House of Commons - Health - Appendices to the Minutes of Evidence

Select Committee on Health Appendices to the Minutes of Evidence

APPENDIX 18

Memorandum by the Sainsbury Centre for Mental Health (MH46)

Executive summary

Introduction

Definitions and categorisation of mental illness

Care in the community for people with acute mental illness

Acute and secure mental health care

Crossing from adolescent to adult mental health care

Conclusion and recommendations

References

EXECUTIVE SUMMARY

1. The Sainsbury Centre for Mental Health is an independent national charity that aims to improve the quality of life for severely mentally ill people by supporting the development of excellent mental health services.

Definitions

2. There is currently a range of administrative and legal definitions of mental illness across public agencies and government. It is unrealistic to attempt to impose a single definition across all sectors. However, it is important that:

— local partner agencies delivering services develop and disseminate shared definitions of severe mental illness;

— users receive high quality information about definitions and access criteria for different services and entitlements.

Care in the community for people with acute mental illness

3. Although most individuals with mental health problems can be cared for in the community, acute inpatient care is a key service for most individuals with severe mental illness. However, acute inpatient care has many drawbacks. There is little evidence that it is cost-effective, is disliked by patients who see it as coercive, and little therapy is delivered apart from medication. Hospital and community services alike are under great pressure. Hospital beds are frequently blocked because there are no appropriate alternatives—whether in the community or in secure accommodation.

4. Crisis services in the community have the potential to deal with many acute episodes, but they are poorly developed. Research has shown that such services can reduce hospital admission and deal with crisis just as effectively, at lower cost. However, they have to be set up and supported correctly.

5. More widely, there are serious problems in the adequate development of community services:

— community psychiatric nurses have increasing and unsustainable workloads;

— accommodation options, and meaningful daytime activity, including supported employment, are in short supply.

6. Assertive outreach teams can have a significant role in reducing pressure on beds and are being developed rapidly. The introduction of community treatment orders, as proposed in the Government's Green Paper on reforming mental health legislation, will increase the momentum to develop community services.

7. The development of the mental health workforce is crucial if there is to be rapid growth in community services. Significant and sustained growth in funding is also required. Carers require much greater levels of support, but little attention has been paid to this so far. Specialist services must link effectively with primary care.

Acute and secure mental health care

8. The secure and acute sectors—together with relevant community services—need to be managed as parts of a whole system if patients are to be placed where they can be given the care and security that best meets their needs. Currently there are many patients waiting to be transferred from special hospitals and medium secure units to lower levels of security and vice versa. There is merit in:

— as far as possible bringing secure services into the mainstream of NHS structures;

— developing community forensic mental health teams;

— developing shared risk management protocols to be used across all mental health services;

— developing a cadre of nurses with specific forensic skills.

Crossing from adolescent to adult mental health care

9. Adolescent and adult services often fail to work well together. Suitable inpatient services for adolescents are in short supply and many 17-18 years old are falling through gaps in the care system. Mechanisms for liaison between adult and adolescent services must be strengthened. Care pathways should be established to manage the transition of care from child and adolescent services to adult services, and from adult services to services for older people. Specific conditions and problems should be identified and shared between the two services before responsibility for an individual is transferred. Two key components are:

— dedicated early intervention services to identify and help adolescents at their first crisis and follow them over time;

— a combination of care management and care planning led by a single practitioner who coordinates care across all the relevant agencies.

INTRODUCTION

10. The Sainsbury Centre for Mental Health, a national independent charity, aims to improve the quality of life for people with severe mental health problems by promoting the development of excellent mental health services. It seeks to achieve this by influencing policy and practice through a co-ordinated programme of research and evaluation, communication and development and training.

11. The Centre embraces a range of expertise including the main professional groups within mental health, service users, senior managers, clinicians and policy experts. It works with a variety of local, regional and national agencies. In formulating policy positions it seeks to draw on its own research and evaluation work, the wider literature, expert opinion and on in-house experience. While fully evidence-based policy making is not always possible, the Sainsbury Centre for Mental Health seeks to provide an evidence-based perspective on national mental health policy.

12. The Centre has summarised the task in developing mental health service as follows:

"To develop an evidence based policy framework and a pattern and style of service which prevents the social exclusion of mentally ill people and allows them to exercise choice and participate in society safely and to the best of their ability".

13. In order to achieve this, the following steps are essential:

— Building an integrated range of services. These need to include a wide range of community and inpatient services so that users can receive efficient and effective care, appropriate to their needs. Services must be integrated across agencies, and this will be aided by the flexibilities available from 1 April 2000 under the Health Act 1999. Despite the current emphasis on partnership much remains to be done to integrate services horizontally. They must also be integrated vertically so that users receive appropriate care at primary, specialist and low volume service level.

— Development of high quality commissioning. Skills and knowledge in primary care groups (PCGs) and primary care trusts must be developed to allow effective commissioning at this level. The role of health authorities, local authorities and regional offices needs to evolve to reflect the development of PCGs. The creation of lead commissioners using the Health Act has potential for improving efficiency and co-ordination in mental health.

— Tackling the workforce issues. Staff must have the right skills and be available in sufficient numbers to match users' needs. This requires a human resources strategy that addresses core competencies, skill mix, recruitment and retention, staff development and education and training.

