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Jcpmh.info

Guidance for commissioners of rehabilitation services for people with complex mental health needs 1 Joint Commissioning Panel for Mental Healthwww.jcpmh.info Guidance for commissioners of rehabilitation services for people with complex mental health needs Joint Commissioning Panel for Mental Healthwww.jcpmh.info 2 Practical Mental Health Commissioning Ten key messages for commissioners health rehabilitation services important to commissioners? service look like? Guidance for commissioners of rehabilitation services for people with complex mental health needs 3 Ten key messages for commissioners 1 Mental health rehabilitation services
4 People using rehabilitation
6 There is good evidence that
specialise in working with people
services are a "low volume, high
rehabilitation services are effective:
whose long term and complex needs
• around two-thirds of people cannot be met by general adult mental
• 80% have a diagnosis of a supported by rehabilitation services health services.
psychotic illness (schizophrenia or progress to successful community Rehabilitation services: schizoaffective disorder), and many living within five years, and around will have been repeatedly admitted 10% achieve independent living • provide specialist assessment, to hospital prior to referral to within this period9 treatment, interventions and rehabilitation services2 support to help people to recover • people receiving support from from their mental health problems • many experience severe rehabilitation services are eight and to (re)gain the skills and "negative" symptoms that impair times more likely to achieve/ confidence to live successfully in their motivation, organisational sustain community living, skills and ability to manage compared to those supported by everyday activities (self-care, generic community mental health • always work in partnership with shopping, budgeting, cooking etc) service users and carers, adopting and place them at risk of serious a recovery orientation that places 7 Investment in a local rehabilitation
collaboration at the centre of all care pathway is cost-effective:
• most have symptoms that have not • local provision of inpatient and responded to first-line medications • work with other agencies that community rehabilitation services and require treatment with support service users' recovery and ensures that service users with complex medication regimes social inclusion, including supported complex needs do not become accommodation, education and • around 20% have co-morbidities "stuck" in acute mental health employment, advocacy and peer such as other mental disorders, support services.
physical health problems and • historically, where there is a lack substance misuse problems that 2 Rehabilitation services are not the
of local provision, service users with complicate their recovery further6,7 same as recovery services.
complex needs have been placed • most require an extended outside the local area in hospital, A recovery orientation should be at admission to inpatient rehabilitation nursing or residential care. Out of the centre of all health and social care services and ongoing support from area placements cost around 65% service provision to people with mental specialist community rehabilitation more than local placements, are health problems and is not limited to services over many years.
socially dislocating for service users rehabilitation services. and are of variable quality11 5 People with complex mental health
3 There is an ongoing need for
problems often require a large
• recent guidance for commissioners specialist rehabilitation services.
proportion of mental health resources.
on out of area placements Despite the investment in community emphasises the importance of Around one half of the total mental mental health services in recent provision of local care pathways for health and social care budget is decades, there remains a group of people with complex mental health spent on services for people with service users with very complex needs needs to minimise the use of out of longer term mental health problems. who require specialist inpatient and area placements12. Half of this (one quarter overall) is community rehabilitation. Around 10% spent on rehabilitation services and of service users presenting to mental specialist mental health supported health services for the first time with a psychotic illness will go on to require rehabilitation services due to the severity of their functional impairment and symptoms1. 4 Practical Mental Health Commissioning Ten key messages for commissioners (continued) 8 Commissioning a ‘good' rehabilitation
9 Mental health rehabilitation services
service includes components of care
require multidisciplinary staffing.
provided by the NHS, independent
Multidisciplinary teams are required in and voluntary sector:
inpatient and community rehabilitation • inpatient and community based services with the expertise to address rehabilitation units – for voluntary their service users' complex and diverse patients and those requiring needs including: complex medication detention under the Mental Health regimes; physical health promotion; psychological interventions, arts therapies; self-care; everyday living • community rehabilitation teams skills; and meaningful occupation.
