MEMORANDUM
1. THE CENTRE
FOR MENTAL
HEALTH SERVICES
DEVELOPMENT
1.2 The Centre for Mental Health Services
Development (CMHSD), within Kings College, University of London,
was created by the DoH in 1991 to support the translation of national
policy into local practice. As well as having worked on implementation
of mental health policy in most localities in the UK, it 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.
1.3 At the moment the Centre assists around
fifty Local Implementation Teams in the development and achievement
of Local Implementation Plans to put in place the requirements
of the National Service Framework for Mental Health. It is perhaps
uniquely positioned, therefore, to reflect on the strengths and
weaknesses of mental health policy in practice. CMHSD represents
no sectional interest, and employs a range of clinicians, managers
and service users in its work.
2. AREAS OF
FOCUS
From our work with providers within NHS and
social care services, there are three areas on which we wish to
focus:
Interface, organisation & commissioning of
services:
— Primary/secondary care interface.
— Service configurations.
— Organisational issues regarding commissioning.
The ability of care in the community to cater
for people with acute mental illness:
— Assertive Outreach Services.
— Services for people also misusing
substances (dual diagnosis).
— Opportunities for maintaining employment.
The effect of organisation and service arrangements
on adolescents experiencing mental distress:
— Acute care and prevention for adolescents.
— Services for young people leaving
care.
— Lack of integration between child
and adolescent psychiatry (health) and adult mental health services.
3. THE EVIDENCE:
INTERFACE, ORGANISATION
AND COMMISSIONING
OF SERVICES
3.2 Primary Care/Secondary Care Interface
3.2.1 The recognition in the NSF of the contribution
that primary care makes to the treatment of mental health is welcome.
There are a number of general practices committing time and energy
to improving their expertise and extending their range of services.
3.2.2 However, in our experience, the role
of primary care in the delivery of mental health care and the
contribution of PCGs to the Local Implementation Teams (LITs)
is the one issue with which LITs most regularly struggle. It is
our view that there are a 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.
3.2.3 Consideration should also be given
to one of the performance management measures for PCGs being the
extent to which they have engaged patients, including users of
primary care mental health services, in the planning and monitoring
of services.
3.3 Service Configurations
3.3.1 Research undertaken by CMHSD demonstrates
that there is no robust evidence to link specific service configurations
with specific outcomes for service users. There is an emerging
consensus that specialist mental health Trusts are most appropriate
for inner-city environments and that acute Trusts do not give
sufficient priority to mental health services. Although there
are exceptions to these generalisations, CMHSD would broadly support
them. Much of the time-consuming and distracting debate on service
configuration has little connection, however, with the important
and challenging service issues raised in the NSF. Indeed, CMHSD
has shown the extent to which constant structural change is an
obstacle to the achievement of the modernisation agenda of the
government.
3.3.2 Is 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 and then declare a moratorium
on further structural change for at least three years. Within
this process, there should be 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.
These pilots should be evaluated and the results be made available
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
Partnership Trust) will also be published.
3.4 Commissioning Mental Health Services
3.4.1 The Health Act and subsequent guidance
on "flexibilities" create opportunities for the closer
collaboration between health and social services which has been
a theme of previous Health Committee Reports during this parliament.
Mental health services are in the forefront of these initiatives,
and many localities are drawing PCGs, Trusts, Users, Carers, and
Independent Agencies into fruitful formal arrangements for commissioning
with Health Authorities and Local Authorities.
3.4.2 Again, 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, and are sustained over the same period as the provider configurations.
4. THE
EVIDENCE: ABILITY
OF CARE
IN THE
COMMUNITY TO
CATER FOR
PEOPLE WITH
ACUTE MENTAL
ILLNESS
4.2 Assertive Outreach
4.2.1 Until January 1999, the development of
assertive outreach services (AOS) in the UK was relatively unknown.
However, with the advent of the government's mental health strategy,
there are in excess of 25 health districts currently developing
these services. Thirteen areas were targeted by the government's
first round of Modernisation Funds.
