University of Ulster at Magee

The Practice of Nursing Module Code NUR107C2

Module Level B

Credit Points 20

Semester 2 Nursing

2.00pm-4.00pm Thursday 21^st March 2002.

Aim: To provide you with an understanding of theoretical and clinical aspects of your nursing to enable you to benefit from your placements in semester 3.

Module Learning Outcome No.4 : To demonstrate an awareness of the health needs of a range of clients in hospital and community settings.

These are my suggestions to you for designing and setting your own learning outcomes as part of this module. I am not advising you to accept my suggestions. If you think that my suggestions sound reasonable, and if you think that any of my suggestion may enhance your achievement of your module learning outcomes, then you are quite free to make your own choices as to how best you can support your learning. Why not talk it over with your peers?

My suggestions are that you may think about, reflect on, and read literature relating to:-

1. Principles of inclusion for those suffering severe and enduring mental illness.
2. Consider your values and attitudes towards people with mental illness.
3. Familiarise your self with the nature and possible causes of mental illness.
4. Seek opportunity to be with and speak with people suffering severe and enduring mental illness.

You may find online links relating to diversity and inclusion issues useful. These links are hosted on StudyTime 2002. URI http://www.studytime.homestead.com/index.html

You may find scales for measuring attitude useful. Information about such scales may be found at Ericae Test Locator URI http://www.studytime.homestead.com/Psychosocial_Interventions.html

You may find the online links to information about severe and enduring mental illness useful. These links are hosted at URI http://www.studytime.homestead.com/Psychosocial_Interventions.html You may find the books on mental health that you have access to useful. You may find it useful to introduce yourself to a range of mental health professionals who work with people who suffer severe and enduring mental illness. Talk to these people and leave no question unasked. You may find it useful to talk with your fellow students. Begin to learn how you may contribute to being interdependent with your peers regarding peer support. The skills that you begin to develop now will serve you well in your future. Can you discover for yourself some of the possible contributing factors, that may contribute to a person developing a mental illness? If you think that you can do this, then list these possible contributing factors. Think about your list and ask yourself one question, “What can I do to help reduce the effect of these possible contributing factors within my local population?” If you can do this exercise you will be demonstrating an awareness of the health needs of a range of clients in hospital and community settings. Have you been able to make any shape at this exercise? You have? Then well done! You have not been able have a go at the exercise? Then don’t worry about that! Try again later when you have time. Try to eventually do this exercise with your peers at coffee breaks. Discuss the exercise with your peers during the next few weeks. Bring up the topic yourself at coffee time. Or, contribute to the coffee-break discussion if one of your peers brings up the subject. Your mission should you wish to accept it is to demonstrate an awareness of the health needs of a range of clients in hospital and community settings.

You may find it useful to discover and create opportunities for yourself to begin learning how Action Research works, and you may find it useful to learn how Action Research can work for you. There is an online link to Action Research resources hosted at URI http://www.studytime.homestead.con/Psychosocial_Interventions.html You will learn much at the bedside. In preparation for this learning experience start now to prepare yourself so that you share the fruits of your learning experiences with your peers. Learn to share your experiences with your peers. Identify good practice when everything goes well. Share your thoughts on how to do things when the best-laid plans are not achievable.

“Introduction to Mental Health Nursing” Gerarde Dawe Staff Nurse, Windsor House, [028 9026 3819] URI http://www.gerardedawe.homestead.com/index.html 21^st March 2002.

E-mail webmasters@arainnmhor.com [Leave no question unasked!]

Books in your Library that you may find useful.

Maslin-Prothero, S (2001) Study skills for nurses. London. Baillier Tindall.

Magee RT71.B24 (5 copies)

Orem, D.E. (2001) Nursing Concepts of Practice 6^th ed London: St Louis. Mosby

Magee RT62.073 (3 copies)

Weller, F.B. ed (2000) Nurses Dictionary 23^rd edition, London, Balliere Tindal. Magee RT21.B24 (2 copies)

Johns, C (2000) Becoming a reflective practitioner. Oxford. Blackwell Science. Magee RT84.5.J63 (3 copies)

Roper, N (2000) The Roper Logan and Tierney Model of Nursing. Edinburgh. Churchill Livingston. Magee RT73.T28 (2 copies)

Andrews, M.M. (1999) Transcultural concepts in Nursing Care. 3^rd edition. Philadelphia. Lippincott. Magee RT86.54.A53 (3 copies).

Newman, J. ( ed ) Transcultural Nursing; Assessment and interventions. London. : St Louis. Mosby. Magee RT86.54.T72. (3 copies)

Barker, P.J. (1999) Philosophy and Practice of Psychiatric Nursing. Edinburgh. Churchill Livingstone. Magee RC440.B36 (2 copies).

(1997) The mental Health Nurse, Veins of practice and education. Oxford. Blackwell Science. Magee RC440.M44

References to Journals

Evidence based literature to support your learning that you may find useful :

Patel, A. & Knapp, M. (1998). Costs of mental illness in England. PSSRU Mental Health Research Review 5, 4- 10

NHS Centre for Reviews and Dissemination. Mental health promotion in high risk groups. Effective Health Care Bulletin 3 (1997).

Kagan, N., Kagan, H. & Watson, M. (1992) Stress reduction in the workplace: the effectiveness of psychoeducational programmes. Journal of Counselling Psychology 42, 71- 78.

Durlak, J. A. & Wells, A. M. (1997). Primary prevention mental health programs for children and adolescents: A meta- analytic review. American Journal of Community Psychology 25, 115- 152

Heaney, C., Price, R. & Refferty, J. (1995). Increasing coping resources at work: a field experiment to increase social support, improve work team functioning and enhance employee mental health. Journal of Organisational Behaviour 16, 211- 215

Proudfoot, J. & Carson, J. (1997) Effect of cognitive behavioural training on job- finding among long term unemployed people. Lancet 350, 96- 100

Vinokur, D. & Ryn, V. (1991) Long term follow-up and benefit-cost analysis of the jobs program: a preventive intervention for the unemployed. Journal of Applied Psychology 76, 213- 219

Bloom, B. L., Hodges, W. F., Kern, M. B. & McFaddin, S. C. (1985) A preventive intervention programme for the newly separated: final evaluations. American Journal of Orthopsychiatry 55, 9- 26 .

Caplan, R. D., Proudfoot, J., Guest, D. & Carson, J. (1997) Effect of cognitive- behavioural training on job- finding among long term unemployed people. Lancet 350, 96.

Vinokur, A. D., Price, R. H. & Schul, Y. (1995) Impact of the JOBS intervention on unemployed workers varying in risk for depression. American Journal of Community Psychology 23, 39- 74.

Perry, B. D. (1993) Neurodevelopment and the neurophysiology of trauma: Conceptual considerations for clinical work with maltreated children. The APSAC Advisor (American Professional Society on the Abuse of Children) 6, 1- 18.

Finkelhor, D. (1995) The victimization of children: A developmental perspective. American Journal of Orthopsychiatry 65, 177- 193.

Mullen, P. E., Martin, J. L., Anderson, J. C., Romans, S. E. & Herbison, G. P. (1993) Childhood sexual abuse and mental health in adult life. British Journal of Psychiatry 163, 721- 732 .

Hall, D. & Lynch, M. A. (1998) Violence begins at home: Domestic strife has lifelong effects on children. British Medical Journal 316, 15.

Nazroo, J. (1998) Rethinking the relationship between ethnicity and mental health. Journal of Social Psychiatry and Psychiatric Epidemiology 33, 145- 148.

NHS Centre for Reviews and Dissemination. Ethnicity and health: Reviews of literature and guidance for purchasers in the areas of cardiovascular disease, mental health and haemoglobinopathies. (NHS Centre for Reviews and Dissemination, York, 1996).

Commander, M. J., Sashidharan, S. P., Odel, S. M. & Surtees, P. G. (1997) Access to mental health care in an inner city health district: I. Pathways into and within specialist psychiatric services. British Journal of Psychiatry 170, 312- 316 (1997).

Commander, M. J., Sashidharan, S. P., Odell, S. M. & Surtees, P. G. (1997) Access to mental health care in an inner city health district: II. Association with demographic factors. British Journal of Psychiatry 170, 317- 320 .

Koffman, J., Fulop, N., Pashley, D. & Coleman, K. (1997) Ethnicity and use of acute psychiatric beds: one- day survey in North and South Thames regions. British Journal of Psychiatry 171, 238- 241

Craig, T. K. & Hodson, S. (1998) Homeless youth in London: I. Childhood antecedents and psychiatric disorder. Psychological Medicine 28, 1379- 1388.

NHS Centre for Reviews and Dissemination. Brief interventions and alcohol use. Effective Health Care 3 (1997).

Hawton, K. (1997) Assessment of suicide risk. British Journal of Psychiatry 150, 145- 153 (1987).

Wolff, G., Pathare, S., Craig, T. & Leff, J. (1996) Public education for community care: a new approach. British Journal of Psychiatry 168, 441- 447

Crisp, A. (1998) Changing Minds: every family in the land. The coming College campaign to reduce the stigmatisation of those with mental disorders. Bulletin of the Royal College of Psychiatrists 22, 328- 329 (1998).

Johnson, Z., Howell, F. & Molloy, B. (1993) Community mothers programme: randomised controlled trial of non-professional intervention in parenting. British Medical Journal 306, 1449- 1452 (1993).

Goldberg, D. & Bridges, K. (1987) Screening for psychiatric illness in general practice: the general practitioner versus the screening questionnaire. Journal of the Royal College of General Practitioners 37, 15- 18

Doherty, J. D. (1997) Barriers to the diagnosis of depression in primary care. Journal of Clinical Psychiatry 58, 5- 10

Vazquez-Barquero, J. et al. (1997) Mental health in primary care: an epidemiological study of morbidity and use of health resources. British Journal of Psychiatry 170, 529- 535.

