National Service Framework for Mental Health

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Mental Health

Modern Standards and Service Models

national

service

frameworks


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September 1999

A N a t i o n a l S e r v i c e

Fra m e w o rk fo r

M e n ta l H e a lth

Forew ord b y the Secretary of State 1

1 The National Service Framework for Mental Health 3

2 Standards, interventions, evidence and 13service models

Stand ard one 14

M ental health p rom otion

Standard tw o and three 28

Prim ary care and access to services

Standard four and five 41

Effective services for people w ith severe m ental

illness

Standard six 69

C aring ab out carers

Stand ard seven 76

Preventing suicide

3 Local implementation 83

4 Ensuring progress 94

5 National support for local action 104

Finance: revenue, capital and estates 105

W orkforce planning , ed ucation and training 108

R esearch and developm ent 113

C linical decision support system s 117

Inform ation strategy 120

Conclusion 123

6 Annex A - Outcome indicators for severe mental illness 124

M em bership of the External R eference G roup 127

G lossary 128

B ibliography 136

R eferences 138

c o n t e n t s p a g e


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National Service Framework for

M e n t a l H e a l t hModern Standards & Service Models


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M odern Standards & Service M odels

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Forew ord by the Secretary of State

At any one tim e one adult in six suffers from one or other form of m ental illness.

In other w ords m ental illnesses are as com m on as asthm a. They range from m ore

com m on conditions such as deep depression to schizophrenia, w hich affects

few er than one person in a hundred. M ental illness is not w ell understood, it

frightens people and all too often it carries a stigm a.

D espite its prevalence and im portance m ental illness hasnt had the attention it

deserves. Thats w hy the G overnm ent is determ ined to give it a m uch higher

priority. That is w hy w e decided that m ental health should have the sam e priority

as coronary heart disease in our program m e of N ational Service Fram ew orks

w hich w ill lay dow n m odels of treatm ent and care w hich people w ill be entitled

to expect in every part of the country.

So this N ational Service Fram ew ork for M ental H ealth spells out national standards

for m ental health, w hat they aim to achieve, how they should be develop ed and

delivered and how to m easure perform ance in every part of the country.

These standards are founded on a solid base of evidence, w hich has been

exam ined and validated by the External Reference G roup chaired by Professor

G raham Thornicroft. I am very grateful to them for their thorough and

professional w ork w hich should help raise standards, tackle inequalities and m eet

the special needs of w om en, m en, and different ethnic groups.

This National Service Fram ew ork fleshes out the policies announced in our W hite

Paper M odernising M ental H ealth Services. It w ill be a guide to investm ent in m ental

health services including the extra 700 m illion w hich the G overnm ent is providing

over this year and the next tw o. It w ill be backed up, in due course, by changes to

bring the law on m ental illness up to date to reflect m odern treatm ents and care,

follow ing the root and branch review conducted by the independent expert group

under Professor G enevra Richardson.


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The N ational Service Fram ew ork for M ental H ealth

developing the National Service Framework for mental health

a new vision for mental health

a Government wide agenda

Introduction

The new NHS and Modern ising Socia l Servi cesw ere landm arks for the future of health

and social services. The tw o W hite Papers set out a range of m easures to drive up

quality and reduce unacceptable variations, w ith services responsive to individual needs,

regardless of age, gender, race, culture, religion, disability, or sexual orientation.

A Fi rst Class Servi ce explained how N H S standards w ould be:

set by the N ational Institute for Clinical Excellence and N ational Service Fram ew orks

delivered by clinical governance, underpinned by professional self-regulation andlifelong learning

monitored by the Com m ission for H ealth Im provem ent, the new N ational Perform ance

Assessm ent Fram ew ork, and the N ational Survey of Patients.

Sim ilarly,A New Appr oach to Social ServicesPerformance described a Perform ance Assessm ent

Fram ew ork for social services, outlining plans to strengthen assessm ent by the D epartm ent of

H ealth and detailed proposals for national perform ance indicators for social services.

The first tw o N ational Service Fram ew orks cover tw o of the m ost significant causes of ill

health and disability in England - coronary heart disease and m ental health - tw o

priorities in Savin g lives: Our Healthi er Nation. The N ational Service Fram ew orks have

also been identified as priorities in Modern isin g Health and Social Servi ces: Nati ona l

Prioriti es Guid ance for 1999/00 - 2001/02.

This N ational Service Fram ew ork focuses on the mental health needs of working age

adults up to 65. M ental ill health is so com m on that at any one tim e around one in six

people of w orking age have a m ental health problem , m ost often anxiety or depression.

O ne person in 250 w ill have a psychotic illness such as schizophrenia or bipolar affective

disorder (m anic depression).

M ost people w ith m ental health problem s are cared for by their G P and the prim ary care team .

This is w hat m ost patients prefer, and is m ore likely to be effective w hen specialist services

provide support, and w here there is local agreem ent on how to provide integrated care.

G enerally, for every one hundred individuals that consult their G P w ith a m ental healthproblem , nine w ill be referred to specialist services for assessm ent and advice, or for treatm ent.

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N ation al Service Fram ew ork - M ental H ealth

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Som e people w ith severe and enduring m ental illness w ill continue to require care from

specialist services w orking in partnership w ith the independent sector and agencies

w hich provide housing, training and em ploym ent.

Specialist services, including social care, should ensure effective and tim ely interventions

for individuals w hose m ental health problem s cannot be m anaged in prim ary care alone,

for exam ple, patients w ith severe depression or psychotic disorders. Specialist services

are essential w hen these problem s coexist w ith substance m isuse - co-m orbidity or

dual diagnosis.

W orking partnerships w ith agencies w hich provide housing, training, em ploym ent and

leisure services w ill be required to address the needs of som e people w ith enduring

m ental health needs.

Developing the National Service Framework

The N ational Service Fram ew ork has been developed w ith the advice of an External

Reference G roup, chaired by Professor G raham Thornicroft from the Institute of

Psychiatry, Kings College London. The External Reference G roup brought together

health and social care professionals, service users and carers, health and social service

m anagers, partner agencies, and other advocates.

A full range of view s w ere sought by the External Reference G roup, w hich w as assisted

by the D epartm ent of H ealth.

Em erging findings from the External Reference G roup w ere incorporated in Modernising

Menta l Heal th Servi ces. The G roup distilled existing research and know ledge, and

considered a num ber of cross cutting issues, such as race and gender. This N ational

Service Fram ew ork is founded on their w ork.

Guiding values and principles

The External Reference G roup developed ten guiding values and principles to help shape

decisions on service delivery. People w ith m ental health problem s can expect that services w ill:

involve service users and their carers in planning and delivery of care

deliver high quality treatm ent and care w hich is know n to be effective and acceptable

be w ell suited to those w ho use them and non-discrim inatory

be accessible so that help can be obtained w hen and w here it is needed

prom ote their safety and that of their carers, staff and the w ider public

offer choices w hich prom ote independence

be w ell co-ordinated betw een all staff and agencies

deliver continuity of care for as long as this is needed

em pow er and support their staff

be properly accountable to the public, service users and carers.


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N ational Service Fram ew ork - M ental H ealth

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A w ide range of evidence has been synthesised in this National Service Fram ew ork.

Evidence has been graded, according to the system used, for exam ple, by Bandolier

www.jr2.ox.ac.uk/Bandolier and in the H ealth Evidence B ulletin for W ales: M ental H ealth1 (V).

Type I evidence - at least one good system atic review , including at least onerandom ised controlled trial

Type II evidence - at least one good random ised controlled trial

Type III evidence - at least one w ell designed intervention study w ithoutrandom isation

Type IV evidence - at least one w ell designed observational study

Type V evidence - expert opinion, including the opinion of service users and carers.