— Strategic leadership to deliver change and improvement in services at national, regional and local levels.

— Increases in financial resources for mental health, year on year and sustained in the medium to long term.

— Improving quality. The National Service Framework for Mental Health (NSF)2 sets out performance indicators for mental health and the implementation of A First Class Service3 will provide a robust quality framework for mental health. To be fully effective, this will need to be owned locally and to incorporate user perspectives on quality. A set of quality indicators which reflect user and professional understandings of what constitutes a good mental health service is urgently needed.

— Managing demand through locally agreed definitions of severe mental health problems, and local agreements and protocols on which services are provided by which agencies.

— Stigma must be addressed through a national communications strategy on mental heath issues and by a programme to tackle discrimination.

CURRENT GOVERNMENT DEFINITIONS AND CATEGORISATION OF MENTAL ILLNESS

14. A variety of definitions of mental illness and other mental disorders have been adopted across government at various different times. These are not necessarily consistent. The recent National Service Framework for mental health4 does not define mental illness, stating that mental illness embraces

"a range of diagnosable mental disorders which excludes learning disability and personality disorder".

15. The operational framework definition for severe mental illness presented in the Department of Health publication Building Bridges5 has been widely used as a basis for developing local definitions. It has five dimensions that are often summarised using the acronym SIDDD. All dimensions must be present if the individual is to be regarded as severely mentally ill:

S	=SAFETY	self harm, harm to others and abuse.
I	=INFORMAL AND FORMAL CARE	care from informal carers and/or statutory services.
D	=DIAGNOSIS	psychotic illness, dementia, severe neurotic illness, personality disorder or developmental disorder.
D	=DISABILITY	impaired ability to function effectively in the community.
D	=DURATION	of the above for periods which vary between six months and more than two years.

16. This definition has, to some extent, been reflected in the recent guidance revising the Care Programme Approach (CPA)—the care planning system for people with mental health problems in touch with NHS services.6 Standard CPA is addressed to individuals who:

— require the support or intervention of one agency or discipline, or who require only low key support from more than one agency or discipline;

— are more able to self-manage their mental health problems;

— have an active informal support network;

— pose little danger to themselves or others;

— are more likely to maintain appropriate contact with services.

17. Enhanced CPA is addressed to individuals who:

— have multiple care needs, including housing and employment, requiring inter-agency co-ordination;

— are only willing to co-operate with one professional or agency, but who have multiple care needs;

— may be in contact with a number of agencies, including the criminal justice system;

— are likely to require more frequent and intensive interventions, perhaps with medication management;

— are more likely to have mental health problems co-existing with other problems such as substance misuse.

18. These definitions affect local practice and user's experiences because they are used for gate-keeping and managing the vertical and horizontal interfaces in and between mental health agencies. They are generally helpful, as local agencies cannot function efficiently without definitions of severe mental illness, and national guidelines support local agreement of definitions and allow for some standardisation. However, these frameworks are too vague for assumptions to be made that the CPA is being used in an equitable way across the country.

19. Practical problems arise when definitions are different or are even mutually contradictory. Looking across government, there are a variety of definitions in legislation affecting mentally ill people. For example:

— the Mental Health Act 1983 does not define mental illness, but lists it as a subset of mental disorder. Whether someone is mentally ill is in practice a judgement for clinicians, Mental Health Act Managers or Mental Health Review Tribunals;

— the Mental Health (Northern Ireland) Order 1986 defines mental illness for the first time in UK legislation as

"a state of mind which affects a person's thinking, perceiving, emotion or judgement to the extent that he requires care or medical treatment in his own interests or in the interests of other people".

— the Disability Discrimination Act 1995 defines someone as disabled if he has a physical or

"mental impairment which has a substantial and long-term adverse effect on his ability to carry out normal day to day activities".

20. It is not clear from the recent Green Paper on the Reform of the 1983 Mental Health Act whether the Government intends to move away from the approach in the 1983 Act. In one section it states that "if a new Mental Health Act is to be effective its scope must be clear to those who use it and to those who may fall within its provisions". It records the scoping review committee's recommendations as "new legislation should apply to those with a 'mental disorder' and should not define the group more tightly".

21. Later the Green Paper states that "a more specific definition might result in unwittingly excluding some of those who should be within its scope. However, definitional schemes might be referred to in the Code of Practice".

22. The Sainsbury Centre for Mental Health agrees with the Government's view that definitional schemes should be referred to in the Code of Practice, and regretfully accepts that a satisfactory definition within the Act will be difficult to achieve.

23. There are a number of different definitions of mental illness, ranging from general, such as the definition in the Mental Health (Northern Ireland) Order 1986, to more specific multi-level definitions, such as SIDD. And as has been noted, there is no definition in the 1983 Act. Its is not surprising therefore that there are wide variations in the way mental ill health is defined and legislation applied in practice by mental health professionals. This is confusing for users. However, it is almost certainly unrealistic to standardise definitions across government and across all arenas, because different issues and services inevitably have to work to different criteria. A far more effective approach would be for:

— local partner agencies to agree a common definition of severe mental illness, probably based on the SIDD model, and to disseminate it to professionals and explain it to users and carers;

— all relevant agencies to provide high quality information to users and carers about how to access services, or who qualifies for which services.

