Memorandum
INTRODUCTION
1. This memorandum covers the provision
of NHS and social care mental health services for both adults
of working age and children and adolescents. It first considers
measures to improve mental health services including the Mental
Health National Service Framework, changes in prison health care
services, secure services, developments in child and adolescent
mental health services and people with personality disorder. Second,
it considers the ways in which the legislative framework is being
modernised, through the reform of the Mental Health Act, and proposals
for new legislation on dangerous people with severe personality
disorder. The specific issues raised by the Committee are covered
in annexes to the memorandum.
2. Older people's mental health is dealt
with in the Older People's National Service Framework, which is
expected to be published in autumn 2000. Work is also underway
on a drug and alcohol strategy. While mental health services of
course work in partnership with these services, they fall outside
the Committee's terms of reference. Personal Social Services,
which were not specifically mentioned in the Committee's note,
are included, as effective mental health services integrate health
and social care.
BACKGROUND
3. Mental health services are a priority
for this Government, confirmed in the most recent National Priorities
Guidance (2000-03). Developments in mental health services are
being carried out in the context of the Government's White Paper,
The new NHS, Modernising Social Services and Saving Lives:
Our Healthier Nation.
4. The Government's strategy for mental
health is set out in Modernising Mental Health Services (published
in December 1998) and is designed to improve mental health services
as part of the overall programme to modernise the health and social
care system. It began by identifying a number of problems:
— Some service users with severe mental
illness—typically schizophrenia—may be socially isolated,
difficult to engage and in need of long term care, and may not
get the treatment and support (including drugs and psychological
therapies) that they need;
— Families and other informal carers
who contribute to the care of people with mental illness are often
under-supported;
— Inadequate systems, poor management
of resources and under-funding had resulted in widespread and
unacceptable variation in standards;
— Problems of recruitment, retention
and poor staff morale were commonplace, particularly in inner
cities;
5. There was also evidence that there were
significant pressures on mental health beds. The National Beds
Inquiry was commissioned to look further into this matter and
the report was published on 10 February 2000. It found that there
is currently a significant mismatch of mental health services
and mental health needs. It considered that there are too few
medium secure and intensive care beds, and a shortfall in supported
accommodation in the community, including 24 hour staffed beds.
In some localities, especially the inner cities there are currently
severe pressures on acute mental health beds. At the same time
there is evidence of admissions and continued hospital stays which
would have been unnecessary if other services had been available.
6. The Government recognised that as part
of the strategy to address these problems there would be a need
to review the existing legal framework relating to people with
mental disorder. In particular:
— the focus of the 1983 Act, which
is on the compulsory assessment and treatment of patients in hospital,
does not fit with contemporary patterns of service provision and
does not adequately support delivery of treatment and care for
patients in the community;
— there is wide variation in the way
that the provisions of the Act are applied in different parts
of the country, variation that cannot be explained simply on the
basis of differences in availability of services or population
characteristics; and
— the 1983 Act does not provide an
adequate framework for dealing with the small minority of people
with severe personality disorder who present a serious risk to
the public.
Action
7. Modernising Mental Health Services
therefore proposed action in three areas:
— new investment and systems to manage
resources more effectively, taken forward through the Comprehensive
Spending Review which has invested an additional £700 million
in mental health services over three years;
— legislative powers which work with
the grain of comprehensive mental health services, taken forward
through the review of the 1983 Mental Health Act and consultation
on the management of dangerous people with severe personality
disorder; and
— properly integrated care processes,
which cross professional and organisational boundaries, taken
forward through the development and early implementation of the
National Service Framework.
8. These issues are considered in more detail
in the following sections which cover:
Better mental health services for working age
adults:
— Mental Health National Service Framework;
— secure mental health services;
— prison health care services; and
— new services for dangerous people
with severe personality disorder.
Better child and adolescent mental health services:
— child and adolescent mental health
services; and
Modernising the legislative framework:
— reform of the 1983 Mental Health
Act; and
— legislation for the management of
dangerous people with severe personality disorder.