Achieving systematic change

The national standards in this N ational Service Fram ew ork w ill be achieved only by:

recognising that change needs to be system atic and sustainable

m easuring change w ith early m ilestones and longer term goals

building a program m e w hich is both am bitious and realistic - am bitious standards andrealistic local delivery system s w ith national underpinning program m es

applying concerted action - using local m echanism s such as health im provem entprogram m es, joint investm ent plans, the clinical governance fram ew ork, and the newflexibilities betw een health and local governm ent to secure change in m ental health

services as a priority.

D elivering the N ational Service Fram ew ork w ill require new patterns of local partnership,

w ith m ental health a cross cutting priority for all N H S and social care organisations and

their partners.

The focus for delivery w ill be w ith local health and social care com m unities. Som e of the

issues are long-standing and com plex. This N ational Service Fram ew ork therefore

includes five underpinning program m es w hich w ill be led nationally and w ill support

local health and social services to achieve essential changes.

Remaining relevant

D uring the im plem entation of the N ational Service Fram ew ork, there w ill be changes

such as new treatm ents, innovations, and different expectations. All N ational Service

Fram ew orks w ill have to evolve if they are to stay relevant and credible in a changing

environm ent. To ensure this Fram ew ork starts and stays up-to-date a national group,

outlined in Section three of the m ain docum ent, has been set up to oversee both

im plem entation and future developm ent. M ilestones w ill be m ade m ore challengingw hen earlier ones have been reached.


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Ensuring successful progress

Som e national m ilestones have been established, and progress w ill be m easured through

a sm all num ber of high-level perform ance indicators w ithin the N H S and Social Services

Perform ance Assessm ent Fram ew orks, the latter applying the Best Valu eprinciples to

social services. These w ill be com plem ented by the program m e of system atic service

review s w hich w ill be undertaken by the Com m ission for H ealth Im provem ent and the

Social Services Inspectorate, w orking w ith the Audit Com m ission.

To help local planning and im plem entation of this am bitious program m e of change, local

m ilestones for each standard have been outlined to m easure progress along the w ay.

These w ill be m ore challenging for som e than for others, and it is not intended that all

w ill reach each m ilestone at the sam e tim e.

In m any areas the first priority w ill continue to be addressing gaps in current services for

people w ith severe and enduring m ental illness - 24 hour staffed accom m odation,

assertive outreach, hom e treatm ent or secure beds, for exam ple. This w ill address issues

of equity of access and safety, including public safety. In areas w here specialist m ental

health services are able to m eet local needs for severe m ental illness, the m ost cost-

effective focus w ill now be on people w ith com m on m ental health problem s.

Modern ising Men tal Health Servi cessets an am bitious agenda. The G overnm ent has

already com m itted an extra 700 m illion over three years to help local health and social

care com m unities reshape m ental health services. Together w ith m ain allocations, this

provides the resources for im plem entation of this N ational Service Fram ew ork over the

next three years. Further studies of cost effectiveness, and rigorous perform ance

m anagem ent, w ill ensure that the Fram ew ork is im plem ented, m aking better use of

existing resources. The future speed of im plem entation of this N ational Service

Fram ew ork w ill be shaped by evidence of increased cost effectiveness in delivering

m ental health services, available resources, and rigorous perform ance m anagem ent.

N ew investm ent and reinvestm ent of existing resources w ill need to be prioritised,

recognising that m ental health services are w hole system s w hich w ork effectively only

w hen the com ponent parts are all in p lace and in balance.

The N ational Service Fram ew orks program m e of change cannot be im plem ented in a m atter

of m onths. Additional facilities, extra staff and m ore training w ill be required in som e areas to

achieve som e of the standards. Recruitm ent and training of som e specialist m edical staff m ay

take five to ten years. Im plem enting the N ational Service Fram ew ork fully across the N H S

and social services, and throughout other agencies, could take up to ten years. These

challenges can be m et if concerted, focused and determ ined action is applied from the start.

Measuring progress and managing performance

The targets set out in the N ational Priorities G uidance, alongside the targets set for efficiency

and value for m oney, w ill m ake health and social services accountable to the G overnm ent

and the public for delivering new national standards of m ental health and social care.


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A First Class Servi cesets out how the N H S w ill deliver quality standards and The NHS

Performan ce Assessment Frameworkdescribes how these w ill be m easured. And

A NewApproach to Socia l Servi ces Perf orman ce explains how best value and perform ance w ill

be m anaged in social services. Together, these new system s w ill help to ensure that

services develop in the right direction, additional investm ent for change is targeted

through the M odernisation Fund and the M ental H ealth G rant and resources are used

efficiently according to the principles ofBest Valu e.

New vision for mental health

Soon after the G overnm ent cam e into office it started to take action on m ental health,

setting up an Independent Reference G roup to advise M inisters on the closure of the

rem aining long stay psychiatric hospitals. And additional in-year resources w ere m ade

available to m ental health services in 1997/98.

M inisters announced the establishm ent of the External Reference G roup in July 1998. Its

findings w ere taken into account in Modern isin g Mental Health Servi ces, w hich

em phasised three key aim s:

safe services - to protect the public and provide effective care for those w ith m entalillness at the tim e they need it

sound services - to ensure that patients and service users have access to the fullrange of services w hich they need

supportive services- w orking w ith patients and service users, their fam ilies and

carers to build healthier com m unities.

Modern ising Mental Health Servi cesgave m ental health care a new direction, aw ay from

neglect and deterioration, and on to a process of reform , rebuilding and renew al.

It pledged an additional 700 m illion in this year and the next tw o years, and a fresh

start for m odern and dependable m ental health services through this N ational Service

Fram ew ork. The m ental health strategy prom ised:

extra investm ent and new system s to m anage resources m ore effectively

w ell integrated care processes, crossing professional and agency boundaries

legal pow ers w hich w ork w ith and underpin com prehensive local services.

For the first tim e m ental health w as m ade a shared national priority for health and social

services in Modern isin g health an d social servi ces: National Pri ori ties Gui dan ce for

1999/00 - 2001/02.


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Review of the law

In July 1998, M inisters announced a root and branch review of the M ental H ealth Act, to

ensure that the legislative fram ew ork supports m odern m ental health care.

An independent expert group, chaired by Professor G enevra Richardson of the U niversity

of London, published its initial proposals for consultation earlier this year. The group

reported to M inisters in July and their report w ill be published later this year, alongside a

G overnm ent consultation paper on proposed changes to the law .

N either m ental health nor crim inal justice law currently provides a robust w ay of

m anaging the sm all num ber of dangerous people w ith severe personality disorder. H om e

O ffice and H ealth M inisters are considering a m ore effective fram ew ork for assessm ent

and m anagem ent w hich w ill protect the public w hilst ensuring that the requirem ents of

the European Convention on H um an Rights are m et. A consultation paper w as published

in the sum m er.

Mental health care in prison

The recent joint report on prison health care2 (V) called for closer partnerships betw een

prisons and the N H S at local, regional and national levels. This w ill have significant

im plications for som e m ental health services. Better needs assessm ent is likely to identify

unm et or inappropriately m et need, and local services w ill need to explore opportunities

to im prove m ental health care for prisoners w ithin existing resources. Im provedpartnership w ork betw een the N H S, local authorities and the probation service w ill also

be required for service developm ent and the care of service users, especially individuals

w ith severe m ental illness.

The configuration of mental health services

M ental health services represent a continuum from prim ary care to highly specialised

services. For any local health and social care com m unity m ental health services w ill be

provided by tw o or m ore organisations. N o reconfiguration w ill unify all provision; the

interfaces and boundaries m ust be m anaged effectively to provide and com m ission

integrated services.