CARE IN THE COMMUNITY FOR PEOPLE WITH ACUTE MENTAL ILLNESS

Acute hospital care

24. Hospital care has been the usual setting and mode of treatment for people with acute mental illness since the building of the Victorian asylums. It remains so today, despite the moves towards "community care" which started in the 1960s. There have been some advances in developing alternatives to hospitalisation, such as the creation of crisis and home treatment teams, but these have been very limited despite evidence of ineffectiveness and poor conditions in many inpatient units8.

25. The recent report Shaping the future: Long term planning for hospitals and related services9 states:

"Over the last 40 years there has been a steady decline in the number of mental health inpatient beds; around 28,000 mental health beds are currently provided within the NHS in England. This reduction has been concentrated in the long stay sector. The number of short-stay beds, less than one year duration of stay, has remained generally stable.

"Although in some places more acute beds may be required in the short term, this may not be the appropriate longer-term strategy. Studies show that as many as 29 per cent of admissions to acute mental health beds would not have been necessary had resources been available to provide care at home or in another community setting. Between 24 per cent and 58 per cent of patients may stay longer in an acute bed than they need to, because of shortfalls in:

— ordinary housing (25 per cent-41 per cent);

— home based community support such as a group home (19 per cent-28 per cent);

— or rehabilitation services (22 per cent-36 per cent).

"The pressures on acute beds therefore appear to reflect a wider mismatch of provision and need. Within each local health community, the requirement for acute mental beds needs to be assessed in the context of the whole mental health system. There is growing evidence that properly resourced services can prevent inappropriate admission to an acute hospital bed, and enable early discharge. Thus in the medium and longer term the emphasis should be on establishing a better balance between acute inpatient services and services to provide the packages of care which enable people with severe mental illness to remain at home and in their local communities."

26. The Sainsbury Centre for Mental Health endorses this analysis.

27. It has long been recognised that acute hospital care is under great pressure and provides a poor therapeutic environment. It is also costly and lacks any significant evidence base for its effectiveness relative to other interventions. While the number of hospital beds declined by a quarter between 1992-93 and 1997-98, there was no reduction in the pressure on hospitals, according to a key measure of hospital activity—finished consultant episodes for mental illness. As long and short stay bed numbers fell from 26,3000 to 19,370, finished consultant episodes rose from 234,000 to 236,000 between 1992-93 and 1997-98. The number of patients being detained under the 1983 Mental Health Act is also on the increase, rising by 11 per cent from 23,165 in 1993-94 to 25,826 in 1998-99.

28. The overall picture is therefore one of increased throughput coupled with a more severe case mix.

29. The Sainsbury Centre for Mental Health report Acute Problems10 detailed the results of a major research study on patient's experience in acute inpatient psychiatric care. The results were sobering. Four core problems emerged:

— there are no clear goals for acute care;

— the setting is usually neither pleasant or therapeutic;

— staff are not delivering targeted programmes to improve users' health or social functioning, based on individual needs;

— acute care is not seen as part of a system of mental health care;

— connections with community services are poor.

30. Other significant problems included concerns that women were unsafe on mixed sex wards and the wide mix of different types of patients with different needs on wards. Acute care is expensive—costing up to £1,000 per patient per week and absorbing two-thirds of the NHS mental health spend—yet it is not clear that it is effective and it is not managed as part of an overall system of care including community services. The study found that nearly one in five patients no longer needed inpatient care at the end of the first week of their stay, rising to 45 per cent by the end of the second week and 70 per cent after eight weeks. One recommendation of this report was that:

31. "Acute 24 hour care should be viewed as one component of a comprehensive and integrated service—a range of crisis services should be available of which hospital care is one component".

32. Some patients will always need to be taken to a place of safety when they break down, either because their behaviour is too challenging or damaging to be managed in another setting, or because their home circumstances make crisis intervention there unfeasible. However, the arguments for developing alternatives are overwhelming in both economic and human terms.

Crisis services

33. The Sainsbury Centre for Mental Health has researched the feasibility and effectiveness of community alternatives to hospital care. The report Open All Hours11 dealt with crisis services and reported on an evaluation of the Psychiatric Emergency Team in North Birmingham. It concludes that community based crisis services have been slow to develop. A survey in the mid '90s showed that only 11 per cent of Trusts had such services12. There is considerable confusion about what crisis services are and what form they can take.

34. Crisis services are required when:

— an individual's mental health has deteriorated so much that they may harm themselves or others, and

— they are in need of intensive specialist support and treatment.

35. Five broad types of crisis services exist across the country:

— out of hours services;

— rapid response services/team;

— early intervention service/team;

— psychiatric emergency service/team;

— home treatment team.

36. Some of these services will form part of mainstream mental health services, others will be separate services exclusively for people in crisis. Some are provided by the voluntary sector and not all of these are well connected with mainstream services; most do not provide a range of therapeutic interventions although they may provide a valuable resource for users.

