The National Service Framework for mental health: The national picture

1. The National Service Framework for mental health: The national picture Dr Anna Higgitt 5th December 2001 ExCel, London

2. The Direction of Travel (mental health policy) • Mental Health Strategy (1998) • Managing dangerous people with severe personality disorder (1999) • National Service Framework for mental health (1999) • New policy on care co-ordination • Green paper (Reform of the Mental Health Act 1983) (1999) • NHS Plan (2000) • White paper (Reform of the Mental Health Act - 2000) • Policy Implementation Guide (2001)

3. Mental Health Strategy • Early stages SAFE • improve places & access  increased confidence of public and politicians • Medium term SOUND • new services, integrated services, workforce development, developing evidence • Longer term SUPPORTIVE • improve public understanding, reduce discrimination, citizenship

4. WHAT IS THE QUALITY FRAMEWORK? National Service Frameworks National Institute for Clinical Excellence Clear standards of service CLEAR STANDARDS OF SERVICE Patient and public involvement Prof. self regulation Lifelong Learning Clinical Governance Dependable local delivery National Performance Framework Commission for Health Improvement National Patient and User Survey Monitored standards MONITORED STANDARDS

5. National Service Frameworks • Mental health was the first framework to be published • Was drawn up in conjunction with clinicians and users • Aims to produce greater consistency in availability and quality of services nationally • Directed at health as well as social services • Focus on requirements for comprehensive mental health services from needs assessment through to treatment, maintenance, staff training and workforce planning for adults of working age

6. Mental Health National Service Framework Seven National Standards: Health promotion & social inclusion Primary care Access to services (Effective services for people with ‘severe’ mental illness) CPA focus Care away from home focus Caring for carers Suicide prevention - Our Healthier Nation 1 2&3 4&5 6 7

7. NHS Plan • High profile announcement summer 2000 confirming the provision of a universal service for all based on clinical need, not ability to pay - public consultation • A Modernisation Board to be chaired by the Health Secretary (includes Royal College reps, NHS Clinicians, patient reps) • 10 task forces (with non-DH representation) (6 relating to service delivery and development including mental health) (4 relating to the means of implementation - workforce, quality, reducing inequalities/public health, capital and IT systems)

8. Some principles of the NHS Plan Care focused around the patient • prevention • self-care • more convenient access • electronic patient records • more information for patients • greater choice • patient advocates (PALS) • patients’ forums and citizens’ panels • greater regulation of professionals

9. NHS Planvery specific for mental health • Kind of services • Specific service models • Numbers of people being helped • Timetable for delivery • Financial resources

10. Mental Health in the NHS Plan • Extra investment above modernisation fund • Primary care • 1000 new workers to help GPs manage common mental health problems • 500 community mental health staff to work with GPs, Primary care, A&E, NHS Direct • Enable mental health and social care trusts

11. NHS Plan and secondary care • Early intervention in psychosis (first episodes) 50 teams • Crisis Resolution 335 teams over next 3 years • Assertive outreach further 50 teams (on top of the 170 already in place) • Services for women - women only day service in each HA • Support for carers - 700 more staff to increase breaks for carers, build up networks etc

12. More on the NHS Plan and mental health • High secure hospitals • developing more medium secure (long term) beds (200) • more community (forensic) staff 400 • Prison health care • 300 extra staff - in the prison/NHS partnership • ensuring care co-ordination in place for all on discharge who need it

13. More on the NHS Plan generally • No reason why other well publicised NHS Plan proposals should not include mental health • better food • more TVs • clean wards etc

14. National Director • Professor Louis Appleby • 1st June 2000 • Early priorities: • mixed sex accommodation • out of area acute admissions • 24hour access to mental health services for patients and carers • consideration of mental health R&D • Involving psychiatrists in the implementation programme

15. Task Force Membership • Paddy Cooney Matt Muijen • Prof John Cox Tony Russell • Stephen Firn Prof Sashidharan • David Fordham Diana Whitworth • Sue Hunt Prof Stefan Priebe • David Joannides Ruth Liserge • Prof Tony Kendrick Richard Brook • Barbara Kennedy Cliff Prior • Prof Sir Denis Pereira Gray Dr Chris Manning