Providing integrated services

The new NHS and Modern isin g Mental Health Servi cesset out the advantages of specialist

m ental health N H S trusts. M ental health service providers need to dem onstrate:

senior leadership of and com m itm ent to m ental health services

clinical governance, including continuing professional developm ent and lifelong learning

evidence of a com m itm ent to the underpinning program m es including education andtraining, recruitm ent and retention, inform ation services and research and developm ent

clear lines of accountability for m ental health services.


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And specific arrangem ents should be in place to ensure:

service user and carer involvem ent

advocacy arrangem ents

integration of care m anagem ent and the Care Program m e A pproach (CPA )

effective partnerships w ith prim ary health care, social services, housing and otheragencies including, w here appropriate, the independent sector.

In the m edium term these criteria are m ost likely to be m et in N H S trusts w ith a critical

m ass of m ental health services. Single speciality m ental health N H S trusts are likely to be

the preferred option in inner cities and som e m etropolitan areas. W here populations are

m ore dispersed other options m ay be better, although these are unlikely to includecom bined m ental health and acute N H S trusts in the longer term .

O ver recent years, the advantages of a closer relationship betw een prim ary care and

specialist m ental health services have becom e clearer. Som e prim ary care trusts m ight be

given responsibility for the provision of local specialist m ental health services -

com m unity m ental health team s, local residential care, day care, dom iciliary support and

local inpatient care - subject to the follow ing criteria:

either an established track record:

the trust includes m anagers, m ental health professionals, G Ps and prim ary care

team s w ho have developed a good track record by applying, for exam ple:

- guidelines and protocols for the integrated care of people w ith m ental

health problem s

- a system atic approach to diagnosis, treatm ent and care, and to disease

prevention and health prom otion

- rigorous m onitoring of health indicators and focused action to tackle ill health

and inequalities in health

or robust plans in the prim ary care trust proposal for im provem ent of m ental

health services that:

- m eet the requirem ent in health im provem ent program m es to im prove and

develop m ental health provision

- com m and the broad support of local service users and carers, and are subject to

rigorous m onitoring

effective arrangem ents to m anage the interface betw een local specialist and m orespecialised m ental health services, including secure psychiatric services

a continuing focus on individuals w ith severe and enduring m ental illness, in line w ith

the standards and service m odels in this National Service Fram ew ork, and acom m itm ent to joint w ork betw een health and social services


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board m em bership includes com petent m anagem ent of specialist m ental health services

proportional representation of m ental health professionals on the executive of theprim ary care trust.

Commissioning mental health services

Com m issioning of local m ental health services should be consistent w ith service

priorities em phasised in Modern isin g Mental Health Servi cesand the standards set in this

N ational Service Fram ew ork.

Comm ission in g in the new NHS(H SC 1998/198) identified a num ber of m ore specialised

services, including m edium and high secure psychiatric services, services for severe

eating disorders, m other and baby units, early dem entia, and gender dysphoria. Theseservices w ill continue to be provided w ithin specialist m ental health N H S trusts; high

security services w ill rem ain w ithin the three high security hospitals.

Local specialist m ental health services should be com m issioned through a unified local

com m issioning process. H ealth authorities, under the aegis of regional specialised

services com m issioning groups, w ill retain responsibility w ithin the N H S for

com m issioning specialised m ental health services. G uidance on the arrangem ents and

m anagem ent of regional com m issioning of high and m edium security services has been

set out in H SC 1999/141.

Local health and social care services w ill need to agree their arrangem ents forcom m issioning w ith the N H S Executive regional offices and social care regions. It is

likely that these arrangem ents w ill evolve over tim e as local health and social care

com m unities m ake use of the new flexibilities betw een health and local authorities,

w hich allow budgets to be pooled, integrated provision, and the identification of lead

com m issioning roles.

O ptions for com m issioning could include:

a joint com m issioning board, including the local authority, health authority andprim ary care group

a lead com m issioner, w hich could be either local authority, prim ary care group orprim ary care trust or health authority.

W hichever option is selected, long term service agreem ents, w hich w ill replace contracts,

should be consistent w ith the health im provem ent program m e and com m unity care plans.

W here N H S patients are treated under contract in the private and voluntary health care

sector, the responsible N H S com m issioning body should ensure that its contracts apply the

sam e clinical governance principles, including the use of this National Service Fram ew ork.


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Links to Government wide policies

M ental health is a priority for health and social services in Modern isin g Health an d

Social Servi ces: National Pri ori ties Gui dan ce for 1999/00 - 2001 /02.Partn ership in

Action proposed new flexibilities betw een health and local authorities that have been

enacted through the 1999 H ealth Act, flexibilities w hich w ill be essential to the

successful im plem entation of this N ational Service Fram ew ork.

The W hite Paper,Savin g lives: Our Healthi er Nation, includes m ental health as one of its

four key areas. This Fram ew ork sets out the action to be taken by health and social

services to deliver their contribution to the achievem ent of the target for m ental health -

a reduction in the suicide rate by at least one fifth by 2010.

M oreover, a range of G overnm ent policies w ill also support this National Service

Fram ew ork. Social exclusion can both cause and com e from m ental health problem s.

Initiatives designed to prom ote social inclusion - for exam ple, Sure Start, W elfare to

W ork, N ew D eal for Com m unities and the w ork of the Social Exclusion U nit - w ill all

strengthen the prom otion of m ental health and individual w ell-being, and reduce

discrim ination against people w ith m ental health problem s.


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N ational standards and service m odels

national standards

interventions and evidence-base

service models

examples of good practice

measuring progress

This N ational Service Fram ew ork sets out standards in five areas; each standard is

supported by the evidence and know ledge-base, by service m odels, and by exam ples of

good practice. Local m ilestones are proposed; tim e-scales need to be agreed w ith N H S

Executive regional offices and social care regions, and progress w ill be m onitored.

Standard one addresses m ental health prom otion and com bats the discrim ination and

social exclusion associated w ith m ental health problem s.

Standards tw o and three cover prim ary care and access to services for any one w ho m ay

have a m ental health problem .

Standards four and five encom pass the care of people w ith severe m ental illness.

Standard six relates to individuals w ho care for people w ith m ental health problem s.

Standard seven draw s together the action necessary to achieve the target to reduce

suicides as set out in Savin g lives: Our Healthier Nati on.

These standards w ill be challenging for all m ental health services. Although som e

services m ay already have reached a num ber of m ilestones, none can claim to have

achieved them all. As progress is m ade, the national m ilestones w ill be rolled forw ard;N H S Executive regional offices and social care regions w ill agree further m ilestones w ith

each health and social care com m unity.

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Standard one

M ental health prom otion

Aim

To ensure health and social services prom ote m ental health and reduce the

discrim ination and social exclusion associated w ith m ental health problem s.

Standard one

Health and social services should:

promote mental health for all, working with individuals and communities

combat discrimination against individuals and groups with mental healthproblems, and promote their social inclusion.

Rationale

M ental health problem s can result from the range of adverse factors associated w ith

social exclusion and can also be a cause of social exclusion. For exam ple:

unem ployed people are tw ice as likely to have depression as people in w ork

children in the poorest households are three tim es m ore likely to have m ental health

problem s than children in w ell off householdshalf of all w om en and a quarter of all m en w ill be affected by depression at som e

period during their lives

people w ho have been abused or been victim s of dom estic violence have higher ratesof m ental health problem s

betw een a quarter and a half of people using night shelters or sleeping rough m ayhave a serious m ental disorder, and up to half m ay be alcohol dependent

som e black and m inority ethnic groups are diagnosed as having higher rates ofm ental disorder than the general population; refugees are especially vulnerable

there is a high rate of m ental disorder in the prison population

people w ith drug and alcohol problem s have higher rates of other m ental health problem speople w ith physical illnesses have higher rates of m ental health problem s.