37. The Psychiatric emergency Team (PET) in North Birmingham is a multi-disciplinary, community based, psychiatric emergency team which can provide support within people's own homes. It provides counselling, practical help, monitoring and liaison with other services and is available 24 hours a day. Research on the team, as detailed in the report, established that:

— during the study period there were only 27 hospital admissions of people receiving support from PET as opposed to 61 in an equivalent group receiving a conventional service;

— there was no difference between the two groups in terms of symptom reduction or occurrence of untoward incidents (eg suicide or violence) or re-admission;

— the cost for PET was £2,750 per client as opposed to £4,000 for a conventional service;

— service users liked the 24 hour availability of the service, the quick response and the practical help and support they received;

— staff enjoy working in PET and there is high job satisfaction and low turnover.

38. On this evidence home treatment seems to be a viable alternative to hospital admission for a range of patients. However, observations by the Sainsbury Centre for Mental Health suggest that a number of attempts to set up effective crisis services around the country are currently failing or even increasing bed utilisation. This can occur where:

— teams focus on access and assessment to the detriment of treatment;

— staff lack specific skills in home treatment;

— medication is often not offered in the home setting. It is essential that psychiatrists work with the teams.

39. Crisis teams are also at risk of having their funding cut if they have been set up with special allocations or non-recurring funding, and this has happened in a number of instances.

Community mental health services

40. In addition to directly managing crisis through crisis teams, the provision of a range of other services in the community is likely to either prevent crisis, manage crisis better, or allow earlier discharge from hospital. This range of services is broadly as set as:

The range of services required to support mentally ill people

Community support:

24 hour care and accommodation:

Daycare and daytime activities

Financial support

— Welfare advice

41. Many elements of such services are currently in short supply in most areas:

— Community mental health teams (CMHTs) are the centre of community services for mentally ill people, co-ordinating care for the majority of those in contact with specialist services. However, case loads are often very high which means that the scope for input with individual patients is often very limited. The 1997 Census of Community Mental Health Nursing13 showed that 18 per cent of Trusts still lacked multi-disciplinary CMHTs and that average caseloads had risen from 34.6 in 1990 to 38.2 in 1996. However, over the same period the workforce of community mental health nurses rose by 52 per cent from 4,440 in England and Wales to 6,739. During this time the caseload of clients with severe mental illness increased by 85 per cent from 66,212 to 122,723. First patient contacts with clinical psychology and community nursing services also show significant rises:

	1992-93	1997-98	change
Clinical psychology	191,000	257,000	34%
Community psychiatric nursing	406,000	584,000	49%

Shaping the future NHS: Long term planning for hospitals and related services

— Access to primary care is not often easy for many people with severe mental illness. Some areas may have significant numbers of clients who are not registered, others find it hard to get good quality primary care;

— There is a shortage of all types of accommodation options, and particularly of intensive support programmes for ordinary housing. There is also almost certainly a national shortage of 24 hour nursed care. At present there are 4,301 24 hour nursed beds in England, although 316 new places are currently planned;15

Safer Services

— The role of work and meaningful daytime activity for sustaining and rehabilitating people with severe mental illness has been understated in the National Service Framework. This needs attention and the Sainsbury Centre for Mental Health will consider how it might take this issue forward.

42. It is not just the volume of services that is often inadequate. Services have sometimes been set up using the wrong models, with the wrong skills mixes. There is also a wide failure to meet the needs of certain client groups:

43. National figures on the numbers of assertive outreach and crisis teams, for example, have not been collected at a local level, making it impossible to gauge the growth of specialist mental health services over recent years. Measures of overall service adequacy in the community need to be developed so that local providers and commissioners can judge whether community services are adequate to deal with morbidity.

Assertive outreach

44. The assertive outreach function can also be helpful in managing crisis and reducing hospital admission for the client group it serves—people with severe mental illness who are hard to engage and have complex needs. There is strong evidence that assertive outreach teams can reduce bed use. Regular services can achieve considerable reductions of up to around 50 per cent. It is also clear from research that assertive outreach is more efficient than hospital based care and costs less per person. Savings can vary depending on the quality and intensity of care, and savings ranging from 40 per cent to 1-2 per cent have been reported17.

45. Assertive outreach is however, only effective if services are faithful to the evidence based model described in the literature and if a range of other interventions are present. There are a number of assertive outreach teams being set up which are not focused on hard to engage clients with multiple needs and focus on those who are already engaged, to little additional effect. Others are simply re-badged CMHTs or do not contain staff with an adequate skill mix. There is an opportunity cost in creating assertive outreach teams in terms of finance and human resources so unless teams are focused and effective, it is hard to justify creating them.

Care homes

46. The Care Standards Bill sets out the new regulatory framework for mental health services provided by independent providers of acute care, and for statutory and independent providers of social care. The Bill, which replaces the Registered Homes Act 1984 and sets up the Care Standards Commission, gives powers to the Secretary of State to issue national required minimum standards (NRS).

47. The Department of Health is currently drawing up draft NRS for consultation in April. It is not known precisely how many places for adults with mental health problems will be subject to the new regulations. This is because the Department of Health statistics on nursing homes include adults with mental illness and elderly mentally ill people together. In 1998 the total figure was 25,50018. In addition, there are some 16,900 places in residential homes for adults with mental health problems which will be subject to the new regulations and standards.