– support service users when they leave hospital and/or move 10 The quality and effectiveness of
to supported accommodation; rehabilitation service provision can be
support supported accommodation assessed with simple indicators and
providers; liaise with providers to standardised outcome tools.
ensure that vacancies are matched This guidance recommends outcome with clinical priorities; facilitate measures and indicators that can be service users' move-on to less used to monitor the quality of services, supported accommodation flow through the care pathway and • supported accommodation better service user outcomes. services – these provide day to day support for service users to live in the community, and include nursing/residential care; supported tenancies; and floating outreach services • services that support service users' occupation and work; advocacy services and peer support services; and any services that support service users' social inclusion and rights.
Guidance for commissioners of rehabilitation services for people with complex mental health needs 5 The Joint Commissioning Panel The JCP-MH is part of the implementation WHo IS THIS guIde foR?
for Mental Health (JCP-MH) arm of the government mental health This guide is about the (www.jcpmh.info) is a new strategy No Health without Mental Health.13 commissioning of good quality col aboration co-chaired by The JCP-MH has two primary aims: mental health interventions and the Royal Col ege of General • to bring together service users, carers, services for people with complex Practitioners and the Royal clinicians, commissioners, managers and and longer term problems to Col ege of Psychiatrists, others to work towards values-based support them in their recovery. which brings together leading It should be of value to: organisations and individuals • to integrate scientific evidence, with an interest in commissioning service user and carer experience and • Health and Wel being Boards who wil have a key role in transforming for mental health and learning viewpoints, and innovative service evaluations in order to produce the best health and care and achieving better disabilities. These include: possible advice on commissioning the population health and wel being through design and delivery of high quality mental their responsibility for preparing Joint • Service users and carers health, learning disabilities, and public Strategic Needs Assessments (which • Department of Health mental health and wel being services.
should take account of the current and • Association of Directors future health and social care needs of of Adult Social Services the entire population), Joint Strategic • NHS Confederation • has published Practical Mental Asset Assessments, and Joint Health and Health Commissioning,14 a briefing on Wel being Strategies • Rethink Mental Il ness the key values and principles for effective • Clinical Commissioning Groups and Local • National Survivor User Network mental health commissioning Authorities as they wil jointly lead the • National Involvement Partnership • has so far published six other practical local healthcare system, through Health • Royal Col ege of Nursing guides on the commissioning of primary and Wel being Boards and in col aboration mental health care services15, dementia with their communities • British Psychological Society services16, liaison mental health services • Representatives of the English • The NHS Commissioning Board as this will to acute hospitals17, transition services18, Strategic Health Authorities support and hold to account the work of perinatal mental health services19, and • Mental Health Providers Forum Clinical Commissioning Groups public mental health services20 • New Savoy Partnership • Service providers including those in • Representation from • provides practical guidance and a primary and secondary care, social care, developing framework for mental health local authorities and third-sector providers • Healthcare Financial • wil support commissioners to deliver of supported accommodation and other the best possible outcomes for community services that promote social inclusion health and wel being including supported employment and other meaningful occupation • Public Health England as reducing mental disorder and promoting wel -being is an important part of their role and also contributes to a range of other public health priorities.
6 Practical Mental Health Commissioning Introduction (continued) What are mental health rehabilitation services? HoW WIll THIS guIde HelP you?
This guide defines mental health Rehabilitation services operate as a This guide has been written rehabilitation as: whole system that includes a range of inpatient and community services, by a group of rehabilitation A whole systems approach to supported accommodation and vocational service experts. recovery from mental illness rehabilitation services provided by that maximises an individual's statutory, independent and voluntary The content is primarily evidence-based sector organisations but ideas deemed to be best practice quality of life and social by expert consensus have also been inclusion by encouraging their The specific components required in skills, promoting independence any locality will vary according to local psychiatric morbidity and need and are By the end of this guide, readers should and autonomy in order to give described on pp.12-17. be more familiar with the concept them hope for the future and of rehabilitation services and better leading to successful community These pages also describe the functions of equipped to understand: living through appropriate these components and the interventions delivered by staff.