The W orld H ealth Report 1999 3 (IV) dem onstrates that neuropsychiatric conditions are

the com m onest cause of prem ature death and years of life lost w ith a disability - 10% of

the burden of disease in low and m iddle incom e countries and 23% in high incom e

countries. The W orld H ealth O rganisation (W H O ) M ental H ealth U nit of the Regional

O ffice for Europe has prioritised action to reduce stigm a, counteract depression and

suicide, and to audit m ental health services.

Besides the im m ense costs in personal and fam ily suffering, m ental illness costs in the

region of 32 billion in England each year. This includes alm ost 12 billion in lostem ploym ent and approaching 8 billion in benefits paym ents4 (IV).


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Interventions and evidence-base

page

A ction across w hole populations.................................................................................................15

Program m es for individuals at risk ..............................................................................................16

Program m es for vulnerable groups.............................................................................................16

Victim s of child abuse..................................................................................................................17

D om estic violence .......................................................................................................................17

R ace and m ental health...............................................................................................................17

People w ho sleep rough..............................................................................................................17

People in prison...........................................................................................................................18

People w ith alcohol and drug problem s......................................................................................18

C om bating discrim ination and social exclusion..........................................................................18

Action across whole populations

M ental health prom otion 5(V) is m ost effective w hen interventions build on social

netw orks, intervene at crucial points in peoples lives, and use a com bination of m ethods

to strengthen:

individuals to enhance their psychological w ell-being

com m unities in tackling local factors w hich underm ine m ental health.

A report by the M ental H ealth Foundation this year - Bri ght Futu res - promotin g

chil dren and youn g peoples mental health6(V) - sum m arised the evidence on m ental

health prom otion for children and young people. It highlighted the significance of

supporting parents during pregnancy and after birth w ith hom e visits, high quality child

care, and helping through schools and com m unity netw orks.

Exercise, relaxation and stress m anagem ent have a beneficial effect on m ental health.Reducing access to illicit drugs, taking alcohol in m oderation, m aintaining social contacts,

reducing sm oking, and talking things over are also helpful m easures7,8 (I). Teaching

interpersonal aw areness reduces em otional exhaustion and depression 9 (III).

Another report by the M ental H ealth Foundation underlined the need to consider the

physical and spiritual facets of m ental health and m ental health problem s, and to tailor

individual program m es to individual circum stances 10 (V).

The H ealth and Safety Executive 1995,Survey of Self Reported Wor k Rela ted I ll ness,

estim ated that alm ost 300,000 people in Britain believed that they w ere suffering from

w ork related stress, anxiety or depression.


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Programmes for individuals at risk

There is increasing evidence of effective interventions to help to develop better coping

m echanism s and reduce the risk of m ental health problem s in individuals w ho are at risk

because of a life event.

Professional em otional support for pregnant w om en caring for their existing young

children can decrease the rate of postnatal depression 11 (I). H elping new parents to

develop child rearing skills is effective 12 (V), and young, single parents can be helped to

cope better13 (I).

H igh quality pre-school and nursery education have been show n to produce

im provem ents in self-esteem , m otivation and social behaviour. Pre-school education m ay

substantially decrease the chances of drug dealing 20 years later14 (I). Program m es w hich

target children w ith behavioural problem s can reduce the developm ent of difficulties

later on 5 (II).

W ork can cause both m ental and physical ill health. Studies show significant levels of

stress w ithin the w orkforce, including in the N H S 15 (V). A healthy w orkplace can

prom ote m ental health 15 (V). Learning to m obilise support at w ork and to participate in

problem solving and decision m aking can im prove m ental health 16 (III).

M ental health problem s associated w ith w ork include depression and anxiety, alcohol

m isuse, and sickness absence. W ork overload, m onotony, and pressure of w ork are key

factors, as are lack of control over w ork and exclusion from decision m aking 15 (V).

H igh quality interventions for individuals w ho are unem ployed can reduce the

psychological im pact of job loss, and prom ote re-em ploym ent, particularly in those at risk of

m ental ill health 5,17( I)( II I ).

M ental health can deteriorate during long term unem ploym ent. O ne study 18(II), enhanced

self-confidence, increased m otivation and reduced the negative feelings associated w ith

unsuccessful job-seeking. D epressive sym ptom s w ere reduced and confidence im proved.

Long term , the treated group had higher m onthly earnings and few er job changes.

M any local authorities and N H S trusts, often in partnership w ith independent sector

agencies, have set up vocational training and em ploym ent support schem es for people w ith

m ental illness. These need to be planned and integrated w ith other statutory em ploym ent

services to ensure effective use is m ade of skills, resources and support system s.

People w ho are vulnerable as a result of either divorce 19 (II) or unem ploym ent20 (III) 21(II)

can be helped to adjust, and show n how to build coping skills.

Programmes for vulnerable groups

Som e groups face a high risk of m ental illness, for exam ple, individuals w ho have

suffered severe abuse, black and m inority ethnic groups, people w ho sleep rough,

individuals in prison, and people w ith physical illnesses. Problem s w ith alcohol and

drugs can exacerbate m ental health problem s.


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Victims of child abuse

Research on the neurophysiological effects of child abuse 22 (IV) has show n that traum a

during childhood can have a devastating affect on all functions of the developing brain -

em otional, cognitive, behavioural and psychological including self-harm . D evelopm ental

effects of child victim isation include insecure attachm ents, dissociation, drug abuse, self

injury and aggression 23 (IV).

Childhood sexual and other abuse is know n to be m ore frequent in the histories of

individuals w ith both m ental illness and personality disorder 24 (IV).

Domestic violence

Violence betw een adult partners occurs in all social classes, all ethnic groups and

cultures, all age groups, in those w ith disability as w ell as the able bodied, and in both

hom osexual and heterosexual relationships25 (V). W om en are usually the m ost frequent

victim s. Exposure to violence in the hom e is linked to juvenile crim e and aggression.

There is evidence of the effectiveness of com m unity-w ide m ental health interventions

w hich use parent support, voluntary groups, com m unity parent advisers, and school

program m es aim ed at reducing bullying and prom oting interpersonal skills26 (I).

Race and mental health

In the A frican-Caribbean population, especially in young m en, the rates of diagnosis of

psychotic illness are high, relative to the w hite population, as is adm ission to hospital

under the M ental H ealth Act, treatm ent by physical rather than talking therapies, and

adm ission to secure services. This group is also m ore likely to be referred to m ental

health services by the crim inal justice system , than by G Ps or social care services27 (II).

D epression is diagnosed relatively less frequently in the A sian population than in the w hite

population, although young A sian w om en have a relatively high rate of suicide 28 (I).

The stigm a attached to m ental illness can be com pounded by racial discrim ination 29(V),

w ith access to appropriate assessm ent, treatm ent and care inhibited 30, 31, 29, 32, 33 (IV,IV,V,IV,IV).

Refugees and asylum seekers are a particularly vulnerable group 34(V). Post traum atic stress

disorder is the m ost com m on problem , and the risk of suicide is raised in the long term .

Com bined evidence suggests that services are not adequately m eeting m ental healthneeds, and that black and m inority ethnic com m unities lack confidence in m ental health

services. All m ental health services m ust be planned and im plem ented in partnership

w ith local com m unities, and involve service users and carers. If services are to m atch the

needs of black and m inority ethnic com m unities and reduce the present inequities, this

principle is especially im portant.