Kessler, D., Lloyd, K., Lewis, G. & Gray, D. (1999) Cross- sectional study of symptom attribution and recognition of depression and anxiety in primary care. British Medical Journal 318, 436- 440

Musselman, D. L., Evans, D. L. & Nemeroff, C. B. (1998) The relationship of depression to cardiovascular disease. Archives of General Psychiatry 55, 580- 592.

Gask, L., Usherwood, T., Thompson, H. & Williams, B. (1998) Evaluation of a training package in the assessment and management of depression in primary care. Medical Education 32, 190- 198.

Sibald, B., Addington Hall, J., D., B. & Freeling, P. (1993) Counsellors in English and Welsh general practices: their nature and distribution. British Medical Journal 306, 29- 33 (1993).

White, M., Nichols, C. & et al. (1995) Diagnostic overshadowing and mental retardation: a metaanalysis. American Journal on Mental Retardation. 100, 293- 298

Wing, J. & Bebbington, P. (1982) Epidemiology of depressive disorders in the community. Journal of Affective Disorders 4, 331- 345.

Murray, L. T(1992) The impact of postnatal depression on infant development. Journal of Child Psychology and Psychiatry 33, 543- 561.

Field, T. (1995) Infants of depressed mothers. Infant Behavior and Development 18, 1- 13

McKenzie, K. et al. (1995) Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom. British Medical Journal 311, 1325- 1328

NHS Centre for Reviews and Dissemination. The treatment of depression in primary care. Effective Health Care Bulletin 5 (1993).

Paykel, E. S. & Priest, R. G. (1992) Recognition and management of depression in general practice: a consensus statement. British Medical Journal 305, 1198- 1202 (1992).

Ali, I. (1998) Long term treatment with antidepressants in primary care: are sub- therapeutic doses still being used? Psychiat ric Bulletin 22, 15- 19.

Catalan, J., Smith, H. & Watson, J. (1998) General practice patients on long term psychotropic drugs: a controlled investigation. British Journal of Psychiatry 152, 399- 405

Wallen, J., Pincus, H., Goldman, H. & Marcus, S. (1987) Psychiatric consultations in short term general hospitals. Archives of General Psychiatry 44, 162- 168.

Zornberg, G. L. & Pope, H. G. (1993) Treatment of depression in bipolar disorder: New directions for research. Journal of Clinical Psychopharmacology 13, 397- 408

Muller-Oeleringhausen, B., Muser-Causeman, B. & Volk, J. (1992) Suicides and parasuicides in high risk patient groups on and off lithium long term medication. Journal of Affective Disorders 25, 261- 269.

NHS Centre for Reviews and Dissemination, E. H. C. The treatment of depression in primary care. Effective Health Care Bulletin 1 (1993).

Thase, M. E. et al. (1997) Treatment of major depression with psychotherapy or psychotherapypharmacotherapy combinations. Archives of General Psychiatry 54, 1009- 1015

Paykel, E. & Priest, R. (1992) Recognition and management of depression in General Practice: consensus statement. British Medical Journal 305, 1198- 1202 (1992).

Elliott, S. A. (1989) Psychological strategies in the prevention and treatment of postnatal depression. Bailliere’s Clinical Obstetrics and Gynaecology 3, 879- 903 (1989).

Mitchell, J., Raymond, N. & Specker, S. A. (1993) A review of the controlled trials of pharmacotherapy and psychotherapy in the treatment of bulimia nervosa. International Journal of Eating Disorders 14, 229- 247.

Goldstein, D. & Wilson, M. (1995) Long term fluoxitene treatment of bulimia nervosa. British Journal of Psychiatry 166, 660- 666 (1995).

Andrewes, D. G. (1996) Computerised psychoeducation for patients with eating disorders. Australian and New Zealand Journal of Psychiatry 30, 492- 7.

Oakley Browne, M. A. (1996) Antidepressant drugs relieve symptoms of obsessive-compulsive disorder. Evidence-Based Medicine 1, 82.

Johnson, S. & Thornicroft, G. (1995) Emergency psychiatric services in England and Wales. British Medical Journal 311, 287- 288 (1995).

NHS Centre for Reviews and Dissemination. Deliberate self-harm. Effective Health Care Bulletin 4, 1- 12 (1998).

Joseph, P. L. A. & Potter, M. (1993) Diversion from custody. I: Psychiatric assessment at the magistrates court. British Journal of Psychiatry 162, 325- 330

Joseph, P. L. A. & Potter, M. (1993) Diversion from custody. II: Effect on hospital and prison resources. British Journal of Psychiatry 162, 330- 334

Harris, E. C. & Barraclough, B. (1998) Excess mortality of mental disorder. British Journal of Psychiatry 173, 11- 53

Trieman, N., Leff, J. & Glover, G. (1999) Outcome of long stay psychiatric patients resettled in the community: prospective cohort study. British Medical Journal 319, 13- 16.

Menezes, P. R. et al. (1996) Drug and alcohol problems among individuals with severe mental illness in south London. British Journal of Psychiatry 168, 612- 619.

Allebeck, P. (1989) Schizophrenia: a life-shortening disease. Schizophrenia Bulletin 15, 81- 89

Cox, A. (1989) User centred mental health assessments. The Mental Health Review 3, 2

Horvarth, A. O. & Symonds, B. D. (1991) Relation between working alliance and outcome in psychotherapy: a meta analysis. Journal of Consulting and Clinical Psychology 38, 139- 149

Safran, J. D. & Muran, J. C. (1996) The resolution of ruptures in the therapeutic alliance. Journal of Consulting and Clinical Psychology 64, 447- 458.

Schene, A. H., Tessler, R. C. & Gamache, G. M. (1994) Instruments measuring family of caregiver burden in severe mental illness. Social Psychiatry and Psychiatric Epidemiology 29, 229- 240

Whelan. (1993) The role of social support in mediating the psychological consequences of economic stress. Sociology of Health and Illness 5, 86- 101 (1993).

Turner, T. & Sorkin, A. (1997) Sharing psychiatric care with primary care physicians. Canadian Journal of Psychiatry 42, 950- 954 .

Birchwood, M., McGorry, P. & Jackson, H. (1997) Early intervention in schizophrenia. British Journal of Psychiatry 170, 2- 5 (1997).

Wyatt, R. J., Green, M. F. & Tuma, A. H. (1997) Long term morbidity associated with delayed treatment of first admission schizophrenic patients: A re-analysis of the Camarillo State Hospital data. Psychological Medicine 27, 261- 268 (1997).

Weaver, T. et al. (1997) The Bentham Unit: a pilot remand and assessment service for male mentally disordered remand prisoners. British Journal of Psychiatry 170, 462- 466 (1997).

Robinson, D. et al. (1999) Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry 56, 241- 247 .

Jamieson, K. R. & Akiskal, H. S. (1983) Medication compliance inpatients with bipolar disorder. Psychiatric Clinics of North America 6, 175- 192 (1983).

Bollini, P., Pampalona, S., Orza, M. J., Adams, M. E. & Chalmers, T. C. (1994) Antipsychotic drugs: is more worse? A meta-analysis of published randomised controlled trials. Psychological Medicine 24, 307- 316 .

Dixon, L. B., Lehman, A. F. & Levine, J. (1995) Conventional antipsychotic medications for schizophrenia. Schizophrenia Bulletin 21, 567- 577.

Kemp, R., Kirov, G., Everitt, B. & David, A. (1998) A randomised controlled trial of compliance therapy: 18 month follow-up. British Journal of Psychiatry 172, 413- 419 (1998).

Kuipers, E. et al. (1997) London- East Anglia randomised controlled trial of cognitive behaviour therapy for psychosis: Effects of treatment phase. British Journal of Psychiatry 171, 319- 327 .

Drury, V., Birchwood, M., Cochrane, R. & Macmillan, F. (1996) Cognitive therapy and recovery from acute psychosis: a controlled trial. 1. Impact on psychotic symptoms and 2. Impact on recovery time. British Journal of Psychiatry 169, 593- 607.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D. & Heard, H. (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48, 1060- 1064 (1991).

Harvey, C. A. (1996) The Camden schizophrenia surveys. I. The psychiatric, behavioural and social characteristics of the severely mentally ill in an inner London health district. British Journal of Psychiatry 168, 410- 417.

Bell, M. D. & Lysaker, P. H. (1997) Clinical benefits of paid work activity in schizophrenia: one year follow up. Schizophrenia Bulletin 23, 317- 328 .

Slade, M., McCrone, P. & Thornicroft, G. (1995) Uptake of welfare benefits by psychiatric patients. Psychiatric Bulletin 19, 411- 413 .

Horder, J. (1988) Working with General Practitioners. British Journal of Psychiatry 153, 513- 521.

McNaught, A. S. et al. (1997) The Hampstead Schizophrenia Survey 1991 II: Incidence and migration in inner London. British Journal of Psychiatry 170, 307- 311 .

Meuser, K., Bond, G., Drake, R. & Resnick, G. (1998) Models of Community Care for Severe Mental Illness: A review of research on case management. Schizophrenia Bulletin 24, 37- 73 .

Lehman, A. F., Dixon, L. B., Kernan, E., DeForge, B. R. & Pstrado, L. T. (1997) A randomized trial of assertive community treatment for homeless persons with severe mental illness. Archives of General Psychiatry 54, 1038- 1043 .

Rapaport, L. (1967) Crisis oriented short term case- work. Social Sciences Review 41, 211- 217.

MILMIS Project Group. Monitoring Inner London Mental Illness Services. Psychiatric Bulletin 19, 276- 280 (1995).

Ford, R., Durcan, G. & Warner, L. (1998) One day survey by the Mental Health Act Commission of acute adult psychiatric inpatient wards in England and Wales. British Medical Journal 317, 1279- 1283 .