BETTER MENTAL
HEALTH SERVICES
FOR WORKING
AGE ADULTS
Mental Health National Service Framework
9. The Mental Health National Service Framework
is the first National Service Framework to be published. It is
founded on knowledge based practice and partnership working, not
only between different clinicians and practitioners but also across
different parts of the NHS, between the NHS and local government
and reaching out to the whole community, including the voluntary,
independent and business sectors.
10. The National Service Framework addresses
the mental health needs of working age adults, and covers health
promotion, assessment and diagnosis, treatment, rehabilitation
and care, and encompasses primary and specialist care and the
roles of partner agencies. It sets out seven standards of care:
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| Standard | Objective
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| One | Health and social services should:
Promote mental health for all, working with individuals and communities.
Combat discrimination against individuals and groups with mental health problems, and promote their social inclusion.
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| Two | Any patient who contacts their primary health care team with a common mental health problem should:
Have their mental health needs identified and assessed.
Be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it.
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| Three | Any individual with a common mental health problem should:
Be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care.
Be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services.
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| Four | All mental health service users on the Care Programme Approach (CPA) should:
Receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk.
Have a copy of a written care plan which:
—Includes the action to be taken in a crisis by the service user, their carer and the care co-ordinator.
—Advises their GP how they should respond if the service user needs addtional help.
—Is regularly reviewed by their care co-ordinator.
Be able to access services 24 hours a day, 365 days a year.
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| Five | Each service user who is assessed as requiring a period of care away from their home should have:
Timely access to an appropriate hospital bed or alternative bed or place, which is:
—In the least restrictive environment consistent with the need to protect them and the public.
—As close to home as possible.
A copy of a written care plan agreed on discharge which sets out the care to be provided, identifies the care co-ordinator, and specifies the action to be taken in a crisis.
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| Six | All individuals who provide regular and substantial care for a person on CPA should have:
An assessment of their caring, physical and mental health needs, repeated on at least an annual basis.
Their own written care plan which is given to them and implemented in discussion with them.
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| Seven | Local health and social care communities should prevent suicides by:
Promoting mental health for all, working with individuals and communities (Standard one).
Delivering high quality primary mental health care (Standard two).
Ensuring that anyone with a mental health problem can contact local services via the primary care team, a helpline or Accident and Emergency (A&E) department (Standard three).
Ensuring that individuals with severe and enduring mental illness have a care plan which meets their specific needs, including access to services around the clock (Standard four).
Providing safe hospital accommodation for individuals who need it (Standard five).
Enabling individuals caring for someone with severe mental illness to receive the support which they need to continue to care (Standard six).
In addition they should:
Support local prison staff in preventing suicides among prisoners.
Ensure that staff are competent to assess the risk of suicide among individuals at greatest risk.
Develop local systems for suicide audit to learn lessons and take any necessary action.
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Implementation of the Mental Health National Service Framework
11. Implementation of the National Service Framework
will begin in April 2000. Mental health will be a priority in
Health Improvement Programmes, through commissioning and within
clinical governance. This will represent a long term programme
requiring sustained, concerted and systematic action to combat
long-standing and complex problems. The initial focus will be
on providing safe services.
12. National Priorities Guidance for health and social
services for 1999-02 published in September 1998 included key
objectives for mental health services as follows:
— improve users' and carers' access to services,
the quality of continuing care and treatment they receive, and
work towards the Our Healthier Nation target to reduce the risk
of suicide. This will include putting in place robust mechanisms
for inter-agency working to ensure that joint plans between NHS
and social services for the implementation of the Framework are
included in Health Improvement Programmes by December 1999 for
the period beginning April 2000;
— improve the delivery of appropriate care and treatment
to patients discharged from hospital by reducing nationally the
emergency psychiatric re-admission rate by 2 percentage points
from the 1997-98 baseline by 2002; and
— improve access to relevant mental health services
and increase public safety by setting up mechanisms to support
regional specialised commissioning of high and medium secure psychiatric
services in shadow form by 1 April 1999 and fully by 1 April 2000.
13. The objectives set in the 2000-03 National Priorities
Guidance build upon these. They are to:
— Contribute to the development nationally, by April
2001, of: at least a further 50 crisis teams, bringing the total
to over 170 teams providing services to 15,000 people; an extra
250 secure places (in addition to the 221 planned for 1999-2000);
and a further 100 24-hour staffed beds;
— Ensure by April 2001 that all service users on
the enhanced Care Programme Approach have a written care plan
which explains how to contact specialist mental health services
around the clock.
