Provision of NHS Mental Health Care Services
Government Response and Action
Recommendation P It was clear from the evidence we received both that there are considerable shortages in key mental health professions, and that the National Service Framework is unlikely to become a reality unless these shortages are addressed. We realise that the National Service Framework Workforce Action Team is actively considering these issues, and urge it to take on board the evidence submitted to this inquiry. We would particularly draw attention to the evidence we received on the limited numbers of training places for occupational therapists and clinical psychologists, the importance of providing early placement in mental health services for nurses in training, and the desirability of developing "core-skills" training across professions. We would also urge active consideration of the development of appropriate training and recognition for workers to be the "eyes and ears" of professionals, as described by David Joannides and others (para 78).
There is a growing recognition of the need to develop what might be called core skills which apply to all staff, both professional and non-professional, working with service users and their families. The NHS Plan refers to new joint training initiatives across professions in communication skills so that, by 2002, it will be a pre-condition of qualification to deliver patient care that an individual has demonstrated competence in communication with patients.
Workforce Action Team
The National Service Framework for Mental Health demands concerted local action through Health Improvement Programmes, using local mechanisms for workforce planning, education and training, and continuing professional development and lifelong learning. The Workforce Action Team, which covers both health and social care, will deliver a nationally co-ordinated programme of support to help local health and social services authorities tackle their strategies both around recruitment and retention of staff.
Occupational Therapists and Clinical Psychologists
Workforce planning for all the key staff groups remains a key priority for the Government. There are shortages of occupational therapists in some parts of the country. However, since 1992/93 there has been a substantial increase (some 65% in occupational therapy pre-registration training places). There has also been an increase in the number of clinical psychology training places: 21% between 1996/97 and 1998/99 (from 258 in 1996/97 to 313 in 1998/99). Further increases in therapy and other key health professionals training places (4,450 places by 2004) have recently been announced in the NHS Plan. Whilst these increases in the numbers entering training will not impact on the workforce immediately, we aim to introduce measures that will ensure that between now and 2004 there will be over 6,500 more therapists and other health professionals, as well as 20,000 more nurses, available for employment. The success of retaining qualified mental health professionals within the NHS, together with measures to improve recruitment will ensure the NHS has the professional staff it needs in the future.
Early Clinical Placements for Nurses
The importance of early clinical placements for student nurses is accepted and is a feature of many course programmes. However a balance is needed if students are to gain other appropriate experience, and develop an awareness of and competencies in physical health and other associated areas in the common foundation programme, in order that they can bring a holistic perspective to their thinking and delivery of individualised care.
"Eyes and Ears" The suggestion made by David Joannides of the Association of Directors of Social Services, who is a member of the Workforce Action Team, about developing workers to be the "eyes and ears" of professional staff is an interesting one which the Department has already taken on board.
In addition, the Department is aware of the recent launch of the Mental Health Foundation Certificate in Community Mental Health Care which underpins a level three NVQ. (See Cm 4888 for full response)
Recommendation Q The question of the mandatory homicide inquiries is a very sensitive one. Like the Secretary of State we are anxious that there should never be any question of a "cover-up" if a member of the public has been killed by an individual in touch with mental health services. At the same time, it is clear to us that the effect of these inquiries on the professions, especially psychiatrists, is deeply counter-productive, with the ensuing danger that inquiries set up with the aim of improving services may have the opposite effect by driving away competent staff. We would recommend that there should continue to be public inquiries into such events, but that they should be carried out on a systematic, national basis, for example by a specialised division within the Commission for Health Improvement, with the outcomes published in an annual report on the lines of that produced by the Health Service Commissioner. This would allow a body of expertise to be built up, and for lessons learned from inquiries to be more effectively disseminated (para 79).
We acknowledge that these tragic events involve a huge personal cost to the people involved, both patients and their families, and staff working in the services. A balance needs to be struck between learning the lessons from events where mistakes have been made, maintaining public confidence in services, and supporting families and staff. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness already provides a national system for auditing both suicides and homicides, making recommendations on clinical practice and policy and identifying training needs for a range of mental health staff. A further report from the Confidential Inquiry team will be published next year and will be disseminated widely. In addition, we have accepted the recommendations of the Chief Medical Officer's (CMO's) Expert Group's report An Organisation with a Memory about how we should learn from adverse events in the NHS as a whole. Following the CMO's report, we are considering how to develop a system in mental health that is in line with what is being set up in the rest of the NHS. Professor Louis Appleby was a member of CMO's Expert Group, and is taking a close interest in how this work is taken forward.