Burns, T. & Priebe, S. (1999) Mental health care failure in England: Myth and reality. British Journal of Psychiatry 174, 191- 192.

Lelliott, P. & Audini, B. (1996) The mental health residential care study. The costs of living. Health Service Journal 1, 16- 27 .

Kavanagh, S., Opit, L., Knapp, M. & Beecham, J. (1995) Schizophrenia: shifting the balance of care. Social Psychiatry and Psychiatric Epidemiology 30, 206- 212.

Lewis, G., David, A. & Andreasson, S. (1992) Schizophrenia and city life. Lancet 340, 137- 140.

Gregoire, A. & Thornicroft, G. (1998) Rural mental health. Psychiatric Bulletin 22, 273- 277 .

Davies, S., Thornicroft, G. & Lesse, M. (1996) Ethnic differences in risk of compulsory admission among representative cases of psychosis in London. British Medical Journal 312, 533- 537.

Muijen, M., Marks, I. M., Connolly, J. & Audini, B. (1992) Home-based care and standard hospital care for patients with severe mental illness: a randomised controlled study. British Medical Journal 304, 749- 754.

Shepherd, G., Beadsmore, A., Moore, C. & Muijen, M. (1997) Relation between bed use, social deprivation and overall bed availability in acute adult psychiatric units and alternative residential options: a cross-sectional survey, one day census and staff interviews. British Journal of Psychiatry 314, 262- 266 .

Fulop, N. J. et al. (1996) Use of acute psychiatric beds: A point prevalence survey on North and South Thames Regions. Journal of Public Health Medicine 18, 207- 216.

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Holloway, F. (1997) 24 hour nursed care for people with severe and enduring mental illness. Psychiatric Bulletin 21, 195- 196.

Parkman, S., Davies, S. & Leese, M. (1997) Ethnic differences in satisfaction with mental health services among representative people with psychosis in South London: PRiSM study 4. British Journal of Psychiatry 171, 260- 264 .

Macpherson, R. & Jerrom., B. (1999) Review of twenty-four-hour nursed care. Advances in Psychiatric Treatment 5, 146- 153 .

Kuipers, E. (1993) Family burden in schizophrenia: implications for services. Social Psychiatry and Psychiatric Epidemiology 150, 285- 292.

McGilloway, S., Donnelly, M. & Szmuckler, G. (1996) Caring for relatives with serious mental illness: the development of the Experience of Caregiving Inventory. Social Psychiatry and Psychiatric Epidemiology 31, 137- 148 .

Hambrecht, M. & Hafner, H. (1997) Sensitivity and specificity of relatives’ reports on the early course of schizophrenia. Psychopathology 30, 12- 19.

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Severe mental illness: Published by the Department of Health
© Crown Copyright 1999

• there must be a mental disorder as designated by a mental health professional (psychiatrist, mental health nurse, clinical psychologist, occupational therapist or mental health social worker) and either
  - there must have been a score of 4 (very severe problem) on at least one, or a score of 3 (moderately severe problem) on at least two, of the HoNOS items 1- 10 (excluding item 5 ‘physical illness or disability problems’) during the previous six months or
  - there must have been a significant level of service usage over the past five years as shown by:
• a total of six months in a psychiatric ward or day hospital, or
• three admissions to hospital or day hospital, or
• six months of psychiatric community care involving more than one worker or the perceived need for such care if unavailable or refused.

Key terms Published by the Department of Health
© Crown Copyright 1999

Affective or mood disorders

These reflect a disturbance in mood, resulting generally in either depression or elation, which is often chronic or recurrent in nature. There are usually also associated alterations in activity, sleep and appetite. Affective disorders vary greatly in severity and include bipolar mood disorder or manic depressive illness. It may also be often associated with symptoms of anxiety.

Annual Accountability Agreements

An annual agreement, between a health authority and its local primary care groups, which will contain key targets, objectives and standards for the provision or commissioning of services. These agreements will be consistent with national priorities and local health i m p rovement programmes. Progress should be assessed in the context of the NHS Performance Assessment Framework, using locally available information where, for example, high-level performance indicators are not suitable for use at primary care group level.

Annual Performance Agreement

An annual agreement will be made between each health authority and its regional office to cover all the key objectives of the health authority for the year. The agreement should incorporate plans set out in the service and financial frameworks, along with specific objectives concerned with the development of the health authority and primary care groups. These agreements should include an assessment of the expected influence on performance against local plans across each of the six areas of the Performance Assessment Framework.

Antidepressants

Drugs used to treat depression, and other disorders. Two main subgroups: 1 Tricyclic antidepressants: these have been used for many years, and are inexpensive but can be more dangerous in overdose. 2 Selective serotonin reuptake inhibitors (SSRIs): newer and more expensive but generally have fewer side-effects and are safer in overdose.

Antipsychotic drugs

Drugs used to treat psychosis, including schizophrenia and mania. They also have tranquillising effects, reducing agitation.

Anxiety

A mood state in which feelings of fear predominate and where the fear is out of proportion to any threat. Frequently associated with physical symptoms which include fast pulse rate, palpitations, sweating, shaking, ‘pins and needles’. Anxiety disorders can include simple phobias, fear of a specific object or situation, generalised anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder, or post traumatic stress disorder.

Approved Social Worker (ASWs)

Approved social workers are social workers specifically approved and appointed under Section 114 of the Mental Health Act 1983 by a local social services authority ‘for the purpose of discharging the functions conferred upon them by this Act’. Among these, one of the most important is to carry out assessments under the Act and to function as applicant in cases where compulsory admission is deemed necessary. Before being appointed, social workers must undertake post qualifying training approved by the Central Council for Education and Training in Social Work (CCETSW).

Assertive outreach (assertive community treatment, intensive case management)

An active form of treatment delivery: the service can be taken to the service users rather than expecting them to attend for treatment. Care and support may be offered in the service user’s home or some other community setting, at times suited to the service user rather than focused on service providers’ convenience. Workers would be likely to be involved in direct delivery of practical support, care co- ordination and advocacy as well as more traditional therapeutic input. Closer, more trusting relationships may be developed with the aim of maintaining service users in contact with the service and complying with effective treatments.

Atypical (novel) antipsychotic drugs

Newer and more expensive antipsychotic drugs which have a different range of side-effects from the standard antipsychotics, and particularly do not produce the neuromuscular (Parkinsonian) side-effects.

Care co-ordinator (or key worker)

A worker (team member) with responsibility for co-ordinating CPA reviews for mental health service users with complex needs and for communicating with others involved in the service user’s care. Care co-ordinators usually have the most contact with the service user.

Care management

A system of organising care to vulnerable adults by local authority social services departments. It involves assessing needs, care planning, the organisation of care packages within available resources, monitoring and review and close involvement with service users and carers. For mental health service users it should be integrated with the Care Programme Approach.

Care Programme Approach (CPA)

The CPA provides a framework for care co-ordination of service users under specialist mental health services. The main elements are a care co-ordinator, a written care plan, and at higher levels, regular reviews by the multi-disciplinary health team and integration with the social services care management system. Updated and simplified guidelines, with two levels of CPA, standard and enhanced, will be published by the Department of Health in association with the National Service Framework.

Carers

Relatives or friends who voluntarily look after individuals who are sick, disabled, vulnerable or frail.

Clinical governance

A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will improve.

Cognitive behaviour therapy

A form of psychological treatment based on learning theory principles used mostly in depression but increasingly shown to be a useful component of treatment in schizophrenia.

Commission for Health Improvement

A national body responsible for overseeing and supporting the implementation of clinical governance and the quality of clinical services.

Community mental health nurse

Mental health nurse with specific expertise in working with patients in the community, in functioning in a multi-disciplinary team and in working across the inpatient/community interface.

Community mental health team

A multi-disciplinary team offering specialist assessment, treatment and care to people in their own homes and the community. The team should involve nursing, psychiatric, social work, clinical psychology and occupational therapy membership, with ready access to other therapies and expertise, for example specialist psychotherapy, art therapy, and pharmacy. Adequate administrative and IT support is vital.

Co-morbidity

The simultaneous presence of two or more disorders, often refers to combinations of severe mental illness, substance misuse, learning difficulties and personality disorder. The term dual diagnosis or complex needs may also be used.

Compliance therapy

The frequent finding of poor compliance with prescribed treatments in individuals with severe mental ill health has led to the development of a cognitive-educational treatment package. The aim is to improve a patient’s understanding of their illness and to identify and tackle reasons for lack of adherence to suggested treatments.

Depression

A negative mood state which involves a feeling of sadness. A severe depression can reach the criteria for an affective disorder (q. v.) and require treatment. Depression can frequently coexist with and complicate other physical illnesses. The most frequent disorder found in the National Morbidity Survey was a mixed anxiety-depression.

Dialectical behaviour therapy

A specific type of cognitive behaviour therapy, which includes skills training and exposure to emotional cues, found to be particularly effective in treating those with self-harm behaviour. It is delivered according to a manual to ensure adherence to effective interventions.

Disengagement

Loss of contact with services by the service user.

Dual diagnosis

Dual diagnosis and complex needs are used to describe people with a combination of drug and alcohol misuse and mental illness, a combination of medical needs, including diagnosis, treatment and rehabilitation; and social needs, including housing, social care and independent living. Some of those in this group may also have a history of offending and involvement in the criminal justice system. They are all amongst the most socially excluded.

Eating disorders

These disorders include anorexia nervosa and bulimia nervosa. They are disorders that tend to have an early onset in childhood or adolescence and are less frequently seen in males. Anorexia nervosa involves a distortion of body image in which the person believes they are much fatter than they actually are. They very carefully restrict their intake of calories, exercise to excess, are markedly underweight and may be very secretive. Bulimia nervosa involves episodic binges of over- eating, and self- induced vomiting and laxative abuse in some cases. They may maintain a more normal body weight but can have severe physical complications.