14. A comprehensive baseline survey of current service
provision across health and social care will be undertaken to
inform local planning and against which future progress will be
measured. Local Implementation Teams are in place in every local
health and social care community. These teams have a core membership
which includes representation from local service users, local
authority departments, carers, Primary Care Groups, Health Authorities
and NHS Trusts. These teams have submitted draft implementation
plans and by April 2000 they will produce detailed plans showing
how they will achieve the early milestones in the National Service
Framework.
15. As part of the process of producing Joint Investment
Plans and Local Implementation Plans authorities will also produce
a gap analysis identifying the overall local development needed
to meet all of the National Service Framework requirements within
a 10-year strategy. By autumn 2000, the local teams are required
to produce a 10 year strategic plan, upon which they will have
consulted widely, and a detailed three year rolling plan which
will feed into the local Health Improvement Programme and reflect
targets set locally in Best Value Performance Plans.
16. Implementation of the National Service Framework
will involve pulling all the necessary levers including ensuring
that:
— mental health is at the centre of Health Improvement
Programmes and the commissioning process;
— mental health is a priority for Primary Care Groups;
— mental health is a key theme in clinical governance;
— specialist mental health services are a priority
for regional specialised commissioning; and
— mental health services are identified in Best
Value Performance Plans.
17. Additionally, Regional Champions have been selected
in each of the regions. Their role is to provide a respected voice
for mental health services as and when called upon to do so. Regional
Champions include a service user with a national profile, a present
and a former chair of a Regional Office of the NHS Executive,
a psychiatrist with a joint academic and NHS contract and a Regional
Office Director jointly with a Social Care Region Assistant Chief
Inspector.
18. In 2000 and 2001 the Social Services Inspectorate
will be undertaking an inspection of mental health services to
evaluate the implementation of Government policies relating the
social care needs of adults of working age who experience difficulties
with their mental health (including personality disorder). The
inspection will address the policy and management framework of
local authority social care services and the experience of service
users and their carers. The inspection will also address the policy
and procedural framework in the following areas:
— dual diagnosis (mental health/drug alcohol);
— dual diagnosis (mental health/learning disability);
— child protection and children in need;
— mentally disordered offenders;
— transitional arrangements; and
National Underpinning programmes
19. Local delivery of the National Service Framework
will be supported by a series of underpinning national programmes
across health and social care.
20. As well as ensuring continuing financial support
for the National Service Framework (paragraphs 44-51), four other
underpinning programmes are being developed:
— research and development;
— clinical decision support systems; and
Workforce development
21. Recruitment and retention of suitably skilled staff
is a long standing problem in mental health services.
22. The national standards and service models set out
in the National Service Framework will require additional staff,
properly trained and supported, to provide modern mental health
treatment and care. More staff are needed across all groups, including
care support workers. Skill mix issues must be addressed. Staff
need improved working conditions, modernised education and training
programmes, and a systematic programme of continuing professional
development. And we need to develop a systematic approach to ensuring
that the workforce is competent at teamwork, and in working with
the range of partner organisations.
23. The Department of Health has established a Workforce
Action Team, chaired by Sue Hunt, an experienced Mental Health
Services Chief Executive, to deliver a nationally co-ordinated
programme of support for local health and social services. The
Action Team is focusing on four key areas:
— Recruitment and retention;
— Education and training; and
— Developing and supporting leadership.
24. The Workforce Action Team will submit an interim
report by the end of March 2000.
Research and Development
25. The Department of Health has sponsored mental health
research and development (R&D) via the Policy Research Programme;
the NHS R&D Programme; the Forensic Mental Health Research
Programme; and R&D support for NHS providers.
26. There is an increasing focus on dissemination, to
ensure that those responsible for mental health services are aware
of, and make use of, new and significant evidence. Sound and accessible
research evidence will be readily available from the National
Electronic Library for Health; mental health will be a key component
of the NHS Learning Network.
27. A review has been led by the Central Research and
Development Committee of the NHS to ensure that the NHS R&D
levy is consistent with the principles set out in The new NHS.
This report is due to be published shortly.