Recommendation R We find it very disturbing that there is clearly such a shortage of psychologically-based treatments in the NHS, given the general consensus as to their value for many patients. The evidence we received did not enable us to judge whether the rarity of such treatments is primarily due to the shortage of professionals able to deliver them, lack of awareness among those responsible for purchasing mental health services as to their benefits, or cost. We therefore urge the DoH to undertake further research in this area and, if appropriate, to feed the results of that research into the work of the Workforce Action Team (para 81).
There are a number of factors relevant to the difficulty experienced by many patients in obtaining effective psychological therapy in the NHS. Shortages in the number of trained staff, a lack of appropriate education and training and a lack of guidance all have a part to play. Action in the following areas is being taken:
The National Service Framework makes it clear that a number of different staff groups including psychiatry, nursing, clinical psychology and psychotherapy are involved in providing effective psychological therapies.
Recruitment plans indicate that between now and 2004 there will be over 6,500 more therapists and other health professionals, as well as 20,000 more nurses available for employment in the NHS. The NHS Plan builds on this and sets out proposals to appoint 1000 new workers in primary care mental health to deliver brief, effective, evidence-based treatments for people with common mental disorders. In addition, fifty teams will be established to deliver early intervention, including effective psychologically based treatments, to people with the first signs of a psychosis.
Education and training
The National Service Framework demands concerted local action on staffing through the Health Improvement Programme, using local mechanisms for workforce planning, education and training. Research commissioned from the Sainsbury Centre for Mental Health on essential competencies, including psychologically-based treatments will help to inform this programme of work. The NHS Executive has also commissioned some research looking at university accredited post qualification training and education for staff specifically in respect of work with people who have serious mental health problems. The report includes evidence about psychosocial interventions and is already being considered by the Workforce Action Team. Increases in the number of training places for therapy staff and other key professionals (4,450 placed by 2004) have recently been announced in the NHS Plan. This builds on work already started for some key groups. For example, the number of NHS training commissions for clinical psychologists increased by 21% between 1996/7 and 1998/9 (from 258 to 313).
Clinical decision support systems
The National Service Framework sets out the evidence for psychological therapies for a range of conditions, including severe mental illness. It affirms that effective psychological therapies should form an important part of good quality treatment and care for people with mental health problems. The Framework will help clinicians, service users and purchasers to know more about the evidence base, and how to modernise services and improve access. Eight regional conferences have already taken place to disseminate results from the 1996 NHS Executive survey of all English health authorities on psychotherapy. A further national conference is planned for next April to help clinicians, service users and commissioners to implement the psychological therapy requirements set out in the National Service Framework. An evidence-based guideline on treatment choice decisions in psychological therapies and counselling, managed by the National Institute of Clinical Excellence as part of its inherited programme, will be published shortly. This will help providers, referrers and commissioners to know more about what works for whom. A user guide will also be developed and published. Last year, a National Advisory Group for Psychotherapy was established to provide support for education and training commissioners. This year the group will report formally to the Workforce Action Team to provide professional support for the work of this group and in the psychological therapies field.
Recommendation S We are aware that the National Institute for Clinical Excellence (NICE) is currently considering guidelines on the management of schizophrenia, which are likely to include recommendations as to whether or not the more expensive atypicals should be the first-line treatment. We will not attempt to anticipate the work of NICE, but we would urge those carrying out the evaluation of atypical drugs to give serious consideration to the outcomes of treatment from the users' perspective, including the benefits of making compliance with drug treatments less onerous (para 82).