First-level advice from NHS Direct

First-level advice is to provide comprehensive information about services and treatments that are available locally. If necessary, NHS Direct will aim to ensure callers are directed to the right service, providing referral on to specialist helplines or mental health services.

Gender dysphoria (gender identity disorder)

A conviction that one is ‘trapped’ in a body of the wrong gender. Tends to have been present from childhood. The individual wishes to live in the opposite gender role from their biological one and often pursues the goal of achieving surgical gender re-assignment.

Health Action Zones (HAZs)

HAZs are designated by the Government and help bring together local health services and local authorities, community groups, the voluntary sector and local businesses to establish and foster strategies for improving the health of local people. Twenty-six areas with a history of some deprivation and poor health amongst local residents have now been assigned as Health Action Zones.

Health and social care community

Local health authority, local authority, NHS trusts, primary care groups and trusts, and the independent sector.

Health improvement programmes

Health improvement programmes are the local strategies for improving health and healthcare. Led by the health authority, a health improvement programme will bring together the local NHS with local authorities and others, including the voluntary sector, to set the strategic framework for improving health, tackling inequalities, and developing faster, more convenient services of a consistently high standard to meet the needs of local people.

Home treatment

Treatment may be offered in a patient’s home rather than in clinical settings, either by a separate team or by a community mental health team. Frequent home visits by various members of the multi- disciplinary team can lead to an avoidance of some hospital admissions and provide support to informal carers. Such services should be available at weekends and in evenings as well as during office hours.

Independent sector

Voluntary, charitable and private care providers.

Joint investment plans

Joint investment plans established through Executive Letter (97) 62, are mechanisms for local and health authorities, with key partner agencies, to set out their investment intent together. They will promote transparency between statutory services and ensure more coherent investment across sectors. Joint investment plans for adult mental health are due to be produced for April 2000.

Long Term Service Agreements

Long term service agreements are between health authorities, and increasingly, primary care groups and NHS trusts on the service that should be provided for a local population. All commissioning in the new NHS now take places through long term service agreements, which replaced annual contracts in April 1999. They run for a minimum of three years and are expected to deliver improvements in health and health care. They need to reflect the development of long term relationships between primary care groups and NHS trusts, based on a shared view of the outcomes of care that are needed, and covering ‘pathways of care’ that cross traditional organisational boundaries. Further details can be found in Commissioning in the new NHS (HSC 1998/ 198).

Mental disorder

Mental disorder is defined in the 1983 Mental Health Act as ‘mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind’. The Act does not define mental illness, which is a matter for clinical judgement.

Mental health

An individual’s ability to manage and cope with the stresses and challenges of life.

Mental Health Act (1983)

The Act concerns ‘the reception, care and treatment of mentally disordered patients, the management of their property and other related matters’.

Mental Health Grant

Formerly the Mental Illness Specific Grant. Central Government funding by the Department of Health to supplement spending by local authorities on social care for mentally ill people living in the community. Its objective is to enable local authority social services departments improve the social care of people with a mental illness who need psychiatric care.

Mental Health Minimum Data Set (MHMDS)

A new Mental Health Minimum Data Set has been developed to supplement the information on mental health services currently available from the Hospital Episode Statistics (HES), the Common Information Core (CIC) and the Korner aggregated returns. The data set has been developed initially for use within the specialist mental health services, but is flexible enough for use in other settings such as primary care. The data set is person-centred and records the package of care received by an individual.

Mental health organisations

Health and social care commissioners and providers of specialist mental health care, including independent sector providers.

Mental health services

Specialist provision of mental health and social care provision integrated across organisational boundaries.

Mental illness

Range of diagnosable mental disorders that excludes learning disability and personality disorder.

National Institute of Clinical Excellence (NICE)

Established in April 1999, the Institute is responsible for promoting clinical excellence and cost- effectiveness, producing and issuing clinical guidelines.

NHS Mental Health Modernisation Fund

New investment to underpin the mental health service reforms as set out in Modernising Mental Health Services.

Performance Assessment Frameworks

Performance Assessment Frameworks are designed to give a general picture of NHS or social care performance. Six areas are covered for the NHS: health improvement; fair access to services; effective delivery of healthcare; efficiency; service users and carer experience; and the health outcomes of NHS care. Five areas are covered for social care: national priorities and strategic objectives; cost and efficiency; effectiveness of service delivery and outcomes; quality of services for service users and carers; and fair access.

Personality disorder

This covers a variety of clinically significant conditions and behaviour patterns, which tend to be persistent and to arise in childhood or adolescence. They are not secondary to other mental disorders but may coexist with them. The disorder will generally involve problematic relationships and may be associated with personal distress. A very small subgroup of those with personality disorder may be antisocial and dangerous.

Primary care groups

Groups of family doctors and community nurses with resources for commissioning healthcare. Their budget is based on their local population’s share of available resources for hospital and community health services, the general medical services cash- limited budget, and prescribing.

Psychological therapies

Talking therapies, including psychotherapy, counselling, family therapy, and cognitivebehaviour therapy.

Psychotropic drugs

Medication used in the treatment of mental disorder.

Regional Secure Units (RSU)

Medium secure units for individuals who are thought to pose special risks, particularly of violence to others. (See Security - medium).

Schizophrenia

Schizophrenia is a severe psychotic mental illness in which there may be distorted perceptions and thinking, as well as inappropriate or blunted mood. Individuals with this disorder may hold beliefs that seem impossible to others.

Security

Low: some local hospitals have wards with locked doors and above average staff ratios. Also known as intensive care or high dependency units

Medium: units, including Regional Secure Units (q. v.), which care for patients whose behaviour is too difficult or dangerous for local hospitals but who do not require the higher levels of security available in special hospitals

High: provided by the three special hospitals in England - Ashworth, Broadmoor, and Rampton. Their patients are often very dangerous and violent and require intensive care, supervision and observation within the most secure surroundings.

Service and Financial Frameworks (SaFFs)

Service and Financial Frameworks are annual agreements drawn up by each health authority and partners, such as primary care groups, primary care trusts, NHS trusts, social service authorities, and other local agencies, of the resources and activity needed to deliver the objectives agreed in the local health improvement programme for the year ahead. SaFFs encompass primary care, mental health, community and secondary care. They set out the planned local contribution to key national targets, including priorities in the National Priorities Guidance, and targets associated with the modernisation programme. They are examined each year, and refined in consultation with regional offices of the NHS Executive to ensure they are robust.

Service user/s

People who need health and social care for their mental health problems. They may be individuals who live in their own homes, are staying in care, or are being cared for in hospital.

Social care

Personal care for vulnerable people, including individuals with special needs which stem f rom their age or physical or mental disability, and children who need care and protection. Examples of social care services are residential care homes, home helps and home care services. Local authorities have statutory responsibilities for providing social care.

Substance misuse

Includes illicit drug use, such as heroin and other opiates, amphetamines, ecstasy, cocaine and crack cocaine, hallucinogens, cannabis, and prescribed drugs such as benzodiazepines, as well as substances such as alcohol. Substance misuse can cause psychological, physical, social and legal problems.

Supervised discharge

Under the 1995 Mental Health (Patients in the Community) Act consultant psychiatrists may apply for powers of supervision of patients following discharge from hospital. A supervisor, typically a community psychiatric nurse acting as care co-ordinator, has the power to ‘take and convey’ the patient to a place of treatment, but not to treat them.

Above keyterms Published by the Department of Health
© Crown Copyright 1999

National Service Framework for Mental Health
Modern Standards & Service Models Published by the Department of Health
© Crown Copyright 1999

Introduction

The programme of national service frameworks is part of the Government's agenda to drive up quality and reduce unacceptable variations in health and social services. In the NHS, standards will be:

• set by the National Institute for Clinical Excellence and National Service Frameworks
• delivered by clinical governance, underpinned by professional self-regulation and lifelong learning
• monitored by the Commission for Health Improvement, the new National Performance Assessment Framework, and the National Survey of Patients.

Similarly, A New Approach to Social Services Performance described the Government's new Performance Assessment Framework for social care, including national performance indicators.

The first two National Service Frameworks cover two of the most significant causes of ill health and disability in England - coronary heart disease and mental health - which are priorities in Saving lives: Our Healthier Nation. The National Service Frameworks have also been identified as priorities in Modernising Health and Social Services: National Priorities Guidance for 1999/00 - 2001/02.

This National Service Framework addresses the mental health needs of working age adults up to 65. It is founded on knowledge-based practice and partnership working between those who use and those who provide services; between different clinicians and practitioners; across different parts of the NHS; between the NHS and local government; and reaching out to the community, to individual groups and organisations, including the voluntary, independent and business sectors.

This Executive Summary sets out national standards; national service models; local action and national underpinning programmes for implementation; and a series of national milestones to assure progress, with performance indicators to support effective performance management. An organisational framework for providing integrated services and for commissioning services across the spectrum is also included.

Such an ambitious programme of change cannot be implemented in a matter of months. Additional facilities, extra staff and more training will be required in some areas to achieve some of the standards. Recruitment and training of some specialist medical staff may take five to ten years. Implementing the National Service Framework fully across the NHS and social services, and throughout other agencies, could take up to ten years. These challenges can be met if concerted, focused and determined action is applied from the start.

Modernising Mental Health Services sets an ambitious agenda. The Government has already committed an extra £700 million over three years to help local health and social care communities reshape mental health services. Together with main allocations, this provides the resources for implementation of this National Service Framework over the next three years. Further studies of cost-effectiveness, and rigorous performance management, will ensure that the Framework is implemented, making better use of existing resources. The future speed of implementation of this National Service Framework will be shaped by evidence of increased cost-effectiveness in delivering mental health services, available resources, and rigorous performance management.

New investment and reinvestment of existing resources will need to be prioritised, recognising that mental health services are whole systems, which work effectively only when the component parts are all in place and in balance.