• the policy context for rehabilitation A mental health rehabilitation service Users of rehabilitation services often have • the importance of joined up health provides specialist assessment, treatment, co-morbid physical health problems and and social care commissioning of interventions and support to enable the close liaison with primary care services rehabilitation services recovery of people whose complex needs and, where appropriate, secondary care medical services is a key role for • the centrality of the service user cannot be met by general adult mental and carer voice in the commissioning health services. of rehabilitation services These services aim to work with people THe ReHABIlITATIoN CARe PATHWAy
• the importance of having a to help them acquire or regain the skills "whole system approach" in the and confidence to live successfully in the People who do not recover adequately commissioning of mental health community. They focus on addressing and after acute admission to a mental health rehabilitation services minimising the symptoms and functional unit to be able to be discharged home are referred to rehabilitation services. Therefore • the importance of providing a impairment that people may have, with an most referrals come from general adult local rehabilitation care pathway for emphasis on achieving as much individual inpatient services. Rehabilitation services people with complex mental health autonomy and independence as possible. also provide step-down for those patients needs, from inpatient care through This includes optimal management of moving on from secure mental health to supported housing and vocational symptoms, promotion of activities of services who have longer term and complex rehabilitation services daily living and meaningful occupation, mental health needs. • the key components of a screening for physical health problems and comprehensive rehabilitation service promoting healthy living, and providing Around 10% of people receiving care and the need for local tailoring of support and evidence based interventions from Early Intervention Services have the rehabilitation care pathway to to support carers. longer term and complex needs that will require input from rehabilitation services1. Rehabilitation services adopt a "recovery" However, most of these will be inpatients • the range of providers needed to approach that values service users as in a general or secure mental health deliver such a care pathway.
partners in a collaborative relationship inpatient ward at the point of referral.
with staff to identify and work towards personalised goals. The concept of Figure 1 (p.8) illustrates a typical recovery encompasses the values of hope, rehabilitation care pathway, showing the agency, opportunity and inclusion, themes "direction of travel" for service users with that resonate well with the aims of mental complex and longer term mental health problems, from inpatient services through to community living. The specifications of each are described in detail on pp.12-17.
Guidance for commissioners of rehabilitation services for people with complex mental health needs 7 A recent national survey of inpatient transition from a higher to a lower symptoms and severe negative symptoms, rehabilitation services2 has found that almost level of support. Those commissioning many people who use rehabilitation al NHS Trusts in England have at least rehabilitation services need to be aware services have co-existing problems one type of inpatient rehabilitation unit that a "long term view" has to be held for that make their presentation especially accepting referrals from acute admission this service user group.
complex and difficult to manage. These wards and secure mental health services, include other mental health issues (such but 60% of these units are actual y sited in WHo uSeS MeNTAl HeAlTH
as depression and anxiety), long term the community. Only 11% are wards within physical health conditions (such as a mental health unit and 29% are separate Despite developments in mental health chronic obstructive pulmonary disease units within the mental health unit's interventions and services that provide and cardiovascular disease), pre-existing grounds. Around one third of Trusts also early intervention to people presenting disorders (such as learning disability and have a low secure rehabilitation unit 22. with psychosis, around 10% of people developmental disorders including those on the Autistic Spectrum) and substance The exact configuration of inpatient entering mental health services will have misuse. These problems mean that many rehabilitation services varies in different particularly complex needs that require service users present with challenging localities according to need. Inner city rehabilitation and intensive support from behaviours including aggression to others6. areas, for example, tend to have greater mental health services over many years1. need for a high dependency inpatient At any time, around 1% of people with Most have considerable disability and rehabilitation unit within the mental schizophrenia are in receipt of inpatient impaired mental capacity to make health unit. Taking this approach allows rehabilitation6. everyday decisions. They can be vulnerable service users to generally move on to a A recent national survey of inpatient to exploitation and abuse by others and community based rehabilitation unit in mental health rehabilitation services may require safeguarding.