People who sleep rough

U p to half of the 2,000 people w ho sleep rough on our streets each night have m ental health

problem s but less than a third receive treatm ent, according to a report last year by the Social

Exclusion U nit. O ne in tw o have a serious alcohol problem , and one in five m isuse drugs. In

1997, it w as estim ated that one in three rough sleepers have m ultiple needs, m ost com m onlyrelated to substance m isuse com bined w ith m ental health problem s35 (V).


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H om elessness am ong young people also brings significant problem s.Off to a Bad Star t, a

study of hom eless young people in London aged 16-21 years, found that alm ost tw o

thirds had suffered recently from psychiatric disorders. A third also reported at least one

attem pted suicide at som e point. O nly one fifth, how ever, had been in contact w ith

psychiatric services in the past year 36 (IV).

People in prison

H ealth and local authorities should also be involved in assessing the m ental health needs

of prisoners during their tim e in custody and in preparation for their release, contributing

to their through-care and release plans for support in the com m unity. Rates of all types

of m ental disorder, especially drug and alcohol dependence, are higher in prisons than

in the general population 37(IV) and there is considerable variation in the delivery, quality

and effectiveness of prison health care 38 (V). Continuity of care is also essential,

providing through-care as prisoners return to their local com m unities.

People with alcohol and drug problems

For people w hose alcohol consum ption exceeds recom m ended guidelines, brief prim ary

care interventions such as assessm ent of alcohol intake and provision of advice can help

to reduce it39(I).

Individuals w ho m isuse alcohol or drugs are at a significantly increased risk of

suicide 40,41(IV, V) w ith suicide rates am ong drug users, especially young people,

continuing to rise 42 (V).Safer Servi ces41 (V) stressed the need for stronger links betw een

drug and alcohol services and com m unity m ental health services as part of an overall

suicide prevention strategy.

Combating discrimination and social exclusion

Surveys by the D epartm ent of H ealth, M IN D and the H ealth Education Authority (H EA) all

report that people feel strongly about m ental illness43-45(V,V,V). M ost people are generally

caring and sym pathetic, but they are also concerned about the danger w hich they associate

w ith a very sm all num ber of people w ith severe m ental illness. The H EA reportMaking

Headlines45(V) show s that negative m edia coverage of m ental health is w idespread.

Public education is an effective w ay of reducing stigm a46 (III). The D epartm ent of H ealth,

through itsImpact

strategy w orks in partnership w ith service users, the Royal College of

Psychiatrists, M ental H ealth M edia and the voluntary sector, to provide better inform ation

and build understanding am ong the public. The G overnm ent spent m ore than 2.5 m illion

nationally on public inform ation and m ental health prom otion over 1997/98 and 1998/99.

Subsequent standards in this N ational Service Fram ew ork address the needs of people

w ith m ental health problem s. H ow ever, it is im portant to recognise that they m ay need

help to tackle discrim ination. Legislation requires organisations to m ake reasonable

adjustm ents to accom m odate the needs of disabled em ployees. The D isability

D iscrim ination Act 1996 places a duty upon em ployers to take steps to prevent disabled

persons, including those w ith m ental im pairm ent, from being placed at a disadvantage.


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Service models and examples of good practice

page

M ental H ealth Prom otion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

A nti-stigm a program m e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

A ction across w hole populations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

M ental health prom otion in schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

M entoring program m e for high schools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Support for young people at risk of school exclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

M anaging stress at w ork. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

M ental w ell-being in the w orkplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Im proving the health of the N H S w orkforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

M anaging stress in H ealthy C ities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

A ction for individuals w ho are at risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

H om e visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

B efriending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Initiatives for vulnerable groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

M ental health needs of A sian w om en . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Integrated approach to m ental health and hom elessness . . . . . . . . . . . . . . . . . . . . . . . . . . .25

M ental health prom otion in prisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

C om bating discrim ination and social exclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

H ealth A ction Zones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

H ealthy C harters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

To achieve Standard one, local services w ill need to give priority to m ental health

prom otion in their health im provem ent program m e, and take every opportunity w ithinthe social inclusion agenda to develop effective strategies to prom ote m ental health and

prevent m ental illness.


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Mental Health PromotionM ental H ealth Prom otion:A Q uality Fram ew ork47 (V) provides a fram ew ork for

dem onstrating the benefits and value of m ental health p rom otion w ith a focus on

m easuring success. It provides a practical guide to assist local health and social care

services and em ployers to develop m ental health prom otion strategies. It is based on

three goals to prom ote:

em otional resilience - life skills training, parenting classes

citizenship - m entally healthy w orkplaces, anti-bullying program m es

program m es w hich focus on com m unity im provem ents - environm ental aw areness

and im provem ent, anti-stigm a cam paigns.

Tel: 01235 465565

Anti-stigma programme

In 1998 the R oyal C ollege of Psychiatrists launched a national cam paign, planned to

last for five years. The aim is to reduce the stigm a attached to m ental health prob lem s

via a public and professional educational initiative. The cam paign is entitled C hanging

M inds - every fam ily in the land 48 (V).

The C ollege has produced a series of booklets w ith inform ation on anxiety, depression,

schizophrenia, A lzheim ers disease and dem entia, anorexia and bulim ia, and alcohol

and other drug m isuse.

The cam paign is inclusive and is w orking in collaboration w ith a variety of other

interest groups: service users, carers, professionals, the m edia, the general public,

and those involved in education. A dditionally, the B ritish M edical A ssociation, R oyal

C olleges of Physicians and G eneral Practitioners, and the D ep artm ent of H ealth are

part of the p roject team . B aseline m easures of public opinion w ere recorded to assessthe im pact of the initiative.

Tel: 0207 235 2351 x 122

Action across whole populations

Local health and social care com m unities should focus activity through initiatives such as

healthy schools, healthy w orkplaces, healthy neighbourhoods and other settings, using

program m es to im prove understanding of the factors w hich affect m ental health.


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Support for young people at risk of school exclusionThe B rand on C entre, a voluntary sector, inner London project offering psychological

treatm ents to young people, has a num ber of outreach school-based projects. In

special and m ainstream schools, and in a pupil referral unit, troubled young people

are offered a variety of psychological treatm ent approaches to tackle their m ental

health prob lem s.

Tel: 0207 267 4792

Managing stress at work

The H ealth and Safety C om m ission has issued guidance to help em ployers m anage

w ork-related stress and has com m issioned research to answ er som e of the

outstanding questions. A discussion docum ent M anag ing Stress at W orkhas been

issued for consultation.

www.open.gov.uk/hse/condocs.

Tel: 01787 881165

Mental well-being in the workplace

A resource pack for m anag em ent training and developm ent has b een produced by

the H ealth and Safety Executive and identifies a range of actions to p rom ote m ental

w ell-being. It looks at hum an resources policy, focuses on em ployees, and identifies

good m anagem ent practices and includes case studies 49 (V).

Tel: 01787 881165

Improving the health of the NHS workforce

A partnership of key organisations convened by the N uffield Trust prod uced a rep ort

that includes evidence-based recom m endations on m anagem ent culture and

em ploym ent practice. It outlines interventions to enhance the sense of control staff can

have over w ork and recom m ends how to d evelop a culture in w hich staff are valued

and supp orted.

Tel: 0207 631 8450


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Managing stress in Healthy CitiesIn B irm ing ham , large scale w orkshop s on stress w ere used as part of a H ealthy C ities

program m e. The w orkshops covered the physical, cognitive and behavioural aspects

of anxiety and stress, and offered a w ide rang e of options for m anaging stress.

