Select Committee on Health Appendices to the Minutes of Evidence


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);

    —  keeping jobs open;

    —  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.


 
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