preparation for more independent, but across England found that 80% of those In short, mental health rehabilitation supported community living. Most (67%) using these services had a diagnosis of service users are a "low volume, high people who require inpatient rehabilitation, a psychotic illness, usually schizophrenia whether delivered in a hospital or or schizoaffective disorder. Two-thirds of community based unit, are able to move It is likely that, in addition to those patients service users were male, reflecting the fact on successfully to some form of supported that receive support from mental health that men diagnosed with schizophrenia accommodation within five years9. rehabilitation services, there is a larger tend to have a poorer prognosis than group of people living in the community, Community rehabilitation services work women. On average, service users had diagnosed with schizophrenia, who have closely with supported accommodation experienced mental health problems not been adequately supported to achieve services to provide comprehensive for 13 years and had been recurrently their full recovery potential. Sometimes support to service users as they continue admitted to hospital prior to referral for these people will be receiving support their recovery in the community. When from general adult mental health services service users are able to manage with less Mental health rehabilitation service but considered "stable". Some may not support they move on to less supported users often have prominent "negative" be receiving care from secondary mental accommodation. Once they are able to symptoms that impair their motivation health services but are known to their manage more independent living, their and organisational skills to manage GP. A large "clinical iceberg" of under care is transferred from the rehabilitation everyday activities3,4,5. This places them treatment is suspected. There is good service to a standard community mental at risk of self-neglect. Many also have evidence that clozapine, a medication health service. However, only around 10% ongoing "positive" symptoms (such as prescribed for people with "treatment of service users wil achieve and sustain delusions and hallucinations) which have resistant" symptoms, is under used in the ful y independent living within five years of not responded fully to medication and can community. It is likely that community referral into rehabilitation services9. make communication and engagement mental health teams have not been able It takes a number of years for service users difficult6. It is estimated that around to focus on this group due to many other to move successfully through each step of one third of people with a diagnosis of competing priorities. Improving access to the rehabilitation care pathway due to the schizophrenia do not respond adequately appropriate multidisciplinary and multi- severity and complexity of their mental to antipsychotic medication23.
provider resources, including rehabilitation health needs. Service users often need to As well as "treatment resistant" positive services, is needed to maximise recovery make repeated attempts to successfully for this group.
8 Practical Mental Health Commissioning What are mental health rehabilitation services? (continued) Figure 1: Components of a "whole system" rehabilitation care pathway Services that make Local inpatient mental Community services that support referrals to local health rehabilitation rehabilitation and recovery from complex rehabilitation services mental health problems • Medium secure forensic Low secure rehabilitation PRIMARy CARe
mental health units unit (30% of NHS Trusts SeCoNdARy CoMMuNITy MeNTAl
provide these local y) HeAlTH ANd SoCIAl CARe SeRVICeS
Community Rehabilitation Team
• Low secure forensic mental Assertive Outreach Team health units (regional) Community Mental Health/Recovery Team rehabilitation unit Primary Care Liaison Team (hospital based) • Psychiatric intensive care Supported
other services that support
• Acute inpatient units based "inpatient" • Nursing/residential care • Vocational rehabilitation rehabilitation unit • Supported tenancies (sheltered and supported employment, voluntary Longer term complex care (support on-site) work, welfare benefits rehabilitation unit (hospital • Supported tenancies or community based) (floating outreach ) • Education• Advocacy services• Peer support • Cultural/leisure services WHICH "CluSTeRS" ARe ReleVANT?
As people's symptoms and life skills Those who achieve independent living improve over time, their "cluster" may may ultimately be categorised into Cluster With reference to the Mental Health be re-categorised to reflect their change 11. This group will not need ongoing Clustering Tool (HoNOS), the majority of in needs. Those who are able to move to community mental health rehabilitation people in receipt of inpatient mental health supported accommodation successfully are services. Some may continue to be rehabilitation services are likely to be most likely to be categorised as Cluster 12 supported by other community mental categorised as Cluster 13: and will require ongoing, flexible support health services with the aim of eventual Cluster 13: Complex needs, High Support
from community rehabilitation services discharge from mental health services to "This group will have a history of and/or other community mental health primary care services: psychotic symptoms which are not services to sustain their recovery and Cluster 11: Complex needs, Standard
controlled. They will present with severe to very severe psychotic symptoms and Cluster 12: Complex needs, Medium
"This group has a history of psychotic some anxiety or depression. They have a symptoms that are currently controlled significant disability with major impact on "Possible cognitive and physical problems and causing minor problems if any at all. role functioning. They will have possible linked with long-term illness and They are currently experiencing a period of cognitive and physical problems linked medication. May have limited survival skills recovery where they are capable of full or with long-term illness and medication. and be lacking basic life skills and poor role near functioning. However, there may be They may be lacking basic life skills and functioning in all areas. This group have impairment in self-esteem and efficacy and poor role functioning in all areas".