Tel: 0121 678 3400

Action for individuals who are at risk

Local health and social care com m unities should ensure that individuals identified as at

risk are encouraged to m ake contact w ith either form al services, such as the prim ary careteam , or other sources of practical support, including a self-help group.

Savin g lives: Our Healthi er Nationsum m arises the effective interventions as:

teaching parenting skills

support groups for young isolated m others to im prove their m ental health and theem otional and cognitive developm ent of their children

rapid treatm ent for depressed m others to prevent em otional or cognitive harm to theirchildren

school program m es to help children w ith learning difficulties including dyslexiahelp at school for children w hose parents are divorcing

program m es to build resilience in vulnerable children

social support for unem ployed people to help them to find w ork

practical inform ation for those caring for people w ith dem entia

self-help groups for those recently w idow ed.


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Home visitorsA C hild D evelop m ent Prog ram m e at the U niversity of D ub lin using hom e visitors w as

effective in reducing depression 50 (III).

262 first tim e m others living in a deprived area of D ublin w ere all seen by the public

health nurse, but around half the group w ere also allocated a com m unity m other, one

of 30 exp erienced m others living in the sam e com m unity. C hildren in the group being

seen by the com m unity m others w ere m ore likely at the end of the year to have a

better diet, had all their im m unisations, and to be read to daily.

The schem e dem onstrated that non-professionals can deliver a child-focused health

prom otion prog ram m e effectively.

Tel: 00 353 126 93244

Befriending

The B efrienders in D unstable is a registered charity w orking in partnership w ith local

health and social services and volunteers w ith the aim of providing support for people

w ho are isolated and alone, and lack a supportive com m unity. Their m ain activity

centres on a variety of m em bership clubs and a pub lic caf, op en five days a w eek.

The organisation has over 200 volunteers and over 50 staff.

Tel: 01582 422040

Initiatives for vulnerable groups

Local health and social care com m unities should identify particularly vulnerable

individuals and groups, and explore the opportunities to prom ote better m ental health,

perhaps w ithin w ider social inclusion initiatives and program m es. Follow ing the

publication of the Joint Report on Prison H ealthcare

2

(V) closer partnerships betw eenprisons and the N H S should be established.


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Combating discrimination and social exclusion

The broad approach set out in Savin g lives: Our Healthier Nati on highlights the action

w hich can be taken locally to prom ote social inclusion. For exam ple:

im provem ents in education w ill help to raise standards, expectations andopportunities for everyone

better w orking conditions and reduced unem ploym ent w ill im prove m ental health

tackling discrim ination is a prerequisite for m ore equal access to health and social care.

Health Action Zones

The Lam beth, Southw ark and Lew isham H ealth A ction Zone has a p articular focus onyoung people, disab ility and social exclusion. They aim to im prove em ploym ent

opportunities for young people w ith m ental health problem s. Through flexible support

schem es, it helps to m aintain young people in education or in w ork.

Tel: 0207 716 7000

Healthy ChartersThe H ealthy S andw ell C harter focuses on the need s of the w hole p op ulation, and

especially on the need s of those from black and m inority ethnic com m unities. Sandw ell

is ranked the ninth m ost deprived district in England.

The charter acknow ledges that no one ag ency can be responsible for m ental health

prom otion and prevention. Em pow erm ent, respect for individuals, fairness and equity,

and the encourag em ent of partnerships are key to m aking the strateg y a success.

There are three goals: healthy structures, a healthy environm ent, and em otional

resilience. Specific targets include reductions in alcohol consum ption, tranquilliser

dependence, and self-harm .

Tel: 0121 500 1500


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Performance assessment

Perform ance w ill be assessed at a national level by:

a long term im provem ent in the psychological health of the population as m easuredby the N ational Psychiatric M orbidity Survey

a reduction in suicide rates

health im provem ent program m es dem onstrating action w ithin and linkages betw eenorganisations to prom ote good m ental health:

- in schools, w orkplaces and neighbourhoods

- for individuals at risk

- for groups w ho are m ost vulnerable

and to com bat the discrim ination against and social exclusion of people w ith m ental

health problem s.

Recommended local roles and responsibilities

Lead organisation: health authority

Lead officer: chief executive

Key partners: local authority, N H S trust, independent sector providers, prim ary care

group, including G Ps, local em ployers, educational establishm ents, and

service users and carers.


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Standards tw o and three

Prim ary care and access to services

Aim

To deliver better prim ary m ental health care, and to ensure consistent advice and help

for people w ith m ental health needs, including prim ary care services for individuals w ith

severe m ental illness.

Standard two

Any service user who contacts their primary health care team with a common

mental health problem should:

have their mental health needs identified and assessed

be offered effective treatments, including referral to specialist services forfurther assessment, treatment and care if they require it.

Standard three

Any individual with a common mental health problem should:

be able to make contact round the clock with the local services necessary tomeet their needs and receive adequate care

be able to use NHS Direc t , as it develops, for first-level advice and referral on tospecialist helplines or to local services.

Rationale

M ental health problem s are com m on and prim ary care team s provide m ost of the help that

individuals need. H ow ever, there are a num ber of points of access to m ental health

services, and local health and social care com m unities need to ensure that advice and help

is consistent.NHS Di rect w ill provide a new source of first-level advice, and should in tim e

be able to provide a route to specialist helplines such as the Sam aritans, SAN Eline, N ational

Schizophrenia Fellow ship and M IN D helplines.

People w ith m ental health problem s, including individuals m aking contact for the first tim e,

approach health and social services in a variety of w ays. M any contact their G P, or another

m em ber of the prim ary health care team , including a nurse or com m unity pharm acist.

O ut of hours they m ay:

telephone a helpline

go to an A ccident and Em ergency (A& E) D epartm ent phone for an am bulance.


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And som e are referred from the crim inal justice system through, for exam ple, court

diversion schem es or directly from a police station or from a prison.

W hatever the point of contact, the principles ofThe new NHSshould apply. Individuals

in need should be able to access services w hich are responsive, tim ely and effective. All

services should be sensitive to cultural needs, including the needs of people from black

and m inority ethnic com m unities.


page

Prim ary m ental health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

D epression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Postnatal depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

A nxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

C o-m orbidity or dual diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

C onsistent access to services round the clock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

H elplines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

A ccident & Em ergency (A& E) departm ents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

A ccess to specialist services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Primary mental health care

O ne quarter of routine G P consultations are for people w ith a m ental health problem 51 (IV)

and around 90% of m ental health care is provided solely by prim ary care 52 (IV).

The m ost com m on m ental health problem s are depression, eating disorders, and anxiety

disorders. M any of these disorders can be treated effectively in prim ary care, but som e

w ill need fast referral to specialist services. Effective interventions include m edication and

psychological therapies, alone or com bined.

Reports indicate that only about 30% to 50% of depression in prim ary care is recognised

by G Ps 51,53,54 (IV, IV, IV). O ther reports suggest that G Psrecognition of severe depression

is m ore accurate 55 (IV). Treatm ent outcom es m ay be poor56,57(I,IV).

There is scope for G Ps and practice nurses to im prove their assessm ent and

com m unication skills 58(III), and the know ledge, skills and training to give non-drug

treatm ents 59 (III). Training can im prove the recognition of m ental health problem s in

prim ary care 60 (II) w hich can som etim es be m asked by physical sym ptom s.


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As NHS Di rectis developed it w ill provide a further access point, w hich w ill com plem ent

specialist m ental health helplines. W hen national coverage has been achieved it w ill be

able to provide first-level advice in the first language of the caller.

Depression

Each year, one w om an in every 15 and one m an in every 30 w ill be affected by

depression, and every G P w ill see betw een 60 and 100 people w ith depression 61,62 (IV, IV).