48. The Sainsbury Centre for Mental Health believes that it is important for effective community care, and for the progression of the Government's agenda in mental health, that the new standards and regulations reflect and support national mental health policy, particularly the NSF. To date, work on the NRS has concentrated on generic environmental standards for care homes. It is important that the specific needs of people with mental health problems living in the community are incorporated into the NRS, and that the new registration bodies and inspectors promote and enable implementation of the national mental health strategy and the NSF. Currently, the development of NRSs and the implementation of national mental health policies seem unrelated to one another.

The Review of the Mental Health Act

49. The introduction of community treatment orders (CTOs), as proposed in the Government's Green Paper on reforming mental health legislation, is likely to make only a marginal increased demand on community services depending on the precise nature of the new Act. Such orders form a natural extension to Guardianship and Supervised Discharge, and like these will probably only be used for a small group of patients who are suitable for community treatment but who will comply with medication when an order is attached, but not if there is no order.

50. Where CTOs do apply there will be a need for fairly intensive community services, such as assertive outreach or home treatment, to provide care in the patient's home. It would be inappropriate to use CTOs where such support was lacking. One possible model is to allow the use of CTOs only where services have been assessed by experts as competent to deliver the required level of support. In addition, there are significant staff training implications in terms of enabling staff to utilise the orders appropriately.

Finance

51. Significant investment will be required in community alternatives if the system of care embracing the hospital and the community is to function optimally and cost effectively. Money cannot be released from the hospital sector unless effective community alternatives are put in place first. Even then, most parts of the acute sector require substantial investment to bring the environment up to acceptable standards. The total resources required may be between 20-30 per cent of the current total mental health budget (equivalent to perhaps £0.5 billion per annum).

52. However, simply throwing money at the problem will not help. Staff must be recruited and trained so that they can deliver effective interventions. This cannot happen overnight. In practice, a stepwise growth in resources for many years will be required.

Workforce

53. The National Service Framework for Mental Health19 for the first time points towards a co-ordinated programme of action on human resource issues in mental health. The document acknowledges problems of recruitment and retention, leadership, multi-disciplinary working and professional development. It is acknowledged that more staff are required, properly trained and supported, and that sustained local action is essential. In parallel with work by the NHS Executive, the Sainsbury Centre for Mental Health is undertaking a major review of recruitment and retention in the mental health workforce to report by June.

54. The successful delivery of the NHS Executive's HR programme, and of a similar programme for social care, is fundamental to implementation of the NSF. To deliver on the standards in the NSF it is essential to provide training and development opportunities for the multi-disciplinary workforce which will be required to deliver effective evidence based care within comprehensive, integrated and community based mental health services. In addition, national and local workforce planning will be a vital foundation for implementation. There are a number of signs of demoralisation and burnout in the mental health workforce and these have been reflected in the evidence so far collect by a current Sainsbury Centre for Mental Health review of recruitment and retention in the mental health workforce.

55. The 1997 Sainsbury Centre for Mental Health report Pulling Together20 identified critical skills gaps in relation to the:

56. This report identified a set of core competencies required by staff to deliver modern services. A follow-up report shortly to be published by the Sainsbury Centre for Mental Health will set out a multi-sectoral and multi-disciplinary plan to address skills gaps. Major conclusions include:

57. Urgent attention is also needed to the recruitment and retention of mental health staff. There are shortages in a number of disciplines, such as nursing and psychology, and geographic areas such as inner cities.

58. The National Service Framework provides a generally helpful framework for the development of community services. Standards 4 and 5 in the Framework on Effective Services for Severe Mental Illness are particularly relevant. These standards demand comprehensive services, including 24 hours access, engagement, crisis prevention and access to hospital. Progress towards delivery of such services will require continued national, regional and local leadership to shape the workforce.

Support for carers

59. Standard 6 of the NSF on "caring for carers" is also key to the delivery of better community services. Around half of the individuals with severe mental illness live with family or friends and many require and receive considerable support. Carers must often deal with demanding situations and may experience high levels of stress and anxiety. If supported, carers can be enabled to function effectively and their own mental and physical health can be protected. If they are not supported care can break down rapidly. Standard 6, coupled with the carer's right to request an assessment set out in the Carers (Recognition and Services) Act 1995, has potential to make major demands on community services, but little new resource has been identified for this purpose. Few local authorities have implemented the Act.21 Neither does the NSF make any mention of deploying psycho-social family interventions despite the evidence to support this approach.

Primary care

60. The relationship between mental health services in the community and primary care services is vital because:

61. There are three broad areas where primary care can significantly contribute to the care of people with mental health problems by providing:

— mental, physical and social health care to those individuals with mental health problems who are best managed in primary care;

— physical health care to those individuals with mental health problems who are best managed by the pecialist mental health services;

— physical health care and social support to carers.

62. The Sainsbury Centre for Mental Health supports the policy outlined in the National Service Framework of improving the working relationship between primary care and secondary mental health services through the development of shared guidelines on management and communication.