4.2.2 For existing assertive outreach services,
a few have been recognised as examples of good practice, while
others have raised further debate about the effectiveness of such
models. As current service development has progressed, new concerns
have been expressed about understanding the AOS model. Since the
launch of Keys to Engagement, there has been an active—and
often heated—debate about Assertive Community Treatment
(ACT) or Assertive Outreach Services (AOS) as it is known in this
country. The debate has polarised around one key theme—the
model of service.
4.2.3 Depite research reviews into the efficacy
of assertive outreach suggesting that this type of community care
greatly improves the quality of people's lives, the extensive
development of ACT teams, has also given rise to tremendous variation
in outcomes. In a number of cases, services have not replicated
the original or subsequent successful outcomes. This has resulted
in a response by some to press for programme fidelity or fidelity
to the model.
4.2.4 However, through our work, variations
in proposed service models were examined more closely. We found
local providers raised important questions relating to practical
implementation in a local area, that could not be adequately resolved
by a scale of fidelity. These questions predominantly related
to the service development process:
— Is Assertive outreach a means to
control or social inclusion: services are caught in the tension
between ensuring public safety through client compliance with
medical treatment and developing services to become more proactive,
flexible and socially inclusive; reach those hard to engage. The
greater emphasis on risk has made many clients and practitioners
reluctant to engage with developing these kinds of services.
— Who are services for: AOS are targeted
to people experiencing severe and long term mental distress, who
have chaotic lifestyles and complex needs, and who frequently
readmit to hospital, but many workers, carers and GPs and communities
argue for a broader definition.
— How does assertive outreach fit with
other services: The debate about function together with the confusion
around overall configuration of care pathways and service functions
in community mental health services makes it difficult to best
"fit" assertive outreach services. Furthermore, the
lack of guidance on recommended "forms" means that many
areas continue to inappropriately develop this function within
existing services.
— Are services already providing assertive
outreach? Often, when presenting information on assertive outreach,
practitioners and commissioners would say they were already providing
assertive outreach. However, when outcomes were examined, this
was not the case.
4.2.5 If we are to avoid tremendous variations
in outcomes and avoid the unhelpful debate about service models,
we recommend:
— a different way of determining service
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.
4.2.6 It is suggested that user-defined
standards should be outcome based and may include 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.
4.2.7 Establishing these standards will
not only effectively support those people most disengaged and
disabled from society and services, it may also help to resolve
the questions raised in local areas.
4.3 Services for people also misusing substances
(dual diagnosis)
4.3.1 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 clients.
4.3.2 Statistical Evidence: The OPCS Survey
of Psychiatric Morbidity of GB—Bulletin 1 1994 estimates
the national prevalence of alcohol dependence to 4.7 per cent
and of drug dependence to be 2.2 per cent in the 16-64 age group.
These figures would suggest that within a population of half a
million there would be 15,726 alcohol dependent and 7,361 drug
dependent individuals.
From US studies (eg Co-Morbidity of Mental Disorders
with Alcohol and Other Drug Abuse—Epidemiologic Catchment
Area Study NIMH/ADA 1990) it is known that for people with an
alcohol problem, the incidence of a co-morbid mental health problem
is likely to be 37 per cent and for those with a drug problem
the incidence will be significantly higher at 53 per cent.
4.3.3 What is clear from both the more established
US research and the more recent European research is that prevalence
rates are higher than previously recognised, that the utilisation
of service resources by this group is disproportionately high
in relation to their numbers, and that outcomes tend to be poor.
4.3.4 Impact on mental health services:
Definitions of dual diagnosis vary and there has been debate about
whether there is a specific disorder, which is characterised by
a particular classification system. Consequently many individuals
have been classified as having either a primary mental illness
and secondary substance misuse problem, or vice versa. In either
scenario, clients have not received the services they needed.
4.3.5 People with dual diagnosis will often
come into contact with a range of agencies at a time of crisis.
For example, they are likely to be seen by criminal justice agencies
as well as health, social services and housing agencies. Consequently
they often fall through the gaps in services, because there is
no duty on leadership.
4.3.6 Dual diagnosis is a significant problem
in both psychiatric and substance misuse services:
— A Maudsley study found that 40 per
cent of alcohol patients had some form of mental illness, and
the National Treatment Outcome Research Study (NTORS) found that
drug misusers seeking treatment have significantly higher levels
of mental illness than the general population.