a history of psychotic symptoms with a vulnerability. This group may have full or significant disability with major impact on near full functioning".
role functioning". Guidance for commissioners of rehabilitation services for people with complex mental health needs 9 Assertive Outreach Teams (AOTs) Longer term studies of people with a HoW do MeNTAl HeAlTH
are most likely to work with patients diagnosis of schizophrenia have shown ReHABIlITATIoN SeRVICeS WoRK
categorised as Cluster 16 or 17 who may that half to two-thirds significantly WITH oTHeR AgeNCIeS?
be living independently or in supported improve or recover over time24,25. Rehabilitation services operate as a whole accommodation. AOTs are specialist There is also good evidence that even system that includes a range of other community teams that offer intensive amongst those with complex problems, agencies and organisations. Collaborative support to people living in independent with appropriate rehabilitation, the and partnership working is key to this. It or low support tenancies. They comprise majority (two-thirds) are able to progress helps ensure the provision of a holistic an important component of the local care successfully to supported community and comprehensive care pathway that can pathway for people with longer term and living within five years and around 10% support service users to make incremental complex mental health needs. Many are will achieve independent living9,26. This improvements in their everyday and social commissioned and managed as part of suggests that therapeutic optimism is functioning, and to successfully take the local rehabilitation service, hence their neither idealistic nor misplaced.
on increasing levels of responsibility in inclusion in this guide: A prospective cohort study carried out managing as many aspects of their own Cluster 16: dual diagnosis
in Ireland that compared service users life as possible. in receipt of mental health rehabilitation "This group has enduring, moderate to Rehabilitation services and the wider network services with those receiving care from severe psychotic or affective symptoms of services with which they work develop general adult mental health services who with unstable, chaotic lifestyle and strong links with local community resources to had similar levels of complex needs and co-existing substance misuse. They facilitate service users' social inclusion.
were wait listed for rehabilitation services, may present a risk to self and others found that those receiving treatment Similarly, productive partnerships with users and engage poorly with services. Role and support from rehabilitation services and carers are needed to ensure that local functioning is often globally impaired".
were eight times more likely to achieve provision is adequate to enable recovery Cluster 17: Psychosis and affective
and sustain successful community living and to support informal support networks.
disorder, difficult to engage
eighteen months later10.
Integrated health and social care "This group has moderate to severe A five year programme of research, commissioning is therefore required to psychotic symptoms with unstable, chaotic funded by the National Institute for Health ensure that the local rehabilitation care lifestyles. There may be some problems Research and led by a team at the Mental pathway is appropriate for the local with drugs or alcohol not severe enough to Health Sciences Unit, University College population, that there are functional warrant dual diagnosis care. This group have London, is currently investigating the and productive partnerships between a history of non-concordance, are vulnerable clinical and cost-effectiveness of mental providers to inform this provision, and it and engage poorly with services". health rehabilitation services in England is appropriately used to enable people to (the "REAL" study - Rehabilitation move on smoothly between services. HoW effeCTIVe ARe MeNTAl
Effectiveness for Activities for Life). Commissioners and providers also need HeAlTH ReHABIlITATIoN SeRVICeS?
This includes a national survey of inpatient to take account of the personalisation Due to the complex nature of their rehabilitation services which found that approach within social care. A ful description problems, mental health rehabilitation the quality of services was positively is beyond the scope of this document, but services often work with their clients over associated with service users' experiences in short, personalisation aims to ensure many years, enabling them to gain/regain of care and autonomy2. Later phases will that social care services are tailored to confidence and skills in everyday activities report in 2014 on longitudinal outcomes the needs of every individual, rather than and in managing their mental health including social functioning and successful delivered in a one-size-fits-al fashion. It is community living. (www.ucl.ac.uk/REAL- – to paraphrase the Department of Health Maintaining expectations of recovery over - an approach where "every person who long periods of time can be difficult for receives support…wil have choice and staff, service users and carers. A major control over the shape of that support in aspect of the ethos of rehabilitation al care settings". (For further information services is the continuous promotion of on personalisation in social care, please therapeutic optimism. 10 Practical Mental Health Commissioning Why are mental health rehabilitation services important to commissioners? People with especial y complex • Out of area treatments are expensive, • In times of increasing constraints on mental health needs cannot be costing, on average around 65% more resources it is imperative for local mental adequately managed by general than similar local services11. In 2008-9, health economies that this money is out-of-area placements cost the NHS spent effectively. ‘Repatriating' people adult mental health services and social services around £330 mil ion8. to local services and helping them live since their particular needs Historical y, most placements were as independently as possible is likely to require specialist assessment and commissioned by Primary Care Trusts, benefit the individual as wel as saving treatment (see p.14-15). and – as clinical commissioning groups money which could be used in more may discover – there are often inadequate useful ways.