Commissioning of mental health services

63. The development of primary care groups (PCGs) and primary care trusts (PCTs) has important implications for mental health services. The complexity of mental health services, and the difficulties of transitions across acute and secure services and across adult and adolescent services, discussed below, mean that the commissioning of mental health services is likely to be beyond the capabilities of most PCGs or PCTs. Planning these services and overseeing their change management needs to be done at health authority, or in some cases, regional level. The Sainsbury Centre for Mental Health believes that the ability of PCGs/PCTs to commission and/or provide inpatient mental health services, particularly specialist services, needs to be assessed according to recognised criteria before they are permitted to take on these functions. The model of specialist mental health trusts introduced in The New NHS should not be lost sight of. The Sainsbury Centre for Mental Health believes that the likely proliferation of specialist mental health commissioners should not destabilise specialist provision. Commissioners will need to work together to consolidate and develop specialist mental health services.

ACUTE AND SECURE MENTAL HEALTH CARE

64. There is a continuous flow of patients between services offering various levels of care and security within the mental health system. The levels of care and security can be summarised as follows:

I. in contact only with primary care;

II. managed by a generic community mental health team;

III. managed by a specialist team (eg assertive outreach, dual diagnosis);

IV. managed by a community forensic mental health team;

V. in supported or staffed accommodation (care home);

VI. in an acute psychiatric bed;

VII. low secure ("locked ward"). These are wards with locked doors and above average staff ratio;22

VIII. medium secure unit (MSU). These are units which care for patients whose behaviour is too difficult or dangerous for local hospitals, but who do not require the level of security afforded by special hospitals;

IX. special hospital. The three special hospitals (Ashworth, Broadmoor and Rampton) house very dangerous and violent patients who require intensive care, supervision and observation.

65. The average daily available NHS beds for adults of working age is as follows, excluding beds commissioned from the independent sector:

	1992-93	1997-98	change
Secure units	930	1,920	+106%
Short stay	15,300	14,460	-5%
Long stay	11,000	4,910	-55%

66. In some localities, especially inner cities, there are serious pressures on acute mental health beds. These pressures are due to inadequate access either to secure accommodation or to the range of community based provision. With the enduring shortage in medium secure beds, many patients who do not need the highest levels of security are placed in the special hospitals. Similarly, some patients are inappropriately placed in medium secure because of shortages of low secure, while others are placed in low secure beds to ease psressure on the acute sector. Another 270 extra secure places are planned.

67. Flows within the system are not simple. They can occur between almost any level, although a flow direct from levels (vii)-(ix) to (i) would be highly undesirable. It is important that these flows are managed efficiently and effectively to:

68. At present, there is ample evidence that acute and secure facilities are not used effectively, providing only patchy services:

— up to a third of patients in special hospitals do not require that level of security, for example, the Mental Health Act Commission states that there are 200 patients at Ashworth Hospital who do not need to be there23;

— there are shortages, especially in medium secure beds, high support housing and community forensic mental health teams;

— therapeutic regimes in acute and low secure environments are often lacking24;

— there is heavy use of independent sector secure facilities sometimes at increased cost. These can be remote from the patient's home and disconnected from local services, but this is also true of many NHS MSUs. Whatever the type of MSU provision there is a need to improve integration and care planning;

— people from black and minority ethnic groups are over-represented in the secure psychiatric system and often receive inappropriate or insensitive services25.

69. It is essential that a whole systems approach is adopted and that the levels of secure care are managed comprehensively and systematically. There are a number of steps that can be taken to improve the management of patient flows within secure services:

— forensic services should link with and be centred on local mainstream services. An improved understanding of the heterogeneous groups of patients covered by the forensic label must be built up;

— MSUs and low secure beds should be managed by the same organisation as other services, or alternatively protocols should be agreed for the transfer of patients across relevant provider organisations;

— community based forensic services, working closely with CMHTs, assertive outreach teams, should establish valuable links with acute care and MSUs and support patients as they move through the service. Community forensic mental health teams (CFMHTs) will only be viable where there is a sufficient catchment population. Where the volume is lower some forensic expertise should be developed in the assertive outreach team;

— shared risk management protocols should be developed across the different services;

— integration of special hospitals into the NHS should help links which urgently need to be developed. At present far too many patients remain in special hospitals when they do not need to be there;

— developing highly skilled nurse practitioners capable of delivering behavioural and psychological interventions. There are significant human resource issues flowing from improving and expanding forensic services in terms of both numbers of staff and skills.

70. There is a popular misconception that MSUs provide a natural step between special hospitals and acute care. However, they tend to provide a specialised service aimed at individuals with whom good progress can be made over a period of say two years. They are unsuitable as a step down from special hospitals. Special hospitals provide a whole range of facilities and opportunities on site, as well as having a large campus with recreational facilities which are absent in some MSUs. Users can therefore become frustrated and demoralised if transferred to an MSU. There can be particular problems for women who are provided with a safe environment in special hospitals, as they cannot be segregated in MSUs. The integration of special hospitals with the NHS should allow improved communications, and allow clinicians greater flexibility to operate across boundaries.

71. The provision of local low secure facilities is also an important component in the range of services. Without such facilities, patients have to go straight to an MSU. The higher levels of secure services are managing less disturbed patients than they did in the past, when secure provision was more limited, so the scope for progress and movement out of the system should be greater.