— A study undertaken in Lambeth in
1996 of 42 in-patients, showed that 72.5 per cent smoked, 61.25
per cent used an average of 28.6 units of alcohol per week, 45
per cent consistently smoked cannabis, 12.5 per cent used amphetamines
and 22.5 per cent used cocaine and crack. Except for cocaine and
crack use (33 years), all those surveyed started using alcohol
and drugs in their teens.
— A recent study in Lambeth Southwark
and Lewisham Health Authority suggests that 58 per cent of people
presenting to mental health services have a dual diagnosis.
4.3.7 There are also cultural differences
between substance misuse and psychiatric services. Substance misuse
services largely work with clients who are motivated to change
or at least to engage with treatment. Dually diagnosed clients
are both resistant to treatment and are often very poorly motivated
because of their mental illness. On the other hand it is fair
to recognise that mental health services often choose to exclude
substance misusers.
4.3.8 In addition, there is anecdotal evidence
from substance misuse agencies, service users and nursing staff
about the inability of people in acute need of psychiatric care
being able to be admitted/cared for in a range of residential
and hospital settings, because of substance misuse. Also, there
is anecdotal evidence from nursing staff and service users about
the growth in drug pushing in in-patient units and the subsequent
hire of security staff to keep people out.
4.3.9 There is evidence that the costs of
treating this group are disproportionately higher than for non-substance
using patients with mental illness. This is primarily due to their
high utilisation of institutional services such as hospitals and
prisons. A local survey of an acute psychiatric ward in the South
of England showed over 30 per cent of beds occupied by people
with substance misuse problems and that these people were the
most difficult to discharge because of lack of appropriate accommodation
in the community. Anecdotally this seems to be a typical state
of affairs elsewhere. More systematic studies have found that
10 per cent of a psychiatric service's patients (mostly dually
diagnosed individuals) used 54 per cent of the agency treatment
resources.
4.3.10 Dual diagnosis is also a public safety
issue: US Studies have shown a correlation between dual diagnosis
and violence. A typical survey showed a relationship between violent
behaviour in the last year and substance misuse and mental illness.
Prevalence of violence was as follows:
— 7 per cent for those with major mental
illness;
— 19.7 per cent for those with substance
misuse problems;
— 22 per cent for those with dual diagnosis.
4.3.11 These figures are supported by The
Unlearned Lesson A Study of the Role of Alcohol and Drugs in Inquiries
into Homicides by Mentally Ill People (Ward & Applin 1998).
This highlights that while many of the homicides by mentally ill
people (eg Clunis, Newby, Sinclair et al) are regarded as being
the result of mental illness. In three quarters of the cases the
perpetrator also had a significant substance misuse problem. Also,
in over half the cases substance misuse could be argued to be
the real cause of the homicide. CMHSD are currently discussing
a potential further study into the use of substances for people
admitted to special hospitals, to consider the contribution of
substance misuse to the nature of their confinement.
4.3.12 The National Confidential Inquiry
into Suicide and Homicide by People with Mental Illness at
the University of Manchester was funded by the Government to collect
data on suicides and homicides by people who are mentally ill.
Their latest report (1999) highlights the role of substance misuse
in both suicide and homicide. 14 per cent of suicides in contact
with mental health services had a primary diagnosis of substance
misuse. 38 per cent had a history of alcohol misuse and 26 per
cent a history of drug misuse (p 26). With regard to homicides,
just over a third of all perpetrators had a history of alcohol
misuse but in a larger proportion it is thought alcohol played
a part in the offence. A similar number had a history of drug
misuse, but drugs were less likely to play a part in the homicide
(p 60).
4.3.13 50 per cent of users in one MSU were
"looked after" and over 50 per cent seriously abused
legal and illegal substances.
4.3.14 We positively welcome the inclusion
of dual diagnosis in the proposals for the Reform of the Mental
Health Act, but are concerned at the serious omission in the National
Service Framework.
4.3.15 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 co-ordination
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;
— included working with people with
a dual diagnosis as a requirement within the remit of assertive
outreach services.
4.3.16 Consideration also needs to be given
to the serious resource implications in working with people with
dual diagnosis across the mental health, substance misuse, housing
and criminal justice systems.