In many areas the first priority will continue to be addressing gaps in current services for people with severe and enduring mental illness - 24 hour staffed accommodation, assertive outreach, home treatment or secure beds, for example. This will address issues of equity of access and safety, including public safety. In those areas where specialist mental health services are able to meet local needs, the most cost-effective focus will now be on people with common mental health problems.

The standards and service models in this National Service Framework are based on the evidence of effectiveness, including cost-effectiveness, currently available. This evidence is summarised in the full version. Further work is in hand or will be commissioned to underpin implementation.

Scope

This National Service Framework focuses on the mental health needs of working age adults up to 65. While it touches on the needs of children and young people, these are being addressed through a separate service development programme across the NHS and social services. A National Service Framework for older people, to be published in spring 2000, will include mental health needs.

At any one time around one in six people of working age have a mental health problem, most often anxiety or depression. One person in 250 will have a psychotic illness such as schizophrenia or bipolar affective disorder (manic depression).

Most people with mental health problems are cared for by their GP with the primary care team, and this is what they prefer. Generally, for every one hundred individuals that consult their GP with a mental health problem, nine will be referred to specialist services for assessment and advice, or for treatment. Some people with severe and enduring mental illness will continue to require care from specialist services working in partnership with the independent sector and agencies which provide housing, training, and employment.

Developing the National Service Framework

The National Service Framework has been developed with the advice of an External Reference Group, chaired by Professor Graham Thornicroft from the Institute of Psychiatry, King's College London. The External Reference Group brought together health and social care professionals, service users and carers, health and social service managers, and partner agencies.

Their work was reflected in the Government's strategy Modernising Mental Health Services: safe, sound and supportive, published in December 1998. The Group distilled existing research and knowledge, and considered a number of cross cutting issues, such as race and gender.

The External Reference Group recommended that people with mental health problems should be able to expect that services will:

• involve service users and their carers in planning and delivery of care
• deliver high quality treatment and care which is known to be effective and appropriate
• be well suited to those who use them and non-discriminatory
• be accessible so that help can be obtained when and where it is needed
• promote their safety and that of their carers, staff and the wider public
• offer choices which promote independence
• be well co-ordinated between all staff and agencies
• deliver continuity of care for as long as this is needed
• empower and support their staff
• be properly accountable to the public, service users and carers.

This National Service Framework:

• sets national standards and defines service models for promoting mental health and treating mental illness
• puts in place underpinning programmes to support local delivery
• establishes milestones and a specific group of high-level performance indicators against which progress within agreed time-scales will be measured.

It covers health promotion, assessment and diagnosis, treatment, rehabilitation and care, and encompasses primary and specialist care and the roles of partner agencies.

Remaining relevant

During the implementation of the National Service Framework, there will be changes such as new treatments, innovations, and different expectations. All National Service Frameworks will have to evolve if they are to stay relevant and credible in a changing environment. To ensure this Framework starts and stays up-to-date a national group, outlined in Section three of the main document, has been set up to oversee both implementation and future development. Milestones will be made more challenging when earlier ones have been reached.

National standards and service models

This National Service Framework sets standards in five areas. Each standard is based on the evidence and knowledge-base available, and supported by service models and examples of good practice. The details are set out in the full version of the National Service Framework.

Standard one addresses mental health promotion and the discrimination and social exclusion associated with mental health problems.

Standards two and three cover primary care and access to services for anyone who may have a mental health problem.

Standards four and five cover effective services for people with severe mental illness.

Standard six relates to individuals who care for people with mental health problems.

Standard seven draws together the action necessary to achieve the target to reduce suicides as set out in Saving lives: Our Healthier Nation.

These standards will be challenging for all mental health services. Local milestones are proposed for each standard. Time-scales will need to be agreed with NHS Executive regional offices and social care regions, and progress will be monitored. Although some may already have reached a number of these milestones, none can claim to have achieved them all. As progress is made, the national milestones will be rolled forward and NHS Executive regional offices and social care regions will agree further local milestones with each health and social care community.

All mental health services must be planned and implemented in partnership with local communities, and involve service users and carers. Partnership will be vital if, for example, services are to meet the needs of black and minority ethnic communities and reduce present inequities.

Measuring progress and managing performance

The targets set out in the National Priorities Guidance, alongside the targets set for efficiency and value for money, will make health and social services accountable to the Government and the public for delivering new national standards of mental health and social care.

A First Class Service sets out how the NHS will deliver quality standards and The NHS Performance Assessment Framework describes how these will be measured. And A New Approach to Social Services Performance explains how best value and performance will be managed in social services. Together, these new systems will help to ensure that services develop in the right direction, additional investment for change is targeted through the Modernisation Fund and the Mental Health Grant, and resources are used efficiently according to the principles of Best Value.

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Mental health promotion

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 health problems, and promote their social inclusion.

Rationale

Mental health problems can result from the range of adverse factors associated with social exclusion and can also be a cause of social exclusion. For example:

• unemployed people are twice as likely to have depression as people in work
• children in the poorest households are three times more likely to have mental health problems than children in well off households
• half of all women and a quarter of all men will be affected by depression at some period during their lives
• people who have been abused or been victims of domestic violence have higher rates of mental health problems
• people with drug and alcohol problems have higher rates of mental health problems
• between a quarter and a half of people using night shelters or sleeping rough may have a serious mental disorder, and up to half may be alcohol dependent
• some black and minority ethnic communities are diagnosed as having higher rates of mental health problems than the general population - refugees are especially vulnerable
• there is a high rate of mental health problems in the prison population<
• people with physical illnesses have twice the rate of mental health problems compared to the general population.

Service models

Through health improvement programmes and local mental health strategies, local health and social care communities - local health authorities, local authorities, NHS trusts, primary care groups and trusts, and the independent sector - should develop effective mental health promotion for:

• whole populations - through initiatives to promote healthy schools, healthy workplaces and healthy neighbourhoods
• individuals at risk - supporting new parents, unemployed people, and families in distress, for example, making use of local self-help groups
• vulnerable groups - including specific programmes for black and minority ethnic communities, people who sleep rough, those in prison, individuals with alcohol and drug problems, people with physical illnesses, and others at greatest risk
• action to combat discrimination against people with mental health problems and to promote positive images of mental ill health. <

Performance assessment

Performance will be assessed at a national level by:

• a long term improvement in the psychological health of the population as measured by the National Psychiatric Morbidity Survey
• a reduction in suicide rates
• health improvement programmes demonstrating action within and linkages between organisations to promote good mental health
• in schools, workplaces and neighbourhoods
• for individuals at risk
• for groups who are most vulnerable

and to combat the discrimination against and social exclusion of people with mental health problems.

Local roles and responsibilities

Lead organisation:	health authority
Lead officer:	chief executive
Key partners:	primary care groups, including GPs, local authority, NHS trust, independent sector providers, local employers, educational establishments, and service users and carers

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Primary care and access to services

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 for further 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 to meet their needs and receive adequate care
• be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines or to local services.

Rationale

Mental health problems are common. The majority of all health care is provided by the primary care team, and this should also be the case for the majority of mental health needs. There are a number of points of access to mental health services, and local health and social care communities need to ensure that advice and help is consistent. NHS Direct will provide a new source of first-level advice, and should in time be able to provide a route to specialist helplines such as the Samaritans, SANEline, National Schizophrenia Fellowship and MIND helplines.

Service models

Local health and social care communities need to build capacity and capability in rimary care to manage common mental health problems and to refer for specialist advice, assessment and care appropriately:

• using protocols, for depression as the first priority; then also for postnatal depression, eating disorders, anxiety disorders, and for people with schizophrenia. A number of protocols have been developed locally. The National Institute for Clinical Excellence will be asked to review these, and, where appropriate, to kitemark examples of good practice, which will be promulgated for local use
• managing referrals to specialist services, including psychological therapies, and monitoring waiting times
• specialist mental health services providing primary care liaison, and support for primary care staff through continuing professional development
• supporting patients and their families in understanding their mental health problem and its treatment, and to make contact with local self-help groups.

Local health and social care communities also need to establish explicit and consistent arrangements for access to services around the clock:

• via the GP or primary care team
• through NHS Direct and other helplines
• in Accident & Emergency (A&E) departments through mental health liaison services
• with a gateway to specialist services through effective out of hours arrangements
• including people detained by the police.

Performance assessment

Performance will be assessed at a national level by:

• a long term improvement in the psychological health of the population as measured by the National Psychiatric Morbidity Survey
• a reduction in suicide rates
• the extent to which the prescribing of antidepressants, antipsychotics and benzodiazepines conforms to clinical guidelines
• access to psychological therapies
• experience of service users and carers, including those from the black and minority ethnic communities.

In addition, progress will be monitored through local milestones on:

• timely access to specialist assessment and treatment
• information available for people with mental health problems, including access to self-help groups and support services such as housing and employment
• evidence that services respond to mental health needs quickly, effectively and consistently 24 hours a day, 365 days a year.

Lead organisation:	primary care group
Lead officer:	chief executive
Key partners:	GPs and the primary care team, local authority, NHS trust, independent sector providers, criminal justice agencies, and service users and carers.

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Effective services for people with severe mental illness

Standard four

All mental health service users on the Care Programme Approach (CPA) should:

• receive care which optimises engagement , pr events or anticipates crisis, and reduces risk
• have a copy of a written care plan which:
• includes the action to be taken in a crisis by service users, their carers, and their care co-ordinators
• advises the GP how they should respond if the service user needs additional help
• is regularly reviewed by the 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 care and rehabilitation to be provided , identifies the care co-ordinator, and specifies the action to be taken in a crisis.

Rationale

People with severe mental illness have high rates of psychological and physical morbidity. They are at risk of social isolation and discrimination. All are vulnerable. Individuals with severe mental illness and substance misuse have behavioural and other problems and they need help from a range of services, especially specialist services, and drug and alcohol services. Some individuals pose a risk to themselves. A small number can pose a risk to others, most often their carers or families.