This group often require lengthy systems for monitoring the quality of care admissions and ongoing intensive support • Recent guidance for commissioners and the ongoing need for the level of from rehabilitation and other mental on out of area placements has been support provided31. health services to live in the community produced by the National Mental Health successful y after discharge. Despite being a • Service users placed in out-of-area Development Unit. (www.rcpsych.ac.uk/ relatively smal group, they absorb around facilities have similar profiles in most pdf/insightandinmind.pdf) This stresses 25% of the total mental health budget27.
respects to those placed local y32. the importance of provision of local care Rehabilitation psychiatrists and other pathways for people with complex mental As described earlier, a recent study in experienced rehabilitation clinicians health needs to minimise the use of Ireland found that people with complex should be involved in assessing the out of area placements to the particular mental health needs were eight times more appropriateness of making individual out circumstances where clinical complexity is likely to achieve and/or sustain successful of area placements and reviewing the such that local provision would be clearly community living if they were supported needs of people placed in them in order by mental health rehabilitation services as to clarify whether local services could compared to general adult mental health Since there is geographical variation in provide a better alternative. sociodemographic characteristics and • General adult mental health services are psychiatric morbidity, the exact components Investment in local rehabilitation services unlikely to have the appropriate skil s to of the rehabilitation care pathway that can reduce ‘out-of-area' treatment costs. assess and review people placed out of wil be required in different areas are likely • Disinvestment in NHS rehabilitation area with a view to repatriation. "Out services after the publication of the of area reviewing officers", supported More details on which components of National Service Framework for Mental by rehabilitation psychiatrists and other the rehabilitation care pathway should be Health28 led to a rapid and uncontrol ed clinicians are required for this role. provided local y, and which are more likely rise in provision of ‘out-of-area Without them, many individuals become to be required at a regional level are given placements' in hospital, nursing and "stuck" in placements unnecessarily with on pp.12-17.
residential care homes in the independent no clear care pathway back to their local sector for people with longer term and Commissioning of a local rehabilitation complex mental health problems who care pathway wil be informed by the • Lack of clarity about commissioning and could not be discharged from acute local Joint Strategic Needs Assessment for housing responsibility when individuals admission wards12,28. mental health which should include data on wish to settle in an "out of area" locality individuals currently residing in out of area • This phenomenon has been referred further complicates the situation. It placements due to their complex mental to as the ‘virtual asylum' since, until highlights the importance of integrating health needs.
recently, there was little attention paid to commissioning between health and local the ongoing review of these individuals' council social care and housing resources Successful joint strategic commissioning needs and their potential for recovery and for this group.
of health and housing for this group progress to more independent living29. wil require good co-operation between commissioners, enhanced and supported • Out of area placements displace service by Health and Wel being Boards, and users from their communities and families. the alignment of resources from clinical Furthermore, criticisms of the quality of commissioning groups and local authorities care and lack of rehabilitative ethos in to enable people to achieve their maximum some have been made30. level of independence33.
