var i a t i on

Many teams (those who follow the guidance most closely) work on principlessimilar to those of in-patient wards, with 2-day shifts working from 08.00 h or09.00 h to 22.00 h or 23.00 h, plus an on-call arrangement overnight. Assessmentout of hours is often in a place of safety rather than in a community setting. Teammembers have high levels of patient contact, from once to several times a dayaccording to need and risk. Many trusts are exploring a model in which the crisisservice works only outside office hours and ensures that crisis response is moreexplicitly recognised in CMHT operational policies.

The threshold for admission is raised especially where home treatment teamsalso have access to crisis respite residential accommodation and acute day hospitalprovision as additional options. Whether the home treatment consultant takesconsultant responsibility is not specified in the guidance and practice varies.This is often determined by the number of CMHTs served.

Li a i son and co l l abora t i on

Some crisis resolution/home treatment teams share a triage function with an

open-access telephone crisis line provided in their district. Interfaces with CMHTs,accident and emergency departments, primary care (including out-of-hoursproviders), duty social workers and police need to be established and formulated.Some teams incorporate a part of the accident and emergency liaison psychiatryfunction, although not all mental health presentations are suitable for home treat-ment. Other teams restrict themselves only to those destined for in-patient care.

Staff ing

Teams are often large because of the long shifts and on-call services that they

provide. Typically, 14 multidisciplinary staff are needed whose sole function ishome treatment. They work with 20 30 patients from the catchment area of 2 4CMHTs, depending on the locality, serving populations of 150 000 200 000.Minimum numbers of staff per shift need to be established, as on a ward. Medicalinvolvement needs to be active from both a consultant and middle-grade doctor,ideally with 24-hour access to a duty psychiatrist.

Conclusion

A few patients prefer to be in hospital for an acute episode, and many require

admission for sound clinical reasons. However, home treatment increases the

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choice and sophistication of alternatives to admission for acutely ill individuals,especially if it is extended by acute day hospital and crisis residential facilities.

Early-intervention teamsEarly-intervention services, sometimes called first-episode, first-break or early-onset teams, target young people with first-episode psychosis. First psychosispresentations to specialist psychiatric services often reveal symptoms that havealready existed for 1 2 years (McGorry & Jackson, 1999). Currently most first episodepatients are hospitalised with high rates of involuntary and police admissions.

Funct i on and tr eat ment

There is some evidence that patients with long durations of untreated psychosisfare less well in long-term outcome studies and that they take longer to recoverfrom first and subsequent episodes (Lieberman et al, 1996). Neurocognitivedevelopment and functioning is affected early in the course of psychotic illness,with consequent losses of social roles, employment, friends and educationalopportunities.

The early phase of psychosis presents valuable opportunities to work onsecondary prevention and recovery. Early intervention brings advantages of establishing a collaborative and educational approach with patients and families.Typically low-dose atypical antipsychotics are favored and sensitive engagementprioritised. Treatment resistance can be addressed early. Receiving goodtreatment early is very highly valued by patients and relatives.

The Mental Health Policy Implementation Guide (Department of Health, 2002 a)suggests the following template for services.

Characteristics of early-intervention teams include:an age-specific patient group (14 35 years old)treatment of psychosis onlytreatment time-limited to 3 years;early detection and programmes to educate the public and primary carereferrers

accepting referrals for whom the diagnosis may be uncertaincollaborative, friendly approach centred on young peopleregular contact in low-stigma community settings, in the style of assertiveoutreachsmall case-loads and focus on engagementfocus on reclaiming or maintaining social roles and support such asfriends, family, employment or education.

Government targets centre on reducing the duration of untreated psychosis toa service median of less than 3 months, with no one waiting more than 6 months.The expectation was that each locality would have access to an early-interventionservice by 2004.