They need a range of mental health services to prevent or anticipate crises where possible; ensure prompt and effective help if a crisis does occur; and ensure timely access to an appropriate and safe mental health place or hospital bed (including a secure bed) as close to home as possible, should this be needed.

Service models

Local health and social care communities should focus on:

• the integration of CPA and care management, and the full implementation of the new arrangements for standard and enhanced CPA
• implementing arrangements for the assessment and, where appropriate, care of people who are detained by the police, brought before a court or are in prison
• ensuring that staff are competent to assess the risk of violence or self-harm, to manage individuals who may become violent, and to know how to assess and manage risk and ensure safety
• implementing local protocols for the effective and safe care of people with severe mental illness, including a protocol for sharing information about individuals on enhanced CPA. A number of protocols have been developed locally. The National Institute for Clinical Excellence will be asked to review these, and, where appropriate, to kitemark examples of good practice, which will be promulgated for local use
• the engagement through assertive outreach and effective medication of service users who are at risk if they lose contact with services
• integrated arrangements to prevent and manage crisis, including access to services round the clock
• investing in a balance of hospital beds (including secure beds), staffed and supported accommodation, day places and home treatment to ensure access and to enable effective use of resources, taking account of the conclusions of the National Beds Inquiry. A shortage of provision at any point will result in pressures in other areas -for example, a lack of secure beds may result in reduced access to acute hospital beds or to hostel provision.

Performance assessment

Performance will be assessed at a national level by:

• a long term improvement in the psychological health of the population as measured by the National Psychiatric Morbidity Survey
• a reduction in suicide rates
• the integration of CPA and care management
• access to single sex accommodation in hospital
• a reduction in the psychiatric emergency readmission rate
• prescribing of antipsychotics
• access to psychological therapies
• access to rehabilitation services
• experience of service users and carers, including people from black and minority ethnic communities.
• a reduction in the numbers of prisoners awaiting transfer to hospital.

In addition, progress will be monitored through local milestones on:

• protocols for the management of people with severe mental illness
• access to assessment and services via the criminal justice system
• review of and action on provision of mental health beds and places
• out of area inpatient care
• improved local confidence in mental health services.

Lead organisation:	NHS trust
Lead officer:	chief executive
Key partners:	health authority, local authority, primary care group, including GPs, criminal justice agencies, independent sector providers, and service users and carers.

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Caring about carers

Standard six

All individuals who provide regular and substantial care for a person on CPA should:

• have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis
• have their own written care plan, which is given to them and implemented in discussion with them.

Rationale

Carers play a vital role in helping to look after service users of mental health services, particularly those with severe mental illness. Providing help, advice and services to carers can be one of the best ways of helping people with mental health problems.

While caring can be rewarding, the strains and responsibilities of caring can also have an impact on carers' own mental and physical health. These needs must be addressed.

Service models

Local health and social care communities should ensure that:

• each carer's needs are assessed
• carers receive easy to understand information about both the help available to them, and the services provided for the person for whom they are caring, including: medication, other treatment and care*, and what to do and whom to contact in a crisis

* The service user's consent should always be explicitly sought before information is passed on to their carer. If the service user is incapacitated, information may be passed to the carer if it is in the service user's best interests

• a written care plan is agreed with the carer and covers their caring, physical and mental health needs, and also educational and welfare needs for young carers
• the care plan is reviewed at least annually.

Performance assessment

Performance will be assessed at a national level by:

• a long term improvement in the psychological health of the population as measured by the National Psychiatric Morbidity Survey
• a reduction in suicide rates
• implementation of each local authority's Caring about Carers action plan
• a reduction in the psychiatric emergency readmission rate
• experience of service users and carers, including people from black and minority ethnic communities.

In addition, progress will be monitored through local milestones on:

• improved satisfaction and confidence among carers about local services.

Lead organisation:	local authority
Lead officer:	director of social services
Key partners:	health authority, primary care group, including GPs, NHS trust, independent sector providers, and service users and carers.

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Preventing suicide

Standard seven

Local health and social care communities should prevent suicides by:

• promoting mental health for all, working with individuals and communities (Standard one)
• delivering high quality primary mental health care (Standard two)
• ensuring that anyone with a mental health problem can contact local services via the primary care team, a helpline or an A&E department (Standard three)
• ensuring that individuals with severe and enduring mental illness have a care plan which meets their specific needs, including access to services round the clock (Standard four)
• providing safe hospital accommodation for individuals who need it (Standard five)
• enabling individuals caring for someone with severe mental illness to receive the support which they need to continue to care (Standard six).

and in addition:

• supporting local prison staff in preventing suicides among prisoners
• ensuring that staff are competent to assess the risk of suicide among individuals at greatest risk
• developing local systems for suicide audit to learn lessons and take any necessary action.

Rationale

Mental health is one of the four target areas in Saving lives: Our Healthier Nation with the specific target to reduce the rate of suicide by at least one fifth by 2010. People with mental health problems, especially those with severe and enduring mental illness are at particular risk of suicide. Standards one to six will all contribute to reducing suicides; further action is also required.

Service models

Local health and social care communities will help to prevent suicides by delivering the service models set out in this National Service Framework. In addition, they should also:

• support prison staff in preventing suicides among prisoners including those on remand
• ensure that staff are competent to assess the risk of suicide especially among individuals most vulnerable, including people who have self-harmed or attempted suicide, individuals with serious drug and alcohol problems, or those in contact with specialist mental health services, and know what action to take if they are concerned
• develop local systems for suicide audit to learn lessons and take any necessary action.

Performance assessment

Performance will be assessed at a national level by:

• a reduction in suicide rates.

In addition, progress will be monitored through local milestones on:

• effective progress on Standards one to six
• effective work with local prison healthcare services
• local suicide audits

Lead organisation:	health authority
Lead officer:	chief executive
Key partners:	NHS trust, local authority, primary care group, including GPs, independent sector providers, criminal justice agencies, and service users and carers.

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Implementing the National Service Framework

The national standards in this National Service Framework will be achieved only by:

• recognising that change needs to be systematic and sustainable
• measuring change with early milestones as well as longer term goals
• building a programme which is both ambitious and realistic - ambitious standards and realistic local delivery systems with national underpinning programmes
• applying concerted action - using local mechanisms such as health improvement programmes, joint investment plans, the clinical governance framework, and the new flexibilities between health and local government to secure change in mental health services as a priority.

Delivering the National Service Frameworks will require new patterns of local partnerships, with mental health a cross cutting priority for all NHS and social care organisations and their partners.

Leading change in mental health services

Strong leadership, coupled with a clear commitment from clinicians and managers and effective engagement of all with a responsibility to improve mental health services, will be essential to secure and sustain change. And for the first time, change in mental health is being directed and fostered with clear expectations of what should be achieved; with an approach which balances firm performance management with support to develop local capacity and capability; and with dedicated national and regional support for implementation.

Implementation should be coupled to the learning agenda - including Beacons, the Learning Zone, ImpAct, and learning centres, for example. More information is available from :
nww.learningzone.nhsweb.nhs.uk or telephone 01730 266544.

Local action

Between now and April 2000, those leading the change within each local health and social care community will need to:

• identify and engage key individuals, groups and agencies
• gain commitment to achieving the national standards and service models
• agree arrangements for implementation
• set up a local implementation team led by one person with a clear remit and explicit accountability, and supported by team members with sufficient seniority to commit their organisation to action
• assess mental health needs, prioritising the needs of those with severe and enduring mental illness.
• assess existing local mental health provision against the standards and service models in this National Service Framework, and prioritise a development strategy which focuses on:
• partnership working
• the development of clinical governance
• workforce planning, education and training
• arrangements for Best Value
• information systems
• monitoring and evaluation
• business planning
• service user and carer involvement
• communications
• research and development.
• concentrate on the most significant local pressures and gaps, including workforce, information and leadership
• agree long term goals and early measurable deliverables.

This should be drawn together in a local delivery plan to be published by April 2000. Integrated within overall health improvement programmes, the plan must be consistent with the development plan for clinical governance, and reflected within the Service and Financial Frameworks for the NHS, and the Performance Assessment Framework for Social Services. The programme is likely to be:

By April 2000 - Local delivery plans agreed with regional offices of the NHS Executive and social care regions.

By October 2000 - Progress report on annual performance review of health authorities, clinical governance and fundamental performance review of local authorities.
Health improvement programme published for 2001/04.

By April 2001 - Updated local delivery plans agreed with regional offices of the NHS Executive and social care regions.

Regional support

Each region now has a Regional Mental Health Development Plan, developed by its Regional Implementation Team, setting out essential action the region will take to implement the Framework. Local delivery will be monitored and supported by the regional offices of the NHS Executive and social care regions. A programme of development will be agreed with each local health and social care community.

A new national Mental Health Implementation Group has been set up to prepare for implementation and oversee progress, with representatives from each NHS and social care region, and supported by a national Mental Health Implementation Team.

National underpinning programmes

National programmes will be essential to underpin the efforts of local health and social care communities as they tackle some of the more complex and long-standing problems.
These programmes will each be refocused to support local implementation of the National Service Framework.

Action will be vital in five areas:

• finance
• workforce planning and education and training
• research and development
• clinical decision support systems
• information.

Finance

Local health and social care communities need to prioritise their investment and reinvestment in the whole mental health system.

As indicated earlier, in many areas the first priority will be to continue to address gaps in current services for people with severe and enduring mental illness - 24 hour staffed accommodation, assertive outreach, home treatment or secure beds, for example. This will address issues of equity of access and safety, including public safety.

In areas where specialist mental health services are able to meet local needs for severe mental illness, the most cost-effective focus will now be on people with common mental health problems.