16. 5 Underpinning Programmes { • research and development • clinical decision support systems • information • workforce planning and education and training • finance: revenue, capital and estates • Not mutually exclusive programmes, many cross-cutting issues

17. Chief Officers’ Conference • March 2001 - all Chief Executives, Finance Directors from all MH Trusts, Health Authorities, Primary Care Groups/Trusts, Social Services • Presented with the agenda, with workshops on areas requiring early focus, service specifications

18. The Mental Health Policy Implementation Guide • Aim: to enable LITs to create change in local areas • Detailed specifications for each of 3 principal new service models • Crisis resolution • Assertive outreach • Early intervention • Primary care • Mental health promotion • Tailoring services to local needs • Achieving and securing progress

19. Tailoring services to local needs INFLUENCING FACTORS service user views, carer views, professional views, independent sector views, national and local policies, statutory requirements, resource levels and financial pressures, current organisation and culture of service provision, • REVIEW OF LOCAL SERVICE PROVISION • All elements in place/planned? • Sufficient service, staff, finance? • Co-ordinated pathway for service user and carer? • Quality? NEEDS ASSESSMENT INDIVIDUAL/POPULATION

20. Achievements so far • More secure beds • over 320 24-hour staffed beds • 170 new assertive outreach teams • by March 2002 all on enhanced CPA to have plans to secure suitable employment or other occupational activity, adequate housing, appropriate entitlement to welfare benefits • 3 of the first wave of care trusts taking a mental health lead (Camden and Islington, Manchester, Bradford) • Engage PCTs in LITs

21. Fast-forwarding primary care mental health • November 2001 • follow-on from Chief Officers’ conference • Ministerial speech • whole system to work together better • £75 million announced in November in earmarked revenue to deliver mental health services

22. Achieving and Securing Progress • Clinical governance • Duty to continuously improve services • Workforce development • Workforce Action Team • Improved information • Performance management

23. In-patient wards • April 2001 the Minister of State for Health announced £30 million over the next 2 years to improve wards and conditions for psychiatric patients • Research will be commissioned • In-patient work group set up • Guidance on substance misuse on inpatient psychiatric wards to be published soon

24. Implementation of the NSF/NHS Plan • The implementation guide also published as a CD Rom which was issued along with a new computer to every Community Mental Health Team in the country www.doh.gov.uk/mentalhealth/implementationguide.htm • Consultant psychiatrist advisors to be appointed linking with each Local Implementation Team • Outline national strategies for services for ethnic minorities and women are being prepared • A Forensic Psychiatrists Working Group has been established

25. Mental Health Promotion • Mind Out for Mental Health campaign www.mindout.net • Requirement to include occupation, housing and benefits in care plans for enhanced CPA • Employment sub-group of the Mental Health Promotion Project Group formed

26. Workforce • WAT report came out in the summer • On website www.doh.gov.uk/mentalhealth/work • Continuing work in the area • developing plans in new HR structure • membership new bodies being finalised • joint work with RCPsych, National Director on psychiatric workforce • work on STR workers

27. Users and Carers • National Director convened a National User Forum • A broad network of users established to contribute to policy making and local developments • A ‘Commitment to Carers’ leaflet published as a joint venture with the National Schizophrenia Fellowship (Rethink)

28. National Service Framework Standard Seven • Local health & social care communities should prevent suicides by: • implementing NSF Standards One to Six • supporting local prison staff in preventing suicide among prisoners • ensuring 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

29. Targets for Local Services for March 2002 • Review physical environment in in-patient settings & make necessary changes to reduce access to means of suicide • To help prevent suicides amongst high risk groups, all patients with a current or recent history of severe mental illness and/or deliberate self harm, and in particular those who at some time during their admission were detained under the Mental Health Act because of high risk of suicide, must be followed up (by a face to face contact with a mental health professional) within 7 days of discharge from in-patient hospital care

30. Targets for Local Services for March 2002 (contd) • Every health authority and local authority must have multi-agency protocols agreed and operational for the sharing of information relevant to reducing risk of serious harm to self or others • Develop local systems for suicide audit to learn lessons and take any necessary action • Support local prison staff in preventing suicide among prisoners

31. Prison Health: Key Facts • 65,000 prisoners (throughput 200,000/yr.) • 135 prisons – 135 models of health care • Highly selected mainly male population • High morbidity (mental illness, drug abuse) • 10% of prisoners report sick daily • 7000 cancelled NHS appointments/yr.