The National Institute for Clinical Excellence (NICE) now carries responsibility for the development of this guideline as part of its inherited work programme. NICE has responsibility to consider any representations about the proposed recommendations and for ensuring that final guidance to the NHS fairly reflects the needs of patients as well as the weight of evidence. Work is being undertaken in partnership with the NHS, the Department of Health, the NHS Information Authority, the National Assembly for Wales, bodies representing health professionals, health related industries and patient and user groups. The Institute's guideline will also take account of the cost effectiveness of recommendations, which must be practical and affordable. We are confident that NICE will take account of all the relevant interests. The Department recognises the need to bring about real changes in practice so that medicine taking is given the same prominence as prescribing, within policy development and implementation. The new Chief Pharmacist will be specifically charged with bringing together all the key people to form a joint Task Force to implement a national strategy for achieving partnership in medicine taking. The Department of Health will invest up to £1m over the next two years in the national strategy. This is part of £30m additional resource which will be invested over the next three years, specifically to secure better use of medicines in the NHS. The NHS Plan stipulated that every Primary Care Group/Trust would have medicines management services in place by 2004 in which patients could get more help from pharmacists in using their medicines well. Subsequently, the pharmacy programme, Pharmacy in the Future - Implementing the NHS Plan, announced the establishment of a Medicines Management Action Team as part of the NHS Modernisation Agency, to develop and spread expertise. An Expert Patients Task Force, chaired by the Chief Medical Officer Professor Liam Donaldson, has been examining the role that those affected could themselves play as 'experts' in managing their chronic disease. Its report should be finalised this year and will make recommendations about how the Expert Patients Programme should be taken forward, particularly in the light of the NHS Plan.
Recommendation T We believe that particular attention should be given to the development of a range of accommodation with suitable support arrangements, including long-term supervised hostel accommodation which is adequate to support people with high-level needs, such as those discharged from medium secure units and those with histories of drug and alcohol abuse. There is an additional need for appropriate provision of ordinary high quality housing in the community that can be made available to people with mental health problems who may need support and specialist services from time to time, but who enjoy full rights as tenants. This will require close partnership working by health and social care with housing authorities and local housing providers. We are aware that the Government is currently working on the details of a new single funding stream for housing support services, to replace the current arrangements through Housing Benefit from April 2003 and urge that the needs of people with mental health problems be taken fully into account in the development of the new system.
The single funding stream for housing support services, Supporting People, which will be implemented in April 2003, offers vulnerable people, including those with mental health problems, the opportunity to improve their quality of life through greater independence. The programme will put the funding and development of supported housing on a more secure and co-ordinated basis. Assessing and planning for new needs will be undertaken by local authorities (housing and social services) working in partnership with health and probation and in consultation with users and providers. The Department of Health is working closely with the Departments of Environment, Transport and Regions and Social Security at national level, and with user groups and other stakeholders, to develop the new administrative and funding arrangements. There is a series of "Good Practice Guides" under development to cover housing and support provision for a range of groups affected by Supporting People. This will include a guide to housing and services for those with mental health needs and will be jointly produced by the Department of Environment, Transport and Regions and the Department of Health. The Supporting People arrangements aim to encourage the development of support services that can improve the response to people's needs and preferences and can be delivered in ordinary housing as well as specialist schemes. This is because the new administrative and funding arrangements will break the link between the funding of housing and housing related support as existed under the previous arrangements. This will enable people with mental health needs to receive this type of support wherever they live as opposed to needing to move into a specialist scheme.
Recommendation U We accept that, although organisational change can be immensely disruptive, in particular circumstances it may be appropriate for Primary Care Trusts to take on the provision of specialist mental health services, for example in areas of the country where there is already successful provision of specialist mental health services in primary care settings. However, we strongly believe that this should only take place if the PCT has been able to demonstrate clearly that the new system will provide significantly better services to local users. We would suggest that the Department give consideration to those PCTs that are able to progress early on this front becoming pilot sites, sharing their learning and expertise with others. We also urge the Department to consult with users when setting out the criteria, which PCTs will have to meet before being permitted to provide mental health services (para 92).
Primary Care Groups (PCGs) and Primary Care Trusts will be able to take on the provision of specialist mental health services, where there is already successful provision of specialist mental health services in primary care settings. For example, Milton Keynes Primary Care Group and Herefordshire Primary Care Group both have a proven track record of commissioning and providing mental health services within their local area, and have included this provision in their application for Primary Care Trust status, which Ministers have approved. However, applications will only be approved if they demonstrate how services will be improved and adhere to the criteria outlined in Health Service Circular 1999/167. Both trusts have set out clear arrangements for listening to and involving users and carers. The criteria outlined in Health Service Circular 1999/167 were drawn up after consultation with stakeholders, including patient representatives. Additionally, for each individual Primary Care Trust application the local community is given the opportunity and is actively encouraged to comment at the consultation stage. This includes relevant local patient and voluntary sector representation
Recommendation V The Disability Partnership is currently looking at ways of improving the liaison between general practice and secondary care, and their proposals include: .Educating and orienting primary care staff on mental health issues .Developing some services such as counselling, anxiety management and understanding psychosis at general practice level .Creating and refining care pathways into secondary care .Obtaining user input into training primary care staff, user representation on PCG boards and user involvement in service evaluation. We endorse these proposals which we believe would do much to improve the relationship between general practice and specialised mental health services (para 94).