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Early-intervention team interventions include:rapid and assertive response to first service contact, with flexibility of appointment timesmedication review and treatment switching for treatment-intolerant ortreatment-resistant patientslow-dose or atypical first-line treatment: treatment should minimise side-effects to improve medication compliance while still being effectivecare-coordinator-led psychosocial interventions such as psycho-education, CBT, concordance (compliance) therapy, relapse preventionand behavioural family interventionsindividual early warnings signs and relapse prevention plan agreed anddeveloped with patients and carerscare should address all aspects of daily living

vocational assessment should take place (if appropriate) within 3 monthsof referraleducational or training plan/pathway to valued employment should beproduced (where appropriate) within 3 monthsassessment and management of risk and assessment and treatment of comorbidity, particularly substance misuse, depression, suicidality andanxiety.

St ructure and var i a t i on

Few early-intervention teams are well established, and those that are varyconsiderably. Current descriptions of practice are based mainly on recommend-ations rather than established consensus from experience. The guidance suggeststhat each early-intervention service covering a population of 1 million would see150 new cases a year referred, which would translate into 450 patients managed by the entire service for the 3-year suggested follow-up period. The servicewould be divided into three or four teams, each managing 30 50 new cases ayear, with a team case-load of up to 150 depending on local prevalence.

Teams vary in practice regarding the age range of the patients they treat. Theguidance recommends that they treat patients aged between 14 and 35 years as

the standard, but arrangements for adolescents need to be agreed with child andadolescent mental health services. Some teams limit themselves to a diagnosis of schizophrenia rather than all psychoses. There is likely to be an unavoidablediagnostic uncertainty with first-episode patients and a focus on symptoms ratherthan diagnosis may be pragmatic.

Existing well-resourced teams have subdivided their services, with a numberof continuing-care, assertive-outreach-style teams covering different areas of alocality. Patients are identified for these teams by a single early-detection teamcovering a large area. This team assesses and screens referrals, and raisesawareness both within and outside the region s mental health trust. More

controversially, services that have a particular research bias have set up prodromal

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treatment clinics that try to intervene with high-risk groups (e.g. individualswith a first degree relative family history, or with prodromal sub-clinicalsymptoms and reductions in functioning) before the emergence of first-ranksymptoms. There is no current recommendation for this in routine practice.

If the duration of untreated psychosis is related to long-term outcome thenintervening early and ensuring that treatment is based on best practice becomesan obvious function of early-intervention services. The first 3 years of the illnessis the time of maximum deterioration, with emergence of a revolving-door pattern of treatment, treatment resistance, and major social and occupationaldisabilities. Two-thirds of suicides in individuals with psychoses occur in thefirst 5 years after presentation.

Summary

Modernisation teams initially represented a revolutionary change to replacegeneric CMHTs, but they are now more often viewed as an evolutionarydevelopment to support CMHTs. It will be obvious from this chapter that thestaffing recommendations for these teams will not be achievable in the nearfuture (indeed, it will be a challenge to achieve recommended staffing levelseven for the generic CMHTs). Reasonableness and local judgement are required.In psychiatry, as in law, the best should not be allowed to become the enemy of the good.

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The political accountability of services provided by local authorities is new tothe NHS, which is traditionally based on professional accountability. NHS staff often find the new demands and accountability difficult. However, they can provideopportunities to secure more resources for specialist mental health services. Thisis reinforced by the Local Government Act 2000, which gives local authority electedmembers a duty to promote health and social well being for all their residents.

Early work in London has developed a simple series of questions for councillorsto promote positive action for mental well-being, including support for peoplewith serious mental illness. The questions are set out below.

1. What is your council doing to promote the mental well-being of yourwhole community?

2. How is your council working in partnership with other organisations topromote the mental well-being of the whole community?

3. What is your council s policy for employing people who haveexperienced or are experiencing mental health problems?4. How does your council support tenants who are experiencing mental

health problems?5. How is your council promoting a positive approach to people who

experience mental health problems?6. How do you know that your policies are working?