72. The dynamics of the current system are likely to be altered if proposals to create special units for dangerous people with severe personality disorders are introduced. It is not clear that it is possible to identify with sufficient certainty which people should be in such units and which elsewhere—because of the poor science underpinning the concepts both of personality disorder and of dangerousness. However, if such units are opened they will:

— be recruiting staff from the same pool of people as forensic services, possibly leading to shortages;

— need to be managed in an integrated way with secure services so that patient flows are appropriate—otherwise there is a likelihood of patients ending up in the wrong part of the system or being "dumped".

73. In conclusion, what is required is for both commissioners, specialised and local, and providers, NHS and independent sector, to operate this range of services as a single system of care. This requires major efforts in co-ordination, communication and partnership working. However, it is essential if the service is to be focused on patients' needs and to be efficient.

74. Regional Secure Commissioning Groups have been set up to plan and purchase specialist services in each Region. These groups will be key to the effective provision of integrated secure and specialist services, but to date progress on their development has been slow.

CROSSING FROM ADOLESCENT TO ADULT MENTAL HEALTH CARE

75. Child and adolescent mental health services have long been underdeveloped. This position is again documented in the recent Audit Commission Report Children in Mind26. Adolescent services are particularly poorly developed, and have poor links with other agencies including adult mental health services. The summary report states:

"A sizeable number (29 per cent) [of health authorities] commission CAMHS for those aged up to their 16th birthday only—although adult services are not considered suitable by many for young people aged 16 and 17. The audits revealed the continuing problem of creating services for adolescents in many parts of England and Wales. All the different agencies responsible for a particular population should be clear about how the appropriate services are to be provided for young people of different ages, with different needs."

76. The Sainsbury Centre for Mental Health endorses these findings. It is particularly worrying that the Audit Commission found that only 23 per cent of services had specific arrangements for transferring young people to adult services, especially as the first onset of psychotic illness can often occur in this crucial period of life. The finding accords with the experience of carers of young people with mental illness, who often find that their child's needs are unmet or inappropriately met for long periods of time, just when the illness needs to be tackled effectively to prevent disruption of education, social functioning and development.

77. Inpatient facilities for this group are very limited. The recent report Shaping the Future NHS: Long term planning for hospitals and related services27 states that:

"Designated beds for child and adolescent mental illness have... reduced steadily over the past 10 years, to about 520 at present, the reduction being mainly short stay beds. Some of this reflects positive developments in clinical practice but there is increasing concern about young people with mental health problems being admitted to adult wards and non-specialist (including LA) settings."

78. Some units open only five days each week, denying access to individuals who need in-patient care seven days a week. Average daily available beds for children and adolescents with mental illness fell from 640 in 1992-93 to 520 in 1997-98, a drop of almost 19 per cent27. Increases in dedicated beds for children and adolescents are required to meet estimated need and to ensure they are cared for in settings appropriate to their age. In addition, it should be noted that there is no secure provision for children and adolescents except at the Gardner Unit at Manchester.

79. In its 1998 report Keys to Engagement28, which dealt with the assertive outreach function, The Sainsbury Centre for Mental Health recommended that:

"A mechanism for liaison with local child and adolescent mental health services is required to allow early intervention."

"Teams need to be in touch regularly with local child and adolescent mental health services as well as generic adult mental health services, to identify individuals who may benefit from early intervention."

80. This recommendation holds good, but can be applied more widely to the relationship between adult and adolescent services generally.

81. Commissioners and providers may wish to consider whether they should set up an Early Intervention Service. The Birmingham Early Intervention Service is a good example29.

CONCLUSIONS AND RECOMMENDATIONS

82. The Sainsbury Centre for Mental Health draws the following conclusions and recommendations regarding the provision of mental health services included within the terms of reference of this Health Select Committee Inquiry.

Current Government definitions and categorisation of mental illness

83. The Sainsbury Centre for Mental Health agrees with the Government's view that definitional schemes of mental illness should be referred to in the Code of Practice, and regretfully accepts that a satisfactory definition within the new Act will be difficult to achieve.

84. Because it is almost certainly unrealistic to standardise definitions across government and across all arenas a more effective approach would be for:

— local partner agencies to agree a common definition of severe mental illness, probably based on the SIDD model, and to disseminate it to professionals and explain it to users and carers;

— all relevant agencies to provide high quality information to users and carers about how to access services, or who qualifies for which services.

Care in the community for people with acute mental illness

85. Pressures on acute beds reflect a wider mismatch of provision and need. Thus in the medium and longer term the emphasis should be on establishing a better balance between acute inpatient services and services to provide the packages of care which enable people with severe mental illness to remain at home and in their local communities.

86. Acute 24 hour care should be viewed as one component of a comprehensive and integrated service—a range of crisis services should be available of which hospital care is one component.

87. Evidence suggests home treatment seems to be a viable alternative to hospital admission for a range of patients. However, failure can occur where:

88. The provision of a range of services in the community is likely to either prevent crisis, manage crisis better, or allow earlier discharge from hospital. Unfortunately many services which should be included in the range are currently in short supply in most areas including assertive outreach teams, accommodation including supported accommodation, and structured daytime activities.

89. Assertive Outreach services can achieve considerable reductions in in-patient admissions of up to around 50 per cent. It is also clear from research that assertive outreach is more efficient than hospital based care and costs less per person assertive outreach is, however, only effective if services are faithful to the evidence based model.