We also welcome these proposals as helpful ways to strengthen the relationship between general practice and specialised mental health services, and so improve the quality of mental health service provision.
(See Cm 4888 for full response)
Recommendation W We were very impressed with the work of the home treatment and assertive outreach teams that we saw in our visits to North Birmingham and South West London. We were also struck, however, by the research presented by the Centre for Mental Health Services Development on the variations in outcome achieved by assertive outreach teams, and by the similar evidence on home treatment provided by the Sainsbury Centre for Mental Health. Given the rapid development of these services at present, as part of the National Service Framework, we recommend that the Department should review current research on assertive outreach and commission further research on home treatment and other forms of crisis intervention, so that services can be developed on the basis of the best available evidence. The evidence base should incorporate the views of users and carers about the effectiveness and acceptability of services, including specific views of people from black and minority ethnic communities (para 97).
The Government agrees that assertive outreach and home treatment /crisis resolution are sound approaches for the care and treatment of people with severe mental illness. We also agree that services should be developed on the basis of the best available evidence. The commissioning of assertive outreach and home treatment/crisis resolution services should therefore demonstrate fidelity to the models of proven effectiveness set out in the National Service Framework. To support such commissioning the Department has issued clear definitions of assertive outreach and home treatment teams to Local Implementation Teams
Recommendation X We were very disturbed by the evidence we received on the quality of in-patient care. We feel that the environmental standards on in-patient wards are important for two reasons: because an improved environment will increase the therapeutic value of units; and because natural justice and the principle of reciprocity demand that those who are detained on such wards without their consent should be provided with accommodation which affords reasonable privacy and dignity. We believe that a capital modernisation fund, aimed specifically at improving environmental standards on in-patient wards, could make a significant difference to the quality of life of patients staying on these wards. The views of service users should be incorporated into any local plans for ward improvements (para 99).
The Government agrees with the Committee that the environment on many in-patient wards should be improved. We fully recognise the contribution, which the physical environment of the ward can often make to the quality of the patient experience and sense of wellbeing. This is as true for patients in general medical and surgical wards as for people with mental health problems. With this in mind, earlier this year the Government announced that ward sisters and charges nurses would have the opportunity to control new resources for improving the general environment of their wards. The money was to be spent on whatever nursing staff might feel would best enhance patient care by making the ward a pleasanter place to be for both patients and staff alike. A total of £25m was allocated direct to hospitals for this purpose in September this year. Each individual 'ward budget' will be worth at least £5000 in a full year during the remainder of this year and next. Reports from the Sainsbury Centre for Mental Health, from visits conducted by the Mental Health Act Commission and more recently the Standing Nursing and Midwifery Advisory Committee all were central to the development of recommendations on in-patient care within the National Service Framework. The Standing Nursing and Midwifery Advisory Committee report made a number of wide ranging recommendations relating to the experience of users in acute in-patient units, including the active involvement of users in service development and the need for regular audit of the environment's safety. NHS trusts and health authorities are expected to respond to the recommendations as part of their Health Improvement Plans and local National Service Framework implementation plans. We are taking the following measures to improve inpatient care: .New investment, as set out in the NHS Plan .Ending mixed sex accommodation .Reducing access to means of suicide .Asking for service users' and carers' views (See Cm 4888 for full response)
Recommendation Y It is clear from the evidence we received that the environment of the traditional hospital is not the best environment for helping individuals in crisis: people suffering acute phases of mental illness may need a "safe haven" away from their own homes, and sometimes secure surroundings, but this need not be in an institutional building. Indeed, the use of such buildings appears to be based on necessity rather than on any belief that they are the best or only way of providing care to individuals in distress. We recognise the need to balance domesticity, good quality care and security which is emphasised in the Royal College of Psychiatrists' report 'Not just Bricks and Mortar'. However, we do believe that further research on how these aims can best be achieved would be very valuable. We therefore urge the Department to fund pilot schemes following the "core and cluster" model described by Professor Rowden and Dr. Moodley, so that their effectiveness can be rigorously evaluated. If such pilot schemes are successful, we recommend that the Department commit itself to providing the capital expenditure necessary to expand them swiftly (para 101).