M ost of the 4,000 suicides com m itted each year in England are attributed to depression.

A recent review of the literature 56 (I) concluded that depression can be a m ajor risk factor

both for the developm ent of cardiovascular disease and for death after a m yocardial

infarction. D epression can also be associated w ith chronic physical illness such as arthritis.

D epression can affect other fam ily m em bers. The em otional and cognitive developm ent

of socially deprived children of a depressed m other is especially affected, w ith boys

m ore vulnerable than girls 63,64(II, I).

D epression in people from the A frican-Caribbean, Asian, refugees and asylum seekers

com m unities is frequently overlooked, although the rate has been found to be 60% higher

than in the w hite population, w ith the difference being tw ice as great for m en 32 (IV).

People from black and m inority ethnic com m unities are m uch less likely to be referred to

psychological therapies 65, 66 (IV, V).

Anti-depressant m edication is an effective treatm ent for depression 67-69(I, I, I). D ifferent

groups of anti-depressants (tricyclics, SSRIs etc) have all been show n to be m ore effective

than placebo in treating depression 70 (I). H ow ever, people w ith depression often feel they

do not receive adequate inform ation concerning their treatm ent71, 72 (V, IV).

Anti-depressant m edication is not alw ays prescribed in correct doses 70, 73, 74 (V, IV, I). Anti-

depressant m edication m ay also be over-prescribed 75, 76 (III, IV).

A num ber of second-line treatm ents such as lithium and electroconvulsive therapy (ECT)

provide effective treatm ent of chronic and severe depression 67,77-79 (I, I, V, I). A survey of

ECT use has recently been com pleted. The raised suicide rates in those w ith bipolar

disorder can be reduced by pharm acotherapy 80 (III).

D epression can also be treated by structured psychological therapies, such as cognitive

behaviour therapy; brief, focal psychoanalytic therapy; and interpersonal therapy.

H ow ever, non-directive counselling is less effective 67,81 (I, V).

Cognitive therapy m ay also reduce relapse rates 82,83 (I, II). The com bination of

antidepressants and psychotherapy are currently being review ed 84 (I).

A num ber of clinical guidelines and local protocols for the m anagem ent of depression

have been developed. These include the consensus statem ent by the Royal Colleges of

Psychiatrists and G eneral Practitioners published in 1992 85 (V). Clinical guidelines have

been com m issioned by the N H S Executive and w ill be available in late 2000.


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A person in a public place w ho appears to be suffering from m ental disorder and to be

in im m ediate need of care or control can be taken by the police to a place of safety.

Suitable places of safety should be identified through local agreem ents. As a general rule,

a hospital or other appropriate health service facility should be used rather than a police

station 99 (V). W hen there is no G P and no friend or relative to help, the police can seek

rapid access to health services for people w ith psychosis 100 (IV).

A survey com m issioned by the D epartm ent of H ealth and the H om e O ffice found that at

least 190 m ental health assessm ent schem es for m entally disordered offenders w ere

operating at m agistratescourts and police stations in 1996. These schem es aim to ensure

that people w ho com e into contact w ith the crim inal justice system have their m ental

health needs identified and addressed, as they w ould if in the com m unity, and that

assessm ents are readily available to help choose the best option for dealing w ith each case.

Interventions are m ade on the basis that early access to health and social care w ill

help prevent further deterioration in a persons condition, reduce the likelihood of

re-offending and avoid unsuitable use of custody. An assessm ent schem e in inner

London w as show n to provide better and m ore rapid assessm ent and transfer to N H S

care than prison-based assessm ent 101,102 (IV, IV).

Service models and examples of good practice

page

Strengthening prim ary m ental heath care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

The prim ary care therapy team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

O ne stop shop clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

A udit of a psychological therapy service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Ensuring consistent access to services round the clock . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

C A LM - the C am paign A gainst Living M iserably . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

A local m ental health helpline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

A n A & E m ental health liaison service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Liaison psychiatry - self-harm team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Self-harm intervention service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39


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To achieve Standards tw o and three each prim ary care group w ill need to w ork w ith the

support of specialist m ental health services to:

develop the resources w ithin each practice to assess m ental health needs

develop the resources to w ork w ith diverse groups in the population

develop the skills and com petencies to m anage com m on m ental health problem s

agree the arrangem ents for referral for assessm ent, advice or treatm ent and care

have the skills and the necessary organisational system s to provide the physical healthcare and other prim ary care support needed, as agreed in their care plan, for people

w ith severe m ental illness.

And local health and social care com m unities need to ensure round the clock access tom ental health care via G Ps, helplines, A& E departm ents and other agencies, such as

drop-in centres often run by voluntary organisations. Services should be accessible to the

crim inal justice system .

Strengthening primary mental health care

Prim ary care groups should w ork w ith prim ary care team s and specialist services to

agree and im plem ent assessm ent and m anagem ent protocols across the prim ary care

group, initially for people w ith depression, including the assessm ent of any risk of

suicide. Further protocols should be im plem ented for postnatal depression, eating

disorders, anxiety disorders, and for people w ith schizophrenia. The m ajority of m ental

health care w ill rem ain w ithin prim ary care as at present. The protocols w ill ensure thatm ore com plex cases receive ready access to skilled specialist assessm ent and treatm ent,

including psychological therapies, and continuing care.

A num ber of protocols have been developed locally. The N ational Institute for Clinical

Excellence w ill be asked to review these, and, w here appropriate, to kitem ark exam ples

of good practice, w hich w ill be prom ulgated for local use.

G uidelines on the m anagem ent of m ental disorders have been published by the W H O 103 279.

A U K version of the guide is being developed at the W H O Collaborating C entre, Institute of

Psychiatry, supported by the Royal College of Psychiatrists, and other professional,

educational and service user groups. It em phasises the inform ation needs of service users

and their fam ilies, sim ple social and psychological m anagem ent strategies, and m edication.

It is expected to be available at the end of the year. M ore details are available from the

W H O Collaborating Centre: telephone 0207 740 5293 or em ail: [email protected].


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The primary care therapy teamThe prim ary care psycholog ical therap y service in Salford provides assessm ent and

focused treatm ent for depression, anxiety and other adjustm ent reactions. M axim um

im pact is achieved throug h practice-based protocols, standardised assessm ent tools,

and staff resources targeted on the b asis of need. Services centre on tw o p rim ary care

groups in Salford and Trafford, m axim ising access to services for patients and

reducing unfair variation.

Tel: 0161 772 3479

One stop shop clinics

Seven G P practices have contributed to a pilot schem e in N ew ton-le-W illow s - the

Vista R oad C entre. The m ental health N H S trust and social services dep artm ent

provide a one stop shop, through a m ulti-ag ency team of:

ap proved social w orkers

com m unity m ental health nurses

clinical psychologists

psychiatrists

counsellors

occupational therapists

voluntary sector staff.

A variety of treatm ents are available, ranging from listening and advice, to m edication,

psycholog ical therap y and counselling. The team operates an open door referral policy.

There is a service user-led drop-in centre in partnership w ith the local M IN D

organisation. B ed use has reduced by over 40% since 1994.

Vista R oad C entre Tel: 01925 291094

D rop-in centre Tel: 01925 292190


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Sim ilarly, specialist services w orking w ith prim ary care team s should agree protocols for

the referral, assessm ent and treatm ent of people referred to them

Specialist m ental health services should establish liaison arrangem ents to support the

general practices in the prim ary care group, including continuing professional developm ent

to enable all relevant staff to identify, assess and m anage m ental health problem s.