Provisions outside of office hours are an area of poor integration of health andsocial care. Traditionally, two separate, somewhat skeletal, services operated inparallel. Social services provided small, generic emergency, duty social workteams, confined to the most pressing emergencies (e.g. Mental Health Actassessments). Mental health input has been accessible only via psychiatricassessment, typically by junior doctors in accident and emergency departments.Despite the development of crisis resolution/home treatment services and awider range of response options in the evenings and at weekends, this has notyet involved major progress in integration with emergency duty services.

Fair access to care services

Government guidance on fair access to care (Department of Health, 2002 b) outlinesthe circumstances in which adult social care will be provided. This provides anational framework for councils to use when setting eligibility criteria for accessto services. The framework reflects the risks and needs associated with variousforms of disability and impairment. They must be applied consistently to allclients within a local authority area who have physical or mental health problems.

The guidance prioritises the risks faced by individuals into four bands: critical,substantial, moderate and low.

Local eligibility criteria are then applied to these bands. The framework relatesto both immediate and longer-term risks and therefore allows a preventive

approach to adult social care.

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Individual councils have some flexibility about setting eligibility criteriadependent on resources available. This can create difficulties for NHS trusts,which provide services in more than one local authority area, as there are nocommon eligibility criteria.

Social inclusion

People with mental health problems are frequently prevented from working orparticipating in the community. Mental illness is not well understood by thepublic, can be stigmatising and can lead to exclusion from the range of conditionsthat provide us all with security and social status: financial independence, socialinteraction and a home. These areas are identified by mental health service usersas their areas of greatest need, which have significant effect on their mentalhealth.

Social inclusion is curently an area of great Government interest. The SocialExclusion Unit in the Office of the Deputy Prime Minister is consulting on thedevelopment of a strategy to deal with issues of social inclusion for people withmental health problems.

Accommodation

Stable accommodation of adequate quality and with sufficient support matterscrucially. Effective community care requires the provision of a wide variety of accommodation, offering differing degrees of independence and supportdepending on needs. It cannot always be assumed that living at home with thefamily is the best option. For the immediate future local authorities will have akey role to play in the provision of housing for people with mental healthproblems. It is essential to maintain good, collaborative relations with localauthorities, and particularly with their housing departments.

Many mental health service users rely on public housing (either councilhousing or housing association properties allocated through the local authority).To ensure allocation of the right kinds of property and with the necessary speed(vital for homeless in-patients awaiting discharge), close working relations withlocal authority homeless persons units have to be developed. Effectivecommunication with those responsible for overseeing allocated council tenanciescan be crucial in supporting users.

There is often misunderstanding between mental health service and housingservice staff. Mental health professionals tend to stereotype housing staff ashaving little understanding of mental illness and being too ready to identifywith the prejudices of neighbours and the wider community. Housing staff, fortheir part, see mental health staff as completely focused on the needs and rightsof their patients, unwilling to consider the interests of those around them. Whenproblems do emerge, such as neighbours complaining about nuisance or disturbed behaviour, housing and mental health staff must work constructively together.

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The discussion and negotiation necessary to resolve such problems will involvecomplex issues of confidentiality. These must be handled sensitively. Mental healthprofessionals cannot avoid such issues when actively promoting a programme of social inclusion for their clients. Some joint training between mental health andhousing staff may facilitate collaborative working and mutual understanding.

For individuals who need residential care, local authorities will usually bethe source of funding. The National Health Service and Community Care Act1990 transferred all funds for the provision of residential care to local authorities(away from the Department of Social Security) and included a directive for themto move away from direct provision of residential care. Consequently, there has been a significant growth in the variety of accommodation available, with anincrease in providers in the private and voluntary sector.

Despite undoubted improvements and increased diversity of availableaccommodation, there continue to be gaps. In particular, there is a shortage of highly staffed hostels with the capacity to manage people with more challengingor complex mental health difficulties. Too many service users continue to remainon acute in-patient wards, unnecessarily and to their own frustration, for want of this more specialised accommodation.