A major programme of work is underway in the Department of Health which will enable priorities for research and development in mental health to be established. The existing research on different models and patterns of mental health care is being collated in order that gaps in the research portfolio may be identified. Mental health is viewed as a priority area for research funding and the evaluation of the effectiveness of different models of care provision may well be an area for future investigation. We are also looking into mechanisms for identifying and disseminating good practice. Professor Louis Appleby, the National Director for Mental Health, is taking a leading role in this area.
Recommendation Z The work of the voluntary sector in mental health services is clearly of immense value. Yet, individual organisations are perpetually on the brink of collapse because of the uncertain nature of the funding system. We recommend two improvements in the current system. Firstly, the Government should provide central funding for initiatives offering administrative and practical support (such as pay-roll services) to small voluntary organisations on a local basis. Secondly, Health authorities should apply the same principles to their voluntary sector service agreements as they are required to do in their NHS agreements: If this recommendation were implemented, voluntary organisations would always have the certainty of three years funding, allowing them to plan more strategically and to recruit able and committed staff (para 104).
The Government accepts that the voluntary sector plays a very important role in the delivery of mental health services and we encourage effective partnership working both at national and local level. At national level, the Department of Health already provides considerable support for voluntary organisations, particularly by means of grants awarded under Section 64 of the Health Services and Public Health Act 1968. This scheme currently provides financial assistance to 68 different voluntary organisations amounting some £3.5m per annum. Under this scheme, voluntary bodies may apply for core grants towards their administration costs and applicants for project grants may include an appropriate element of their administration costs. These grants are time-limited. At the local level, health and local authorities have similar grant making powers to assist local voluntary bodies providing services in their areas and this may include assistance with their administrative functions. The Department agrees that, wherever practicable, health and local authorities should enter into longer term contractual agreements and apply the same principle to their voluntary sector service agreements as they are required to do in their NHS and social care agreements. This will be communicated to health and local authorities in future guidance.
Recommendation AA It is clear that the shape of the future legislation will be fundamentally affected by the Government's, and ultimately Parliament's, view on the purpose of mental health legislation. We believe that it would be difficult to equate the emphasis placed in the National Service Framework on non-discrimination and combatting stigma with legislation which focused solely on compulsion. The need for legislation specifically aimed at people suffering from mental disorder certainly derives at least partially from a recognition that in certain circumstances compulsion may be acceptable in a way that has always been regarded as unacceptable for those suffering from physical disorders. But it also derives from an awareness that the possibility of such compulsion brings with it reciprocal obligations: the obligation to provide services for those in mental distress so that compulsion should only ever be a last resort, and the obligation to protect the civil rights of those who have been labelled with what is still seen as a stigmatising condition (para 107).
For the vast majority of those with mental health problems, care and treatment should be provided on the same basis as it is for those with physical disorders. That is why we have emphasised in the Mental Health National Service Framework the principle of non-discrimination and the importance of tackling stigma. However for a small number of those who are severely mentally ill, compulsory powers are required to ensure that patients receive care and treatment that is necessary to protect their own health or safety and, in some cases, to protect the wider public. The Government accepts that where a patient is subjected to compulsory powers the authorities involved in delivery of the care plan have a duty to provide the services stipulated in the care plan. Finally, the Government agrees with the Committee that compulsory powers should only be used when it is clear that essential care cannot be provided on a voluntary and consensual basis. That is the effect of the first of the principles that we have proposed should appear in the new legislation - that "informal care and treatment should always be considered before recourse to compulsory powers".
Recommendation BB We believe that respect for the principle of autonomy need not, and should not, mean that an individual can never be restrained from endangering others. However, it does imply that the refusal of treatment by a competent individual should be taken very seriously, and over-ridden only with good reason, such as the existence of a serious risk to others. We believe that the principle of respect for autonomy, and the principle of non-discrimination from which it flows, should appear on the face of the new Act. We would recommend that, if the Department remains concerned that the wording of the principles could cause legal confusion in an Act concerned at least partly with compulsion, it should seek independent legal advice on possible re-wordings. Any such re-wording should encapsulate the aim that respect for an individual's autonomy should be the starting point in any consideration of treatment, and that decisions to over-rule autonomy must therefore be based on transparent and sufficient criteria (para 117).
The Government agrees with the Committee that the use of compulsory powers to provide care and treatment for mental disorder is a serious matter, and that as we have said, voluntary and consensual care should always be the preferred option. This is reflected in the first of the principles that we have proposed should be included on the face of new legislation. We will consider the scope for including the principles of non-discrimination and patient autonomy within new legislation, but we are concerned that those principles that are to be included are capable of having practical effect.
