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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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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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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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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.
Interventions and evidence-base
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.
Interventions and evidence-base
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
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