Vital core functions that must be in place to provide comprehensive services are:

• agreed protocols between primary care and specialist mental health services to ensure speedy access to primary care and specialist services
• agreed protocols to guide referrals for specialised services, such as medium secure care or eating disorder units.
• multi-professional teams who assess, plan and offer effective interventions through individual care packages, including home-based treatment, and assertive outreach
• early, effective interventions for people with severe mental illness
• a range of services to respond effectively to a crisis, including access to a place away from home if necessary
• adequate local treatment and care facilities, including local inpatient beds, 24 hour staffed accommodation, day and residential care.

To underpin the mental health strategy, the Government is investing an extra £700 million in health and social services over this year and the next two years to deliver its vision for modern mental health services.

A joint circular issued in February on the NHS Mental Health Modernisation Fund and the Mental Health Grant 1999/2000 (HSC 1999/038: LAC99(8)) set out some key steps which local and health authorities are now taking to ensure that funding is directed more effectively towards services which meet the needs of mentally ill people and their carers. Funding arrangements for 2000/01 and 2001/02 will be announced later this year. Services for people with severe mental illness will continue to be given a high priority.

Local partners need to develop effective joint investment plans, which specify the quality improvements which will be secured.

Health authorities and local authorities should work closely with other agencies to avoid duplication, use long term service agreements to give greater funding certainty for all providers, and grasp opportunities provided by the Private Finance Initiative.

As a first step to inform local investment decisions, the NHS Executive has produced an adjusted unit cost of local specialist mental health services. The Department of Health has also commissioned two pieces of work:

• a review of the evidence of cost-effectiveness of the main interventions and changes proposed in the National Service Framework
• a toolkit to assist with the development of local prioritised plans based on local mental health needs. The toolkit will be supported by resources such as the review of evidence on cost-effectiveness, and by comparative performance indicators on mental health services, as benchmark data sets are developed.

The results of this work will be made available by the summer of 2000.

Workforce planning, education and training

Mental health service providers face a number of challenges as they try to recruit and retain adequate numbers of qualified staff. Sustained local action is going to be essential

within the health improvement programme, using local mechanisms for workforce planning, and for education and training, including continuing professional development and lifelong learning.

National standards and service models will require additional staff, properly trained and supported, to provide modern mental health care. More staff across all groups, including care support workers, will be needed. Skill mix issues will have to be addressed.

The Department of Health, working with local employers, education consortia and their higher education partners, and the national training organisations, has commissioned an action plan that will clarify and endorse:

• key principles for the creation of a sufficient, skilled and supported mental health workforce
• key skills and competencies required throughout mental health services to ensure services which are non-discriminatory, and sensitive to the needs of all service users and carers regardless of age, gender, race, culture, religion, disability, or sexual orientation.

An action team, chaired by a mental health services chief executive, has been established to develop and drive forward the plan. Following consultation, the team will undertake an assessment of the workforce implications of the National Service Framework and produce an interim report by March 2000.

Research and development (R&D)

In future, Department of Health investment in mental health R&D will focus on the knowledge-base required to implement this National Service Framework.

The Mental Health Topic Working Group, which is reviewing mental health R&D (including forensic mental health) will complete its work this autumn. Early research priorities are likely to include:

• service delivery and organisation:
• evaluating the individual and collective performance of the component parts of the National Service Framework
• investigating variations in the use of inpatient beds, and their implications
• the management of co-morbidity, and the interfaces between primary care, specialist mental health services and substance misuse services
• investigating ways to enhance staff morale, retention, recruitment and performance, and thereby improve service user engagement and outcomes.National Service Framework - Mental Health
• clinical and practice interventions:
• evaluating the effectiveness and cost-effectiveness under usual service conditions of psychological and psychosocial interventions
• comparing the outcomes for self-harm between different types of services
• assessing relative cost-effectiveness, service user satisfaction and concordance rates of
• atypical antipsychotic drugs
• newer antidepressants
• complementary therapies

compared to standard management

• evaluating the better management of antisocial attitudes/behaviours that attract the label of severe personality disorder
• service user involvement:
• developing and evaluating a range of occupational activities to maximise social participation, enhance self-esteem and improve clinical outcomes
• developing research tools with service users to assess their view on how services can best meet their needs.

Information on the outcome of further discussions and an action plan for mental health R&D will be issued to mental health services.

Clinical decision support systems

Some material exists already:

• the Cochrane collaboration has published systematic reviews of over 150,000 controlled trials concerned with mental health. The Cochrane library contains details of this work
• Effective Health Care Bulletins have been published on depression in primary care; mental health promotion in high risk groups; deliberate self-harm. One on schizophrenia is due later this year
• Clinical Evidence, a recent initiative, will publish regularly updated information on common conditions, including mental ill health to provide material for clinicians and patients to use locally
• the Health Needs Assessment (HNA) on mental illness is being updated and will be available soon. An HNA on prison health care will also be available shortly
• clinical guidelines have been published on the management of violence in clinical settings; and on antidepressant prescribing in primary care. Further clinical guidelines on psychological therapies and counselling in primary care and the management of schizophrenia will both be available later this year; and on depression by late 2000.
• clinical audit methodologies include the administration of electroconvulsive therapy; the management of violence in clinical settings; and service users' satisfaction with CPA and risk management
• the Clinical Standards Advisory Group report on depression will be published shortly. Until the clinical guidelines on depression are published next year, the best source of advice remains the consensus statement developed by the Royal Colleges of Psychiatrists and General Practitioners for the Defeat Depression campaign published in 1992.

All existing Department of Health commissioned clinical guidelines and protocols, and those currently in preparation, will be reviewed and quality assured, and then promulgated by the NHS Executive for early local use. Links will be established with the Electronic Library for Social Care (ELSC) at the National Institute for Social Work.

The future mental health priorities for both National Institute for Clinical Excellence (NICE) and ELSC should reflect the needs of clinicians and practitioners as they begin to implement this National Service Framework.

Information systems

A draft mental health information strategy will be published in spring 2000. It will support implementation of this National Service Framework by focusing on three streams:

• information on the knowledge-base for service delivery
• information for those providing individual service user care
• information to support management decision making.

These will support a healthcare framework to measure needs, resources and outcomes, as well as the high-level performance indicators, reference costs and the Performance Assessment Framework.

The mental health information strategy will incorporate a range of national work: Health of the Nation Outcome Scale (HoNOS), work on clinical terms and casemix, and expertise in communications. It will also encompass initiatives such as the National Survey of Patients, where mental health is an early priority; the second National Psychiatric Morbidity Survey planned for 2000; and the Mental Health Minimum Data Set (MHMD), which is being piloted and will be in use nationally by March 2003.

Early priority will be given to involving all NHS mental health providers in benchmarking.

Work is now underway to develop agreed access and discharge criteria for secure mental health care, and for needs assessment to underpin the development of an information strategy for mentally disordered offenders.

Ensuring successful progress

Some national milestones have been established, and progress will be measured through a small number of high-level performance indicators. These will be consistent with the strategic development of the Performance Assessment Frameworks for health and social services. The first set of high-level performance indicators for mental health will be published in 2000, for local action from April 2001.

The following are proposed for further development:

Performance indicators	Rationale	Availability of data
Measures of the psychological health of the general population	Best measure of population outcome	Data available through National Psychiatric Morbidity Survey. Monitored six yearly - first survey in 1994
Suicide rates - overall suicide rate, plus rates by age, gender and race, and specifically for prisoners	National target within Saving lives: Our Healthier Nation	Data available through the Office of National Statistics (published mortality data) and the National Confidential Inquiry into Suicides and Homicides
NHS Direct includes advice on mental health problems networked to specialist mental health lines able to provide mental health advice in first language of caller	Government commitment	Data collected through NHS Direct
Percentage of those admitted for whom single sex inpatient accommodation is available	Government commitment	Data collected through NHS Charter
Prescribing of antidepressants, antipsychotics and benzodiazepines monitored	Critical indicators of the quality of care across the whole mental health system	Will be monitored through the Mental Health Minimum Data Set
Arrangements in place to monitor access to psychological therapies	Critical indicator of care across the whole mental health system	Data not currently available Will be collected through regional office monitoring.
Percentage of all inpatients deemed to be in a hospital bed when they need not be, or deemed to be placed at an inappropriate level of security	Pre requisite for the efficient use of resources, and for improving access to the appropriate level of mental health support	Data not currently available Will need to develop national method of collating local reviews
Adjusted unit cost of local specialist mental health services	Critical indicator of service efficiency	Data already collected with NHS high-level performance indicators
Psychiatric emergency readmission rate	Indicates the effectiveness of care planning; and the capacity of alternatives to hospital care	Data already collected within Performance Assessment Framework
Measures of the experience of service users and their carers, including those from black and minority ethnic communities. This should include: evidence of the appropriate care need to be addressed of African-Caribbean service users evidence of adequate access to required ensure better assessment of mental health problems in the Asian community	Critical indicator of service delivery Particular concerns about cultural competence need to be addressed	Data not currently available An early priority for the National Survey of Patients Local surveys may also be required
Carers' needs assessed, services provided, and plans regularly reviewed	Prerequisite for safe, sound and supportive mental health services, and to meet carers' needs	Data not currently available New arrangements will be required
Protocols agreed and implemented for the management of depression and postnatal depression, of anxiety disorders, of schizophrenia, and of those who need referral to psychological therapies	Critical indicator of the quality of primary mental health care, and of of the whole mental health system	Data not currently available Will be collected through regional office monitoring
Care management and care programme approach fully integrated for assessment, care planning, and review	Prerequisite for safe, sound and supportive mental health services, and for the efficient use of resources	Data not currently available Will be collected through regional office monitoring.