Guidance for commissioners of rehabilitation services for people with complex mental health needs 11 What do we know about current mental health rehabilitation services? While the Royal College The importance of providing a local of Psychiatrists' Faculty of rehabilitation care pathway to minimise Rehabilitation and Social the use of out of area placements has been emphasised in a number of policy Psychiatry has produced a documents including: template for rehabilitation services (upon which this • guidance produced by the National Mental Health Development Unit for the commissioning guidance is Department of Health12 based)34, there is no nationally agreed service specification • Mental Health and the Economic Downturn; national priorities and within the UK for mental health rehabilitation. Nevertheless, almost all NHS The implementation guide to the Mental Health Strategy; No Health Without Trusts have at least one high Mental Health also supports investment dependency inpatient or in rehabilitation services13.
community based rehabilitation Similarly, the supporting document to the unit per Local Authority area Mental Health Strategy, "The economic with an average 14 beds. case for improving efficiency and quality Over a half of Trusts have a in mental health services" also emphasises community rehabilitation team2. the need for local investment in a rehabilitation care pathway to reduce Around 25% of the total mental health the need for out of area placements36.
budget is absorbed by rehabilitation services and supported accommodation for people with longer term and complex mental health needs. This proportion expands to around 50% if the wider family of services that provide for this group are included (including standard general adult services). Much of this spending on rehabilitation falls within mainstream health and social care services8.
12 Practical Mental Health Commissioning What would a good mental health rehabilitation service look like? An effective rehabilitation Inpatient rehabilitation services require a • Recovery goal: to move on to a service requires a managed range of different facilities that work as high dependency or community functional network of services part of an interdependent system, rather than stand-alone units. Only the largest across a wide spectrum of care, • Site: stand alone unit or within a NHS Trusts will provide a full spectrum and the exact components of hospital campus.
of inpatient rehabilitation services. Most the care pathway provided will work with other providers in the • Length of admission: 2 years plus; should be determined by local independent sector or NHS to provide a variable, depending on the nature of need. These comprise: comprehensive inpatient care pathway. the offending or challenging behaviour Very specialist services, for example units • inpatient and community based for people with co-morbid conditions such • Functional ability: domestic services rehabilitation units as mental health problems and brain injury provided by the unit rather than or Autism Spectrum Disorders, can only be • community rehabilitation teams its residents, although participation provided supra-regionally whereas those • supported accommodation services in domestic activities with support offering rehabilitation in high dependency encouraged as part of therapeutic • services that support service users' and/or community rehabilitation units occupation and work should be available locally. Around one • advocacy services third of Trusts provide a local low secure • Risk management: higher-staffed units rehabilitation unit. Other Trusts access able to manage behavioural disturbance • peer support services.
low secure services through out of area with full range of physical, procedural Some of the components of the placement or through regional forensic and relational security and specialist risk rehabilitation care pathway may be assessment and management skills.
provided by independent and third sector A full range of inpatient services should be • Degree of specialisation: one unit is organisations. Pathways through these provided across the dimensions and types needed for a population over 1 million.
services should be as seamless as possible, described below. which will be dependent on good working High dependency inpatient relationships between the components. Typology of inpatient rehabilitation units
Commissioners play a key role in facilitating these relationships. Low secure rehabilitation units • Client group and focus: people who need this kind of facility will be highly • Client group and focus: this group has INPATIeNT ReHABIlITATIoN SeRVICeS
symptomatic, with multiple or severe diverse needs but have all have been co-morbid conditions, significant risk An inpatient service is a unit with involved in offending or challenging histories and challenging behaviours. ‘hospital beds' that provides 24-hour behaviour. They will all be detained Most will be detained under the Mental nursing care. It is able to care for patients under the Mental Health Act 1983 and Health Act. Around 20% will have detained under the Mental Health the majority under Part 3 of the Act. had forensic admissions. The focus Act, with a consultant psychiatrist or Levels of security will be determined by is on thorough ongoing assessment, other professional acting as responsible Ministry of Justice requirements and a maximising benefits from medication, clinician. This does not mean that all key task will be the accurate assessment engagement, reducing challenging or even a majority of patients will be and management of risk. Clients will behaviours and re-engaging with detained involuntarily. All units should have varying levels of functional skills families and communities. These units have access to the full range of skills and are likely to require therapeutic have a major role in repatriating patients of a multi-professional team. As most programmes tailored to their offending from secure services and out-of-area rehabilitation service users will require behaviour in addition to their mental placements to local services and, lengthy inpatient treatment, rehabilitation ultimately, to local community living.
units should provide a safe and homely space that fosters stability and security, • Recovery goal: to move on to avoids institutionalisation and provides the community rehabilitation unit or to experience for service users of non-abusive supported community living.