4.4 Opportunities for maintaining employment
4.4.1 CMHSD is part of the Institute for
Applied Health and Social Policy, which consists of a number of
strands of work; this includes the Employment Support Unit. From
this units extensive work they identified two substantive issues
that need to be addressed.
4.4.2 Helping to sustain people in work,
who become ill: Current practice, in the main, suggests that neither
employers nor primary care are psychologically or professionally
focussed on keeping people in work. 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.
4.4.3 Reaching people who are disengaged
from services: Evidence shows that 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 the criminal
justice system. In the main, these people are young, male or single
mothers and from black and ethnic minority communities.
4.4.4 Experience from the US, particularly
in relation to the use of a Programme of Assertive Community Treatment
(PACT) has demonstrated that where vocation has been given primacy
in secondary mental health services, work has acted as the "hook"
to engage these people with mental health services and medical
treatment.
4.4.5 The Lambeth Early On-Set Service (LEO),
is an Assertive Outreach service, being established on this premise
and strongly targeted toward the African and African Caribbean
communities. It will be fully evaluated over the next two years,
and the results, if positive, will have significant implications
for influencing service development in the UK.
4.4.6 42nd Street, in Manchester have suggested
that the Welfare to Work programmes have an inappropriate approach
for young people whose social and health factors are making it
difficult for them to concentrate on work or training. If mental
health support could be provided this could enable such programmes
to offer more appropriate vocational opportunities, at a time
when people are in particular need.
5. THE EVIDENCE:
THE EFFECT
OF ORGANISATIONAL
AND SERVICE
ARRANGEMENTS ON
ADOLESCENTS EXPERIENCING
MENTAL DISTRESS
5.2 The Social Care Group-—another
unit within the Institute for Applied Health and Social Policy
has undertaken extensive work within the field of social and health
care regarding the needs of young people. From their work with
client organisations, they identified the following issues:
5.3 Acute care and prevention for adolescents
5.3.1 Young people are mostly alienated
from mental health services because of their fear that they will
become labelled as a patient for life. They do not want to develop
a mental health career, and often will avoid engagement or treatment
until crisis occurs.
5.3.2 Child and Adolescent Mental Health
Services (CAMHS) is mostly seen, and therefore used, as an acute
or near acute service by most participating agencies. This exists
despite a four-tier level of service, with tiers 1-2 being community
based preventative services.
5.3.3 Most services concentrate on tier
three for heavy end community based services and tier four for
impatient. They fail to see that CAMHS have a preventative element
at primary care level, which needs to be further developed. This
may impart a knock-on effect, due to the relatively low level
of health care spending or lack of investment, in acute care for
this client group.
5.3.4 Services for young people with challenging
behaviour one are often confined to tier four. This usually means
residential placement away from home, in what is usually a non-inclusionist
atmosphere.
5.3.5 CAMHS are not always provided to young
people with learning disabilities, reflecting a broader issue
across all age groups about the lack of joined up services for
these people.
5.3.6 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.
5.4 Services for young people leaving care
5.4.1 There are relatively few services
for young people leaving care. This is due, in part, to the lack
of joined up services; CAMHS are provided by agencies other than
SSD and do not share the SSD priorities are looked after children.
5.4.2 Though multi-disciplinary teams work
tolerably well together, they often do not share eligibility criteria
and more often run parallel or sequential assessments rather than
true joint assessments. Duplication and confusion follow, leaving
the parent or carer to effectively manage the interface of several
individual agency care plans.
5.4.3 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.
6. LACK OF
INTEGRATION BETWEEN
CHILD AND
ADOLESCENT PSYCHIATRY
(HEALTH) AND
ADULT MENTAL
HEALTH SERVICES
6.2.1 Health and social care providers categorise
adolescents and adults at different ages, often resulting in a
group of young people from 14-16 years falling through the gaps
in acute care.
6.2.2 Young people in acute phases of illness
may have to be admitted to adult wards without the necessary safe
and therapeutic surroundings conducive for recovery.
6.2.3 There is a widespread and notorious
lack of communication between adolescent and adult mental health
services, meaning that transitional planning is minimal and mostly
ineffective.
6.2.4 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 situation change.
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