90. The Sainsbury Centre for Mental Health believes that it is important for effective community care, and for the progression of the Government's agenda in mental health, that the new standards (NRS) and regulations for "care homes" reflect and support national mental health policy, particularly the NSF.

91. Following the review of the Mental Health Act where Community Treatment Orders (CTOs) do apply there will be a need for fairly intensive community services, such as assertive outreach or home treatment, to provide care in the patient's home. It would be inappropriate to use CTOs where such support was lacking. One possible model is to allow the use of CTOs only where services have been assessed by experts as competent to deliver the required level of support.

92. Significant investment will be required in community alternatives if the system of care embracing the hospital and the community is to function optimally and cost effectively.

93. The successful delivery of the NHS Executive's HR programme, and of a similar programme for social care, is fundamental to implementation of the NSF. To deliver on the standards in the NSF it is essential to provide training and development opportunities for the multi-disciplinary workforce which will be required to deliver effective evidence based care within comprehensive, integrated and community based mental health services.

94. In a forthcoming report, the Sainsbury Centre for Mental Health has identified a set of core competencies required by staff to deliver modern services and recommends a multi-sectoral and multi-disciplinary plan to address skills gaps. Major conclusions include:

95. Standard 6 of the NSF on "caring for carers" is also key to the delivery of better community services. Standard 6, coupled with the carer's right to request an assessment set out in the Carers (Recognition and Services) Act 1995, has potential to make major demands on community services, and additional resources need to be identified for this purpose.

96. The Sainsbury Centre for Mental Health supports the policy outlined in the National Service Framework of improving the working relationship between primary care and secondary mental health services through the development of shared guidelines on management and communication.

97. The Sainsbury Centre for Mental Health believes that the ability of PCGs/PCTs to commission and/or provide specialist mental health services needs to be assessed according to recognised criteria before they are given these functions. The SCMH believes that the likely proliferation of specialist mental health commissioners in the new NHS should not result in the destabilisation of specialist mental health providers.

Acute and secure mental health care

98. At present, there is ample evidence that acute and secure facilities are not used effectively, providing only patchy services. It is essential that a whole systems approach is adopted so that the different levels of secure care are managed comprehensively and systematically.

99. Secure provision requires both commissioners, specialised and local, and providers, NHS and independent sector, to operate this range of services as a single system of care. This requires major efforts in co-ordination, communication and partnership working.

Crossing from adolescent to adult mental health care

100. Increases in dedicated beds for children and adolescents are required to meet estimated need and to ensure they are cared for in settings appropriate to their age. In addition, it should be noted that there is very little secure provision for children and adolescents.

101. A mechanism for liaison between adult services and local child and adolescent mental health services is required to promote early intervention and service planning.

102. Assertive Outreach Teams need to be in touch regularly with local child and adolescent mental health services as well as generic adult mental health services, to identify individuals who may benefit from early intervention.

REFERENCES

1. The NHS Confederation and The Sainsbury Centre for Mental Health (1997) The Way Forward for Mental Health Services. The NHS Confederation.

2. Department of Health (1999) Modern Standards and Service Models: Mental Health: National Service Frameworks. Department of Health.

3. Department of Health (1998) A First Class Service: Quality in the new NHS. Department of Health.

4. As 2.

5. Social Services Inspectorate, Department of Health (1995) Building Bridges.

6. NHS Executive and the Social Services Inspectorate. (1999) Effective Care Coordination in Mental Health Services. Department of Health.

7. Department of Health (1999) The Reform of the Mental Health Act 1983 [proposals for consultation.]

8. The Sainsbury Centre for Mental Health (1998) Acute Problems. The Sainsbury Centre for Mental Health.

9. Department of Health (1999) Shaping the Future NHS: Long term planning for hospitals and related services. Department of Health.

10. As 8.

11. The Sainsbury Centre for Mental Health (1998) Open All Hours. The Sainsbury Centre for Mental Health.

12. The Sainsbury Centre for Mental Health (1996) Acute care in-patient study. Unpublished report.

13. Brooker, C and White, E (1997) The fourth quinquennial national community mental health nursing census of England and Wales. Keele University and The University of Manchester.

14. As 9.

15. As 2.

16 Parker, C and McCulloch, A (1999) Key Issues from Homicide Inquiries. Mind.

17. The Sainsbury Centre for Mental Health (1998) Keys to engagement. The Sainsbury Centre for Mental Health.

18. Department of Health (1998) Community Care Statistics. Department of Health.

19. As 2.

20. The Sainsbury Centre for Mental Health (1997) Pulling Together. The Sainsbury Centre for Mental Health.

21. The Social Services Inspectorate, Department of Health. (1999) Still Building Bridges.

22. As 2.

23. The Mental Health Act Commission (1999) Eight Biennual Report 1997-1999. The Stationery Office.

24. As 8.

25. Warner, L et al (2000) National Visit 2: preliminary report. The Sainsbury Centre for Mental Health.

26. Audit Commission (1999) Children in Mind. Audit Commission.

27. As 9.

28. As 17.

26. The Birmingham Early Intervention Service. Early Intervention in Psychosis: Principles, Clinical Guidelines and Services Frameworks. Initiative to Reduce the Impact of Schizophrenia.



© Parliamentary copyright 2000	Prepared 24 July 2000