Most service users prefer as much independence and privacy as possible.This natural resistance to residential care is compounded by the benefits system,particularly the obligation on local authorities, under the National AssistanceAct 1948, to charge almost all users of community care services for the use of those services. Once these fees have been paid out of their benefits, residents areoften left with little more than pocket money . This poverty further excludesthem from much of mainstream society, so it is not surprising that many preferintensive support in their own homes.

Supporting People is a government initiative that came into effect in April2003. Previously, housing benefit was used to fund projects in which serviceusers held their own tenancies and were supported by social care staff. Now therental and support elements of the package are separated, rent paid by housing benefit and support by social services. Supporting People completes the processinitiated by the National Health Service and Community Care Act 1990, with allsocial care funding in the community consolidated within social services budgets.

Supporting People should give social services more ability to shape the provisionof supported housing to reflect service user priorities. A risk is that service usersmay have to pay for services that were formerly free.

Accommodation for those with mental health problems who also have substancemisuse problems, forensic histories, patterns of antisocial behaviour orcombinations of the three is a continuing problem. There is a lack of highlystaffed hostels willing and able to manage them. Neighbours struggle to toleratetheir presence on council estates and there is a danger that they languish onacute wards or become homeless. There are no easy answers for these individuals.It is important that mental health services maintain good working relations with

local authority housing departments. If they can be engaged in strategic thinking

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about alternatives (e.g. mainstream public housing or suitable residential care)there is some likelihood of reaching more satisfactory conclusions.

Housing has traditionally been primarily the responsibility of social workers.Under community care legislation, funds for residential care were transferred tosocial services, and social workers (as care managers) were responsible forcommissioning most hostel care. Social workers will continue to play a key role, by virtue of their existing skills and long-standing ties with other local authorityservices. However, with increasing integration of health and social care, otherprofessionals (e.g. community psychiatric nurses) are also taking on the roles of advocating for housing needs, commissioning residential services, liaising withproviders and so on. Over time, such working across traditional professional boundaries will become more common.

OccupationEmployment and education provide individuals with a sense of identity andself-worth. They can enable financial security, social opportunities and providestructure and purpose to lives. Occupation can include paid employment, butalso supported work and education.

About 60% of people with a diagnosis of schizophrenia are employed at thetime of their first hospital admission, but this reduces to 10% after a year (Rinaldi& Perkins, 2002). Around 90% of people with severe and enduring mental healthproblems are unemployed. Current evidence indicates that, if properly supported,up to 60% can achieve and maintain employment or education. However, fewpeople with mental health problems receive this support.

When developing care plans, mental health professionals should routinelydiscuss with the service user their preferences for work and education. The careplan should include appropriate support and recognition of existing abilitiesand previous experience.

Social support and leisure

Seriously mentally ill individuals are often excluded from social activities and

interactions with the community. Positive social interaction can provide supportand reduce symptoms and help with adherence to treatment and medication(Repper & Perkins, 2003). Comprehensive care should include support for socialactivity. Those with long histories of mental illness may find social interactiondifficult, and befriending services provided by some voluntary organisationscan offer support.

Health and well-being of children

The existence of mental illness in an adult working or living with a child does

not necessarily mean that the child is at risk. However, the nature of the illness

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might affect the child s development and welfare in many ways, including throughphysical or emotional abuse or neglect (including the consequences to the childof acting as a carer). Mental health trusts are required to set up child protectionpolicies and procedures that have been agreed with the children and familiesdivision of the local social services department. They must also have well-developed and agreed policies and protocols for the transition of patients fromchild and adolescent to adult mental health services.

As part of the care planning process an initial assessment should be made of actual or potential risk to children from the adult service user and any necessaryaction or reporting should be undertaken as indicated in the local agreements.Psychiatrists and other mental health professionals do not have comprehensiveskills to assess parenting, but should alert the local social services children andfamilies division, who do have these skills. Mental health professionals do,however, have a contribution to make in advising about the effect on children of a parent s illness. Confidentiality between agencies can be broken if there is riskto the child. The law states that the welfare of the child is paramount and thatemployees of NHS trusts and local authorities have a duty to assist in childprotection investigations.