28. Future investment in mental health R&D will focus
on the evolving knowledge base required to implement the National
Service Framework. Research priorities will include service user
and carer involvement; clinical and practice interventions; and
service delivery and organisation.
Clinical Decision Support Systems
29. The aim of the clinical decision support programme
is to ensure that clinical and practice decisions are evidence
based. A number of systems currently exist, including:
— The Cochrane collaboration.
30. The Cochrane collaboration prepares, maintains and
disseminates systematic reviews of research on healthcare. An
extensive database is incorporated into the Cochrane library,
including Abstracts of Reviews of Effectiveness, and Cochrane
groups are developing work on dementia and cognitive impairment;
depression, anxiety and neurosis; developmental, psychosocial
and learning problems; and schizophrenia.
31. Work in progress commissioned by the Department of
Health includes a review of therapeutic communities in psychiatric
and other settings, and a review of neuroleptics in schizophrenia
(recently published).
— The NHS Centre for Reviews and Dissemination.
32. The NHS Centre for Reviews and Dissemination at the
University of York provides information through systematic reviews,
principally in the areas of effectiveness and cost-effectiveness.
Four Effective Health Care Bulletins of relevance to mental
health services have been published recently.
33. Prescribing Rationally with Decision support In General
practice study is a computerised system for general medical practitioners,
which provides information for patients and supports prescribing
and other treatment decisions. Responsibility for guideline authoring
within PRODIGY has recently been passed to the National Institute
for Clinical Excellence in order to achieve a coherent approach
across the whole field of clinical guidance.
— Clinical Guidelines and Audit.
34. The National Institute for Clinical Excellence (NICE)
will advise on which treatments are clinically and cost effective,
and will produce clinical guidelines. Discussions are also taking
place with NICE to develop protocols to help GPs decide when to
refer patients on to specialist services.
35. Clinical audit has been funded through baseline allocations
to health authorities, through support to a range of professional
bodies, and through the National Centre for Clinical Audit, which
developed a comprehensive database which can be assessed via the
Internet. In April 1999, the functions of the National Centre
for Clinical Audit were transferred to NICE, which will develop
audit methodologies linked to each of their clinical guidelines.
36. The Clinical Standards Advisory Group was asked to
review services for people with depression. Their report will
be published very shortly. The Standing Nurse and Midwifery Advisory
Committee has examined nursing services in acute psychiatric inpatient
settings and its report, published recently, is due to be supplemented
by two sets of practice guidelines.
37. In addition to the work by NICE, the Department of
Health has also commissioned the Sainsbury Centre for Mental Health
to develop the knowledge base for the change management required
to improve mental health services.
38. Other publications include Clinical Evidence,
a recent initiative designed to provide evidence equivalent to
the national formulary. Clinical guidance will be updated every
six months. At present, it covers about 70 common conditions,
including mental health problems. The Health Needs Assessment
on mental illness is also currently being revised. Links are also
being established with the Electronic Library for social care
at the National Institute for Social Work.
39. Over the course of the coming year, existing and
newly commissioned Department of Health guidelines and protocols
will be reviewed to ensure fitness for the task of supporting
delivery of the National Service Framework for mental health.
Information
40. Information for Health (1998) sets the direction
for information services in the NHS. A Mental Health Information
strategy for NHS and social services is currently being developed
building on previous developments including the Health of the
Nation Outcome Scale and the Mental Health Minimum Dataset. It
will focus on a number of issues:
— information sharing between Local Authority Social
Services and the NHS;
— information on the knowledge base for service
delivery;
— information about individual patient care through
the development of electronic patient records;
— information to support management decision making;
and
— information for monitoring and performance management
of the National Service Framework.
Performance Management
41. The National Service Framework contains a clear set
of timetables, national milestones with high-level performance
indicators covering inputs, processes and outcomes. Thirteen such
indicators are being further developed.
42. Ministers have recently agreed to a comprehensive
Service Mapping exercise, which was initially piloted a year ago.
This will collect information from local health and social care
communities on the type and function of services they provide,
staffing levels and information systems. This systematic national
picture of mental health services will provide a baseline for
benchmarking and performance management.
43. A performance management strategy is currently being
drafted and will be available for consultation shortly.
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