32. SERVICE MODEL Community Mental Health Teams Mental health care delivery on Wings Through care Reception Screening Through care PRISONS Mental health care in Health Care Centre Mental health transfers to secure units NHS

33. Other Departmental Initiatives • Learning Disability Strategy (March 2001) (Valuing People) • NSF for Older People (March 2001) target around managing dementia and depression • Development of a Children’s NSF announced

34. National Institute for Mental Health • Build on regional mental health development programmes • Share good practice across the board • Harness expertise to advise on research agenda • Consider a Learning Centre in each region with complementary programmes rather than duplication • Focus on effective dissemination

35. WHY NIMHE? Research Training NIMHE Service Development Practice

36. AIM “To reshape professional practice in line with the evidence base by bringing together the research, development and dissemination functions of mental health services”

37. STRUCTURE Regional Mental Health Development Centres National HQ Mental Health Research Network Time Limited Programmes

38. MODERNISATION AGENCY National Clinical Governance Support Team Mental Health Task Force National Patient Access Team Leadership Centre Etc. NIMHE National Primary Care Collaborative NIMHE ADMINISTRATIVE CENTRE Research Dissemination Training Service Users & Carers Outcomes & Governance

39. Department of Health Policy Department Directorate of Patient & Public Involvement, Nursing, Mental Health, Disability and Allied Health Professionals Regional Office of Health And Social Care Modernisation Agency NIMHE Centre Regional MH Development Centre Regional Modernisation Team Mental Health Services Branch MH Lead, (Modernisation Team) Local Implementation Teams (Local Strategic Partnerships – Mental Health) PCTS StHAs Local Trusts Service Users Voluntary Authorities and Carers Organisations

40. COLLABORATIVE WORK  Modernisation Agency  NICE / SCIE  CHI  NHS R&D / MRC  Mental Health Act Commission  Performance Management  Education and Training Bodies  Others

41. TIMETABLE  Already open for consultation and information  Permanent structures by Spring 2002  Research network by Spring 2002  Early initiatives as soon as is feasible: - assertive outreach research - training development for home treatment / assertive outreach - service user focused monitoring - mental health promotion in primary care - values

42. Mental health R&D portfolio • Gaps in the evidence base of the NSF • Assertive outreach: workshop => advertised for research proposals • Dual diagnosis ‘brainstorm’ with MRC • Suicide prevention workshop • Systematic review of in-patient care research • Models of services to support carers • Follow-up of psychiatric morbidity survey

43. Expert topic papers • Post-qualification training • Self-help interventions • Occupational outcomes • Early intervention in psychosis • Women’s services • Primary care mental health workers

44. Mental health R&D portfolio contd • Prison mental health services - analysis of officers’ views, WHO primary care guidelines adapted • Severe personality disorder - workshop • Severe personality disorder - two expert review papers • Sex offenders - workshop • Advertised treatment of sex offenders feasibility study

45. Mental health R&D priorities • Initially setting agenda in relation to NHS Plan and mental health NSF priority areas • Input from Task Force, from scoping work by experts • Ministerial imperatives • Expert topic papers likely to point to areas where work needed

46. Outcomes work • Already mentioned in relation to follow-up of the psychiatric morbidity survey • National Director keen to pilot routine outcomes measurement • mortality • morbidity • user satisfaction with services • quality of life

47. A number of documents due to emerge • acute provision • strategy on black and ethnic minority mental health • primary mental health care • strategy on women’s mental health • strategy on suicide reduction • dual diagnosis • mental health services for the Deaf • management of substance misuse in acute psychiatric settings

48. Mental health and NICE: Guidelines • Schizophrenia • Depression • Eating disorders • Anxiety and related common mental disorders • Disturbed behaviour in acute settings • Deliberate self harm

49. Mental health and NICE: Appraisals • Atypical antipsychotics in schizophrenia • ECT • New drugs in bipolar disorder • Computerised CBT

50. Mapping the future NICE products • One possibility would be to consider relatively common conditions not yet covered • bipolar disorder; postnatal mental illness • or to consider areas where management very variable • dual diagnosis; insomnia; benzodiazepine dependence • areas where there is uncertainty • adult ADHD; medically unexplained symptoms