The whole issue of child protection has, of course, been given a much higherprofile recently as a result of the well-publicised Laming inquiry into the deathof Victoria Climbie and the Green Paper Every Child Matters that it provoked. Anew Children Bill is imminent.

The Green Paper proposes significant reforms to the child protection system,and mental health services will need to adjust to these to make their owncontribution to child welfare. Every Child Matters proposes the creation of children s trusts . Mental health services must establish effective working relationswith these new trusts, which will be introduced in 2006. The Green Paperanticipates that health organisations (and the police) will be given a new duty tosafeguard children. Experienced social work staff, familiar with child protectionissues and with child welfare agencies, should contribute significantly to this.

Vulnerable adults also require protection from abuse. Local authorities andNHS trusts are required to agree local adult protection policies. These are broadlysimilar to child protection policies.

Summary

The provision of effective comprehensive mental health care must includeconsideration of all aspects of an individual s life. Government policy and localservice developments have begun to move towards supporting this comprehen-sive care. Psychiatrists and other mental health professionals have already madesignificant progress in this way of working and can anticipate a strengthening of this role. Although some of the changes associated with this closer working mayseem daunting to psychiatrists, they present real opportunities for progress.

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5 Essential partners

Community mental health teams do not operate in isolation: they must liaise withother services that provide essential support. Clear referral criteria and pathways between services are important for comprehensive and seamless care. The fourpartners that we discuss in this chapter are primary care teams, substance misuseservices, forensic services and rehabilitation services. They are not the only partners, but they are the ones who contribute regularly to the welfare of most seriouslymentally ill patients in the community. Several other services (such as accidentand emergency departments and psychiatric liaison teams in general hospitals)refer patients to CMHTs, but these are discussed in detail in other College

documents and will not be considered here.

Introduction

General practitioners are responsible for the care of most of the common mentalhealth problems, which make up a substantial proportion of their consultations.They and the other members of the primary health care team are the most frequentpoint of first contact for individuals with mental health needs and they refer onlya tiny fraction of these patients to secondary services for advice or treatment. Theaverage general practitioner (GP) will refer one patient per fortnight to a CMHT.

The primary health care team plays a substantial role in providing direct treatmentfor psychiatric disorders of mild to moderate severity, in gatekeeping access tosecondary care and other specialist services and in supporting the managementof severely mentally ill people in the community. Access to a CMHT usuallyrequires referral from a GP. Although there is wide variation in the level of experience and training between practices, a number of core skills can be expectedin primary care mental health practice. These include the following functions:

Screening Health visitors are ideally placed to screen for post-nataldepression. GPs and practice nurses screen for treatment side-effects andearly signs of relapse in long-term mental illness.

General medical care Individuals with severe mental illness havemarkedly increased physical health morbidity. Physical ill health is a riskfactor for common mental disorder. Most of these problems will beaddressed and managed by the primary health care team.Mental health assessment GPs are required to fulfil statutory as well asprofessional obligations in conducting mental health assessments.Formulation, diagnosis and referral Having knowledge of a patient sfamily, their personal background and current circumstances, GPs areideally placed to offer comprehensive formulations of psychological andsocial factors that precipitate and maintain psychiatric disorders and tomake appropriate referrals.

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Prescribing Initiation and continuation of complex psychotropicprescribing can be done in primary care. Depot antipsychotics can begiven by practice or district nurses and GPs monitor lithium levels, andrenal and thyroid function.

Variations in structure

The most common form of primary health care team is the group practice. Theselarger practices permit increasing medical specialisation within them. Walk-inmedical centres are a recent development in some cities and, along with minorinjuries units and cottage hospitals, they are also be gateways to secondarymental health services. Out-of-hours care is increasingly being dealt with by avariety of services, with the consequence that mentally ill patients may not beenseen by a doctor who knows them.