Audit of a psychological therapy service

The C entral M anchester H ealthcare N H S Trust develop ed a system atic audit of their

psychological therapy service. This consisted of five full tim e psychiatry trainees, and

a large num ber of sessional staff offering cognitive behavioural treatm ents and

psychod ynam ic therapy. A standard assessm ent procedure now ensures that

referrals are prioritised and standardised m easurem ent enab les outcom es to be

system atically assessed.

Tel: 0161 273 3271

Prim ary care groups should enable patients and their fam ilies to understand their m ental

health problem and their treatm ent, and to m ake contact w ith local self-help groups.

A variety of inform ation is available from , for exam ple, the Royal College of Psychiatrists,

and voluntary organisations such as SAN E, M IN D and D epression Alliance. W ith the

developm ent of inform ation technology, inform ation w ill increasingly be available

through electronic m edia, and health and social care com m unities should explore m eans

of enabling service user access.

Support should be provided to help service users contact relevant self-help groups,

including C RU SE and RELATE, as w ell as groups w ith a specific focus on m ental health.

Ensuring consistent access to services round the clock

Each local health and social care com m unity should establish an integrated system to

enable people to access consistent advice and help at any tim e of the day or night, every

day of the year. This should be via the G P or prim ary care team ; helplines, both national

and local; and A& E departm ents through m ental health liaison services. As it is

developed,NHS Di rectw ill com plem ent existing national helplines such as the

Sam aritans and SAN Eline, and local helplines including CALM .

Each local health and social care com m unity should ensure that there is a gatew ay to

specialist m ental health services through effective out of hours services, w hich should

also be accessible to the crim inal justice system .


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In addition, progress w ill be m onitored through local m ilestones, for exam ple:

Milestones Data

Tim ely access to specialist assessm ent and treatm ent; W aiting list m onitoring usingand action im plem ented to tackle delays C PA database records from

single point of entry and

CPA review s

Inform ation available for people w ith m ental health N H S Executive regionalproblem s, including access to local self-help groups offices and social care regions

and support services such as housing and em ploym ent m onitoring of health

im provem ent program m es

and joint investm ent plans

Protocols on em ergency access agreed and im plem ented N H S Executive regional officesacross local health and social care com m unities w ithin and social care regions

health im provem ent program m es m onitoring of health

im provem ent program m es and

joint investm ent plans

A& E departm ents have liaison arrangem ents - specialist N H S Executive regional officesnurse or other evidence-based app roach and social care regions

m onitoring of health

im provem ent program m es and

joint investm ent plans

D uty doctor, Section 12 approved, and approved social Com m on inform ation corew orker alw ays available for m ental health em ergencies

NHS Directcontacts reported directly to corresponding M ental H ealth M inim umCPA inform ation system D ata Set (from CPA

inform ation system s)

Recommended local roles and responsibilities

Lead organisation: prim ary care group

Lead officer: chief executive

Key partners: G P and the prim ary care team , N H S trust, independent sector

providers, police and crim inal justice system , local authority, and

service users and carers.


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Standards four and five

Effective services for people w ith severe m ental illness

Aim

To ensure that each person w ith severe m ental illness receives the range of m ental

health services they need; that crises are anticipated or prevented w here possible; to

ensure prom pt and effective help if a crisis does occur; and tim ely access to an

appropriate and safe m ental health place or hospital bed, including a secure bed, as

close to hom e as possible.

Standard four

All mental health service users on CPA should:

receive care which optimises engagement, anticipates or prevents a crisis, andreduces risk

have a copy of a written care plan which:

- includes the action to be taken in a crisis by the service user, their carer,

and their care co-ordinator

- advises their GP how they should respond if the service user needsadditional help

- is regularly reviewed by their care co-ordinator

- be able to access services 24 hours a day, 365 days a year.

Standard five

Each service user who is assessed as requiring a period of care away from their

home should have:

timely access to an appropriate hospital bed or alternative bed or place, which is:

- in the least restrictive environment consistent with the need to protect them

and the public

- as close to home as possible

a copy of a written after care plan agreed on discharge which sets out the careand rehabilitation to be provided, identifies the care co-ordinator, and specifies

the action to be taken in a crisis.


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Rationale

People w ith severe m ental illness form a sm all proportion of those w ith m ental health

problem s but have very high rates of psychological and physical m orbidity. The W H O 104

(IV) has found that m ental illness, including drug and alcohol m isuse, accounted for alm ost

11% of the global burden of disease in 1990. This is expected to rise to 15% by 2020.

W orldw ide, m ental illness accounts for about 1.4% of all deaths and 28% of years lived

w ith disability. In 1990,104 (IV) five of the ten leading causes of disability w ere psychiatric

conditions: unipolar depression, alcohol m isuse, bipolar affective disorder, schizophrenia

and obsessive-com pulsive disorder. People w ith severe m ental illness are also socially

excluded, finding it difficult to sustain social and fam ily netw orks, access education

system s and obtain and sustain em ploym ent.

In a pooled analysis of 20 studies of 36,000 people, m ortality am ong people w ith

schizophrenia w as found to be 1.6 tim es that of the general population; the risk of

suicide nine tim es higher; and the risk of death from other violent incidents over tw ice

as high 105 (IV).

Crises should be anticipated or prevented, w ith rapid intervention if necessary. H ospital

adm ission, including secure m ental health care, or the provision of a supported place

m ay be required during the course of the illness.


page

A ssessm ent..................................................................................................................................43

C are planning and review ............................................................................................................45

Engaging service users...............................................................................................................46

R esponse to crisis .......................................................................................................................48

A ccess to hospital.......................................................................................................................48

H om e treatm ent and alternatives to hospital...............................................................................51

Individuals w ith short term severe m ental illness, such as severe depression, anxiety or

panic disorder, generally respond w ell to treatm ent w ith drugs and psychological

therapies, w hich can be provided in prim ary care (Standard tw o) w ith support from

specialised services.


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People w ith recurrent or severe and enduring m ental illness, for exam ple schizophrenia,

bipolar affective disorder or organic m ental disorder, severe anxiety disorders or severe

eating disorders, have com plex needs w hich m ay require the continuing care of

specialist m ental health services w orking effectively w ith other agencies. M ost people

m anage w ell w ith this care and benefit from living in the com m unity, posing no risk to

them selves or others 106 (IV).

M any people w ith severe m ental illness continue to live w ith their fam ilies, and are

treated in the com m unity w ith the support of prim ary care staff. A range of services is

needed in addition to prim ary care - specialist m ental health services, em ploym ent,

education and training, housing and social support. N eeds w ill fluctuate over tim e, and

services m ust be able to anticipate and respond to crisis.

Som e people w ith severe and enduring m ental illness find it difficult to engage w ith and

m aintain contact w ith services, posing a risk to them selves or to others.

Assessment

Assessm ent should cover psychiatric, psychological and social functioning, risk to the

individual and others, including previous violence and crim inal record, any needs arising

from co-m orbidity, and personal circum stances including fam ily or other carers, housing,

financial and occupational status.

The prevalence of co-m orbidity w as indicated in a recent study carried out at the M audsley

H ospital107 (IV). D rug and alcohol problem s w ere assessed in individuals w ith severe m ental

illness such as schizophrenia and depression. O ver the course of a year, 36% of patients had

som e form of substance m isuse problem , 32% for alcohol and 16% for drug problem s.

Assessm ent should also cover physical health needs. The N ational Psychiatric M orbidity

Survey show ed high levels of physical ill health and higher rates of death am ongst those

w ith m ental health problem s com pared to the rest of the population 105, 108 (IV, IV).

Evi

National Service Framework for Mental Health

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Transcript of National Service Framework for Mental Health