Three of these performance indicators, the psychiatric emergency readmission rate, the suicide rate, and the adjusted unit cost of specialist mental health services are currently included in the NHS High-Level Performance Indicator Set. More information can be found on the Department of Health website: www.doh.gov.uk/indicat/nhshlpi.htm

These high-level performance indicators will be complemented by a programme of systematic service reviews which will be undertaken by the Commission for Health Improvement and the Social Services Inspectorate, working with the Audit Commission.

In terms of national milestones, several commitments have been made already:

• Saving lives: Our Healthier Nation sets the target of a reduction in the suicide rate by at least one fifth by 2010
• the Public Sector Agreement between the Department of Health and the Treasury requires a reduction of two percentage points in the rate of psychiatric emergency readmissions by April 2002, from 14.3% to 12.3%
• NHS Direct will be rolled out to cover 60% of the country by the end of 1999 and the whole of England by the end of 2000
• the Government is committed to getting rid of mixed sex accommodation and no new mixed sex wards will be approved. By the year 2002, 95% of health authorities should have removed mixed sex accommodation.

These, together with the following, will form the first set of national milestones:

National milestone	Target
Health improvement programmes should demonstrate linkages between NHS organisations and partners to promote mental health in schools, workplaces, and neighbourhoods for individuals at risk for groups who are most vulnerable and to combat discrimination and social exclusion of people with mental health problems	All health authorities by April 2000
Clinical governance report	All health authorities by the end of 2000
Protocols agreed and implemented between primary care and specialist services for the management of: depression and postnatal depression anxiety disorders schizophrenia those requiring psychological therapies drug and alcohol dependence.	All health authorities by April 2001
Prescribing of antidepressants, antipsychotics and benzodiazepines monitored and reviewed within the local clinical audit programme	All health authorities by 2001
Service users with severe mental illness have an integrated care plan, with a care co-ordinator responsible for implementing, reviewing, and explaining the care plan	All health authorities by April 2000
Service users on enhanced CPA have a written care plan which explains to them, their carer and their GP how to contact specialist mental health services round the clock	All health authorities by April 2001
Assertive outreach in place for service users on enhanced CPA and at risk of losing contact with services	All health authorities by April 2002
Planned increase in secure beds	300 extra beds by April 2002
Increase in percentage of community mental health teams, integrating health and social services staff within a single management structure	Increase of 50% over 1999/2000 baseline by April 2002
Local workforce strategies, within a national framework,which ensure: A review of local workforce issues to identify pressures and priorities, including action needed to match workforce to local community An education and training plan which encompasses recruitment to training grades, continuing professional authorities by April 2001 development, clinical skill acquisition, lifelong learning and team development A retention strategy including measures to tackle stress and to improve working conditions, and provide proper organisations* by supervision and appraisal	All health and local authorities by April 2000 All health and local authorities by April 2001 All mental health organisations* by April 2001 * Health and social care commissioners and providers of specialist mental health care, including independent sector providers.
Local information strategies, within a national framework, which ensure: An action plan is completed to implement information systems to support those managing the care of all on CPA, including access on a "need to know" basis across organisational boundaries; and implementation of the Mental Health Minimum Data Set by March 2003 An annual review is conducted of the appropriateness of bed use and recommendations are implemented	All mental health information systems by April 2001 All mental health organisations by April 2000

Local health and social care communities will also include local milestones within their local delivery plans which will be agreed with NHS Executive regional offices and the social care regions.

A new vision for mental health

The Government took early action on mental health by:

• setting up an Independent Reference Group in 1997 to advise Ministers on the closure of the remaining long stay psychiatric hospitals
• making available additional in-year resources to mental health services in 1997/98
• establishing the External Reference Group for this National Service Framework in July 1998
• and publishing Modernising Mental Health Services: safe, sound and supportive in December 1998.

Modernising Mental Health Services set out the Government's vision for mental health services and emphasised three key aims:

• safe services - to protect the public and provide effective care for those with mental illness at the time they need it
• sound services - to ensure that patients and service users have access to the full range of services which they need
• supportive services - working with patients and service users, their families and carers to build healthier communities.

Modernising Mental Health Services pledged a fresh start for modern and dependable mental health services through this National Service Framework. The mental health strategy promised:

• extra investment together with better delivery systems to manage resources more effectively legal powers which
• well integrated care processes, working across professional and agency boundaries.

Legal framework

In July 1998, Ministers announced a root and branch review of the Mental Health Act, to ensure that the legislative framework supports modern mental health care.

An independent expert group, chaired by Professor Genevra Richardson of the University of London, published its initial proposals for consultation earlier this year. The group reported to Ministers in July and their report will be published later this year, alongside a Government consultation paper on proposed changes to the law.

Neither mental health nor criminal justice law currently provides a robust way of managing the small number of dangerous people with severe personality disorder. Home Office and Health Ministers have been considering a more effective framework for assessment and management which will protect the public whilst ensuring that the requirements of the European Convention on Human Rights are met. A joint consultation paper was published in the summer.

Organisational framework

Mental health services represent a continuum from primary care to highly specialised services. For any local health and social care community mental health services will be provided by two or more organisations. No reconfiguration will unify all provision; the interfaces and boundaries must be managed effectively in order to provide and commission integrated services.

Providing integrated services

The new NHS and Modernising Mental Health Services set out the advantages of specialist mental health services NHS trusts. All mental health service providers need to demonstrate senior leadership of, and a commitment to mental health services; clinical governance, including continuing professional development and lifelong learning; evidence of a commitment to the underpinning programmes, including education and training, recruitment and retention, information services and research and development; and clear lines of accountability for mental health services.

Specific arrangements should be in place to ensure service user and carer involvement; advocacy arrangements; integration of care management and the Care Programme Approach; effective partnerships with primary health care, social services, housing and other agencies; and involvement of the independent sector.

In the medium term these criteria are most likely to be met in NHS trusts with a critical mass of mental health services. Single speciality mental health NHS trusts are likely to be the preferred option in inner cities and some metropolitan areas. Where populations are more dispersed other options may be better, although these are unlikely to include combined mental health and acute NHS trusts in the longer term.

Over recent years, the advantages of a closer relationship between primary care and specialist mental health services have become clearer. Some primary care trusts might be given responsibility for the provision of local specialist mental health services -community mental health teams, local residential care and day care, and domiciliary support and local inpatient care - subject to the following criteria:

• either an established track record:
• the trust includes managers, mental health professionals, GPs and primary care teams who have developed a good track record by applying, for example:
• guidelines and protocols for the integrated care of people with mental health problems
• a systematic approach to diagnosis, treatment and care, and to disease prevention and health promotion
• rigorous monitoring of health indicators and focused action to tackle ill health and inequalities in health
• or robust plans in the primary care trust proposal for improvement of mental health services that:
• meet the requirement in health improvement programmes to improve and develop mental health provision
• command the broad support of local service users and carers, and are subject to rigorous monitoring
• effective arrangements to manage the interface between local specialist and more specialised mental health services, including secure psychiatric services
• a continuing focus on those with severe and enduring mental illness, in line with the standards and service models in this National Service Framework, and a commitment to joint work between health and social services
• board membership includes competent management of specialist mental health services
• proportional representation of mental health professionals on the executive of the primary care trust

Commissioning mental health services across the spectrum

The commissioning of local mental health services should be consistent with the vision and priorities in Modernising Mental Health Services, and the standards set in this National Service Framework.

Local specialist mental health services should be commissioned through a unified local commissioning process. Health authorities, under the aegis of regional specialised services commissioning groups, will retain responsibility for commissioning specialised mental health services. Advice on the arrangements and management of regional commissioning of high and medium security services has been set out in HSC (99)/141.

Local health and social care services will need to agree their arrangements for commissioning with the NHS Executive regional office and social care region. It is likely that these arrangements will evolve over time as local health and social care communities make use of the new flexibilities between health and local authorities, which allow budgets to be pooled, the integration of commissioning and provision, and joint lead commissioning of mental health services.

The options will include:

• a joint commissioning board, including the local authority, health authority and primary care group
• a lead commissioner, which could be either local authority, primary care group or primary care trust or health authority.

Whichever option is selected, long term service agreements, which will replace contracts, should be consistent with the health improvement programme and community care plan.

Links to Government-wide policies

Mental health is a priority for health and social services in Modernising Health and Social Services: National Priorities Guidance for 1999/00 - 2001/02. Partnership in Action proposed new flexibilities between health and local authorities that have been enacted through the 1999 Health Act, flexibilities which will be essential to the successful implementation of this National Service Framework.

The White Paper, Our Healthier Nation, includes mental health as one of its four key areas. This Framework sets out the action to be taken by health and social services to deliver their contribution to the achievement of the target for mental health - a reduction in the suicide rate by at least one fifth by 2010.

Moreover, a range of Government policies will also support this National Service Framework. Social exclusion can both cause and come from mental health problems. Initiatives designed to promote social inclusion - for example, Sure Start, Welfare to Work, New Deal for Communities and the work of the Social Exclusion Unit - will all strengthen the promotion of mental health and individual well-being, and reduce discrimination against people with mental health problems.

Conclusion

The National Service Framework represents an ambitious agenda for change for health and social services in England, driving up quality and tackling variations and inconsistencies in present services.

It encompasses all aspects of mental health - from mental health promotion through to continuing care. The External Reference Group established an inclusive process, engaging a wide range of organisations that have a role in improving mental health and mental health services.

The National Service Framework's standards are clear. Its service models and examples of good practice indicate how the standards can best be achieved. Action on mental health must be integrated into all local delivery systems including health improvement programmes, the development of clinical governance, and the establishment of long-term service agreements.

Performance will be assessed through a small number of national milestones and high-level performance indicators. And local health and social care communities will also agree local milestones with NHS Executive regional offices and social care regions.

Finally, the National Service Framework recognises the learning and development agenda - organisational, professional and personal - and the need to build capacity and capability, and to share good practice. Regional support and national underpinning programmes will support local implementation, as mental health services tackle a demanding but exciting agenda of change.

Published by the Department of Health
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