APPENDIX 17
Memorandum by the Centre for Mental Health
Services Development (CMHSD) (MH 44)
1. EXECUTIVE
SUMMARY
1.2 The Centre for Mental Health Services Development
(CMHSD), welcomes the opportunity to provide evidence to the Health
Select Committee, in its inquiry into the provision of NHS Mental
Health Services.
1.3 CMHSD has worked on implementation of
mental health policy in most localities across the UK, and has
played a role in the formulation of policy by providing members
to the Mental Health Task Force, the Independent Reference Group,
and the External Reference Group.
1.4 From our work with commissioners, providers
and users within NHS and social care services, there are three
areas we feel need to be considered:
— Interface, organisation and commissioning
of services.
— The ability of care in the community
to cater for people with acute mental illness.
— The effect of organisational and
service arrangements on adolescents experiencing mental distress.
1.5 From our experience, we would recommend
the following actions:
1.5.1 Interface, organisation and commissioning
of services
(a) Primary Care/Secondary Care Interface:
there are number of practical steps that the DoH could take
to assist:
— make the appointment of a mental
health lead by PCGs obligatory, preferably a GP, and issue further
guidance on the role of these mental health leads in the NSF implementation
process;
— ensure that PCGs identify time and
support to enable the mental health lead to undertake this role
effectively;
— encourage Regional Offices to support
the establishment of regional networks for PCG mental health leads
in order to increase their effectiveness, including their knowledge
of good practice.
(b) Service Configurations: It is
suggested that the DoH should ask Regional Offices to:
— ensure that localities have agreed
and put in place the most appropriate and achievable configuration
of service providers by April 2001;
— declare a moratorium on further structural
change for at least three years;
— provide scope for pilots of PCTs
taking on the provision of mental health services but only if
the DoH is convinced that the criteria laid down in the NSF are
fulfilled;
— evaluate the pilots and make the
results available, to be discussed and debated within the three
year moratorium period.
During this period of time, the CMHSD evaluation
of the first integrated mental health provider Trust in England
(Somerset NHS and Social Care Partnerships Trust) will also be
published.
(c) Commissioning Mental Health Services:
it is suggested that the DoH asks Regional Offices and Social
Care Regions to ensure that:
— local mechanisms for collaborative
commissioning are in place by April 2001;
— these mechanisms are sustained over
the same period as the provider configurations discussed above.
1.5.2 Ability of care in the community to
cater for people with acute mental illness
(a) Assertive Outreach: through our
work, we found variations in service development models. Closer
examination revealed important unanswered questions relating to
practical implementation in a local area, that could not be adequately
resolved by evidence in the National Service Framework or scales
of fidelity. Questions predominantly related to the service development
process. It is recommended that the DoH asks Regional Offices
and Social Care Regions to ensure that:
— greater emphasis be given to the
service development process, and resources provided through modernisation
funds be set aside for this purpose;
— greater clarity be provided about
the expected outcomes required to avoid tremendous variations
and avoid the unhelpful debate about service models, we recommend:
— a different way of determining standards;
— that standards match what service users
want;
— standards are targeted toward sustaining
community living by tackling some of the root causes of illness;
— work is focussed on enabling clients
to take up active roles as citizens;
— user-defined standards may be established
including some of the following:
— providing an accessible, regular,
reliable and on-going service for as long as it is needed;
— providing on-going good palliative care;
— enabling housing stability to be achieved;
— enabling clients to have more money by
maximising welfare benefits;
— enabling access to services by people
from black and ethnic minority communities;
— enabling access to community facilities
to promote and encourage ordinary living;
— enabling access and entitlement to health
care—mental and physical health;
— enabling access and entitlement to social
care—housing, welfare, family, social support;
— enabling access and entitlement to personal
growth and development—education, training and employment.
(b) Services for people also misusing
substances (dual diagnosis): There are three main reasons
why dual diagnosis may be seen as a cause of concern:
— the simple statistical evidence on
the extent of the problem;
— the impact of these clients on the
operation of mental health services;
— the level of risk presented by the
clients.
We would argue that dual diagnosis is the major
public safety issue, which drains political and public confidence
in services coping with acute mental illness in the community,
and not mental illness per se. This is of further concern when
one takes into account the number of people who have been in care.
It is our view that there are a number of practical steps that
the DoH could take:
— extend the duty on partnership between
health and social care communities to include substance misuse
and housing services;
— require joint working and coordination
between mental health and substance misuse agencies, to address
the complex social and clinical needs of this client group;
— require mental health services to
take the lead for those people on enhanced CPA with a dual diagnosis;
— include working with people with
a dual diagnosis as a requirement within the remit of assertive
outreach services.
(c) Opportunities for maintaining employment:
Substantive issues that need to be addressed are:
Helping to sustain people in work, who become
ill. From this we would recommend that employers need to be informed
of, and proactive about:
— employees rights under the Disability
Discrimination Act (DDA);
— providing clear, secure and supportive
ways of helping people to return to work as required by the DDA.
Medical services need to be geared up to getting
people back to work and not keeping them out, by:
— being aware of the health benefits
of maintaining employment;
— being prepared to work more closely
with employers (with client consent);
— finding supportive ways to enable
them to return to work;
— providing support to people whilst
in work, but still experiencing distress.
Reaching people who are disengaged from services;
there are particular groups of people who disengage from services
and are hard to reach. As a result, their mental health problems
escalate, they develop complex needs and often lead chaotic lifestyles,
ending up using mental health services, and coming in touch with
criminal justice system. In the main, these people are young,
male or single mothers and from black and ethnic minority communities.
Better opportunities for recovery and work can be achieved using
models of services such as:
— Programmes of Assertive Community
Treatment (PACT) where vocation has been given primacy in secondary
mental health services.
— The Lambeth Early On-Set service (LEO),
strongly targeted toward the African and African Caribbean communities.
— Mental health support could be provided
for Welfare to Work programmes to make them more appropriate for
young people whose social and health factors are making it difficult
for them to concentrate on work or training.
1.5.3 The effect of organisational and
service arrangements on adolescents experiencing mental distress:
three key issues have been identified:
(a) Acute care and prevention for adolescents:
It is recommended that:
— greater emphasis is given to the
role of prevention to avoid the escalation of mental health problems
into a life long career;
— greater investment is made in specialist
acute facilities;
— prevention strategies are supported
by education and psychology;
— more locally-based services are needed
for those with challenging behaviours to enable them to live within
their communities and close to families;
— for those with challenging behaviour,
services are steered through clinical governance and training
to respond to the needs of clients who have a co-morbidity of
mental health problems and a learning disability.
(b) Services for young people leaving
care: It is recommended that:
— the duty of joint working be extended
from adult mental health services to those for children and adolescents;
— the local authority be given lead
responsibility for these services;
— community teams move to joint working
arrangements with single entry points for assessment and treatment
and care co-ordination.
(c) Lack of integration between child
& adolescent psychiatry (health) and adult mental health services:
It is recommended that:
— the age band used in health and social
care providers be standardised to one recognised band;
— admissions to adult acute wards be
made unacceptable except as a last resort and where unavoidable,
specialist care be provided including therapeutic interventions
and safe environments;
— the co-ordination and planning of
care is systematised, in particular to manage transitions between
services and at times of change.
| 