Recommendation CC Many witnesses argued that an objective test for capacity should form part of the criteria used for determining whether a patient can be subject to compulsion. In principle we believe that this would be desirable as long as it was workable in practice. We appreciate, however, that there are genuine concerns as to how - or indeed whether - such a test could be developed. We recommend that the Department should investigate further the ways in which such a test might be implemented successfully (para 122).
The Green Paper included two options for the criteria which must be met if care and treatment is to be provided under compulsory powers. One of these included a test of capacity. We are currently considering all the arguments, and will publish our formal proposals in a White Paper at the end of the year. The Committee is right to acknowledge the very real difficulties involved in using capacity as a criterion for the use of compulsory powers which is why we included an alternative option.
Recommendation DD We recommend that the DoH should take legal advice as to whether the capacity "test" set out in the White Paper Making decisions would be interpreted by the courts in such a way that a person making decisions which conflict with their own "real" values (as judged by the patient him or herself when well) would be deemed incapable. If necessary, we recommend that an additional criterion be added to that test, to ensure that this is clear. We also recommend that the new mental health legislation should include provision for advance directives and crisis cards to be used when determining what the patient's "real" views are (para 124).
The Government is currently considering the criteria which should be met to justify the use of compulsory powers. We will take full account of the Committee's recommendation in reaching our decision. We accept the important role that advance directives may have in respect of patients with severe mental health problems, although we will not be giving them special legal status. We will however, as we said in our Green Paper, include very clear guidance on the status and of advance directives in the Code of Practice, which will accompany new mental health legislation.
Recommendation EE Homicides are clearly an appalling tragedy for those directly affected, and proper consideration of risk to others must be a key element in the criteria which determine whether compulsory treatment is necessary. But we believe that the focus of mental health legislation should be on the therapeutic benefit to the patient. We are concerned that the high profile given to tragic, but nonetheless relatively rare, events may hinder the development of services focused on the needs of the patients, and might even be counter-productive in driving patients away from the system (para 128).
It is our aim to ensure that all those with mental health problems receive high quality care and treatment that is appropriate to their needs, whether treated under the provisions of mental health legislation, or informally. In framing our detailed proposals at the end of the year, we will ensure that appropriate emphasis is given both to improvements in the care that people subject to formal care and treatment receive, and to measures designed to protect the wider public. The Government regards both these elements as proper foundations for mental health legislation.
Recommendation FF We are also concerned that the "blame culture" to which we alluded earlier (see para 73) risks driving away much needed staff from mental health services. It seems to us that individual professionals are being asked to make very difficult judgements as to potential risk, with little guidance and in the knowledge that the wrong decision might have disastrous consequences. We ask the Department, in association with the appropriate professional bodies, to bring together and update any existing guidelines on the assessment of risk. We also believe that professionals would welcome an acknowledgement in those guidelines that risk can never be eliminated altogether, and that occasionally decisions will be made in good faith, on the best evidence available, that in hindsight are proved to be wrong (para 129).
The Government accepts the Committee's observation that assessment of potential risk involves very difficult clinical judgements, and that occasionally decisions made in good faith on the best evidence available are, in hindsight, proved to have been wrong. Much work has been undertaken already to improve the guidance available to professional staff involved in these difficult decisions. The learning guide on mental health risk assessment and risk management developed by the University of Manchester, on behalf of the Department of Health, includes a module which looks at the risk of violence, suicide or self neglect and how practitioners can manage the identified risks. The guide also includes information about best practice, groups with special needs, the legislative framework and ethical issues, and the perspectives of services users and carers. The National Service Framework requires local health and social care communities, working with their education consortia, to meet the training and educational needs for risk assessment and management in relevant staff groups including primary care, A&E and midwives as well as their own mental health teams. Safer Services, published by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness in 1999, identifies key indicators of potential risk, and lessons must continue to be learnt from such tragedies in ways which do not encourage a culture of blame. We accept the Committee's view that such a culture risks driving away much needed staff from mental health services. The Department has recently commenced work with the Institute of Psychiatry to develop and field trial a clinical risk assessment and decision support system. The study will be completed in April 2002, and will be taken into account in the work currently being commissioned to update the training and audit materials relating to the implementation of Effective Care Co-ordination in Mental Health Services.