Liaison and collaboration

Clear referral procedures should be agreed between GPs and CMHTs, withparticular attention given to urgent cases. Time spent by CMHTs with primarycare teams in scheduled, regular, face-to-face discussion is highly productive inshaping referral and discharge patterns, setting thresholds and defusing crisesand misunderstandings. CMHTs should have an explicit policy for their GPliaison (e.g. a monthly meeting with each major referring group practice, eitheras a team or via designated link workers). Aligning sectors by GP list rather than

street lists is highly successful in improving liaison. As mentioned in the chapteron Generic CMHTs, where there is conflict between alignment with GPs andsocial services, then social services boundaries should take precedence.

Staffing

A primary health care team typically consists of GPs, practice nurses, nursepractitioners, community nursing team, receptionists and other clerical staff. Someprimary health care trusts receive support from counsellors, communitypsychiatric nurses (CPNs) and clinical psychologists.

Substance misuse services

Drug and alcohol use is increasing throughout society. Patients with mentalillness are not immune from this trend and pay a very high cost.

One third of individuals with a mental disorder have experienced asubstance misuse disorder.One third of individuals with an alcohol problem have experienced amental health disorder.One half of individuals with an illicit drug problem have experienced a

mental health disorder.

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Highest rates of comorbidity are found in the patients of CMHTs. Failure toaddress comorbidity leads to poorer outcomes, increased hospital bed occupancyand an increased risk of violence. Patients with both mental health and substancemisuse problems may fall between services because of exclusion criteria, althoughit is now clear that the responsibility for them lies with mental health services.Effective treatment of substance misuse can lead to mental health improvements,reductions in crime and mortality rates, and a return to a normal lifestyle. However,the task of achieving high standards of care for patients with a dual diagnosis iscomplicated by the piecemeal development of substance misuse services acrossthe country.

Funct i on and tr eat ment

Substance misuse services provide some or all of the following:information, advice and support for individuals and their relativespsychological interventions such as motivational interviewing andrelapse prevention trainingcommunity care assessments for rehabilitation unit placementssubstitute prescribing, prescribing to promote abstinence anddetoxification, if medical support is available.

St ructure and var i a t i on

The wide variation between substance misuse services confounds the developmentof effective links with CMHTs. Some services are consultant-led, provide a widerange of interventions for both drug and alcohol problems and use commonmechanisms for referral and correspondence. Others may be staffed by trainedvolunteers, deal only with one or other problem, accept mostly self-referrals andmay not routinely correspond with medical or psychiatric services. In some areascounselling is provided though social services and medical care from a separatetrust. The situation is gradually improving as the National Treatment Agencyattempts to develop good-quality, consistent services across the country.

Li a i son and co l l abora t i on

Community mental health teams have a responsibility to accept the managementof people with a dual diagnosis where the severity of mental health disorder in apatient who misuses substances is significant or where there is diagnosticuncertainty. Defining such cases requires local agreement with primary care teamsand substance misuse services.

Teams providing integrated care to dual diagnosis patients may offer superior benefits. Shared care between CMHTs and substance misuse services either atthe same time (parallel care) or alternately (serial care) is currently the most

realistic way forward. It is recommended that:

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promote social and cultural reintegrationreduce stigmaimprove quality of life over the longer term.

Target populations are based on levels of disability and complexity (and includeeligible individuals at all levels of secure provision). Inclusion criteria are any orall of the following:

persistent non-adherence to care planning and aftercarecurrent (or recent) serious risk to self or otherssevere behavioural problems, including violence and some offending behaviourshigh risk of relapse making, intensive demands on in-patient services(high need and high demand)inability to survive outside of hospital without a high level of domiciliary

support at least once a dayextreme vulnerability and impoverished lifestyle (high need but lowdemand group).

Treatments include:

prescription and supervision of complex medication regimes, includingclozapine and augmentation therapies, for treatment-resistant disorderspromotion of adherence to and engagement with treatmentevidence-based psychosocial interventionstraining and support for independent living skills

evidence-based psychological interventions, including family workfinancial managementsocial skills training and the management of relationshipsincreasing work and social roles through supported accessliaison with substance misuse services for the provision of appropriatepsychological therapies for patients with a dual diagnosis.

St ructure and var i a t i on

The functional unit of any rehabilitation service is the multidisciplinary team,

which comprises a consultant in rehabilitation (who generally leads the team), apsychologist, social worker and occupational therapist, together with specialistnursing and support staff, all of whom should have access to training inpsychosocial interventions. Structures are underpinned by the care programmeapproach. The team approach should start where the patient is , and is based onregular assessment and review. Whatever the setting, there must be formal linkswith primary medical services, as the physical health care needs of this populationare extensive. Care planning should be formalised at effective care-coordinationreview meetings.

Rehabilitation teams need skills enhancement from other professionals (e.g.

tenancy or employment support workers and staff with particular cultural

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competencies) and access to a range of specialised psychological therapies,according to the needs of the patients. This should be kept under regular review,with input from users and carers.

The rehabilitation team may be based within an in-patient service (e.g. a lowsecure intensive rehabilitation unit or hostel ward) or in the community, withlinks to in-patient services, CMHTs, assertive outreach and other functional teams.However, in some health economies, community rehabilitation teams have beenreplaced by assertive outreach teams. These teams may incorporate therehabilitation skills base, but exclude patients who are not hard to engage , andwho make few demands on services (despite their evident level of need). Effortsshould be made to resist this trend.

Structures should vary in accordance with local needs and relationships withother agencies and services, aiming to provide services that plug the gap .

Li a i son and co l l abora t i on

Rehabilitation services should complete the range of services specified withinthe National Service Framework for Mental Health and the NHS Plan. Theyshould provide for both high-need, high-demand patients (generally throughassertive outreach) and high-need, low-demand patients, and for patients families,requiring dedicated domiciliary support. Rehabilitation services generally providefor patients excluded by other services, provided that clinical risk can be safelymanaged. Clinical collaboration is therefore required with substance misuse andforensic services and with local specialist psychological services.

Collaboration may involve partnerships with voluntary or independent sectorproviders, and should extend into social care, housing, employment and educationalfacilities. There should be links with the criminal justice services, local MAPPPs andwith advocacy services.

User and carer participation in service development, in monitoring and audit,and in training are essential.

Staff ing

The current recommendation for specialist rehabilitation consultant psychiatristsis 0.40.8 whole-time equivalents per 100 000 age-adjusted population, dependingon the scope of responsibility of the post concerned. Where specialistrehabilitation services include assertive outreach or low secure units in additionto high-support residential services the higher figure is appropriate.

Forensic psychiatry services

Forensic services have grown in size and importance as the Government hasgiven greater priority to risk management in mental health. The emphasis on

community safety has also brought a change in the nature of forensic services.

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They used to deal mainly with patients in secure settings, but most have nowdeveloped community services (this approach is usually referred to as outreach ,in recognition of its institutional origins).

Whether patients find themselves in forensic or other services usually reflectstheir needs at the time, and these needs should determine their onward carepathway. A few forensic patients have specialist pathology such as sexualoffending, but for the most part referral is determined not by diagnosis, but bythe level of risk to others. Risk is described in terms of seriousness and immediacy.However, the current state of risk assessment and the lack of reliable measuresleave scope for disagreement about which patients belong in which service.Forensic case-loads are lower, to allow closer supervision, and the overlap withgeneric services can easily generate resource envy. Standardised or structuredrisk assessments may help to provide a common language for debates aboutrisk, but as they cannot be applied rigidly to all individuals there will always bethe need for clinical agreement on the best management of a particular case.

Funct i on and tr eat ment

Assessment and management of risk of serious violent or sexual offending.Management of specialist pathology asso