Guidance for commissioners of rehabilitation services for people with complex mental health needs 13 • Site: ward usually based in the local • Risk management: "open" units, staffed • Degree of specialisation: should be mental health unit to benefit from 24 hours by nurses and support workers available in all Trusts. One unit is needed support from other wards and out with regular input from other members for a population of around 600 000.
of hours cover.
of the multidisciplinary team. Specialist risk management skills are essential.
Highly specialist units • Length of admission: 1 to 3 years.
• Degree of specialisation: should be These units provide specialist treatment • Functional ability: domestic services available in all Trusts. One unit is needed programmes for people with very provided by the unit, although for a population of around 300 000.
particular and complex mental health participation in domestic activities needs and co-morbidities (e.g. acquired with support encouraged as part of Longer term complex care units brain damage, severe personality disorder, autism spectrum disorder). • Client group and focus: patients will • Risk management: higher-staffed (often They are provided at a super-regional usually have high levels of disability locked/lockable) units able to manage or national level and are therefore likely from complex co-morbid conditions, to be commissioned by the National with limited potential for gaining skills • Degree of specialisation: should be required for supported community available in all Trusts. One unit is needed living, and have associated, significant CoMMuNITy ReHABIlITATIoN
for a population of 600 000 to 1 million.
risks to their own health and/or safety and/or to others. Co-morbid serious Community rehabilitation units physical health problems are common A substantial proportion of people with severe mental illness continue to have • Client group and focus: people and will require ongoing monitoring significant problems with social and with complex mental health needs and treatment.
personal functioning many years after who cannot be discharged directly • Recovery goal: other rehabilitation diagnosis, despite optimum treatment. from hospital to an independent or options will usually have been tried Around 10% of service users presenting supported community placement due unsuccessfully; disability and risk issues for the first time with a psychotic illness, to their ongoing high levels of need. remain but a more domestic setting that will go on to require rehabilitation services The focus is on facilitating further offers a high level of support is practical. due to the severity of their functional recovery, optimising medication The emphasis is on promoting personal impairment and symptoms1. regimes, engagement in psychosocial recovery and improving social and interventions and gaining skills for more interpersonal functioning over the longer Most are not so disabled or behaviourally independent living. disturbed that they require long-term hospital care, nor so difficult to engage • Recovery goal: to achieve a successful • Site: usually community-based, or so high-risk as to require assertive return to community living. Most people sometimes on a hospital campus.
outreach, but their problems place them at will move on to a supported tenancy.
• Length of admission: 5-10 years.
risk of social isolation, self-neglect, relapse • Site: local, community based unit into acute illness, inability to cope and • Functional ability: domestic services providing a domestic environment that exploitation in community settings. provided by the unit rather than facilitates service users' confidence its residents, although participation At present, 51% of NHS trusts have a and abilities in managing activities in domestic activities with support community rehabilitation team2. The of daily living (self-care, shopping, encouraged as part of therapeutic skills of these teams provide a key role in cooking, budgeting etc) and promotes keeping the whole system of supported engagement in community based accommodation moving, by supporting • Risk management: higher staffed units clients and supported accommodation but with emphasis on unqualified • Length of admission: 1-2 years.
providers to enable through-put. support staff; risk management based • Functional ability: domestic on relational skills and environmental Referrals to community rehabilitation environments that facilitate service services are received from early users to acquire everyday living skills intervention services, from assertive in preparation for more independent outreach teams for clients who are community living.
now well engaged but have ongoing 14 Practical Mental Health Commissioning What would a good rehabilitation service look like? (continued) problems with everyday living skills, from • hold therapeutic optimism for clients – re/engage with family and friends community mental health teams for and plan for a potential move to a more – access personal budgets as clients whose functional needs are too independent setting (no service user is appropriate to support their severe to be managed by general adult assumed to be in a placement likely to individualised recovery goals services and from inpatient (general adult, suit their needs forever) rehabilitation, low and medium secure • providing support to: • build and maintain partnerships services), nursing and residential care with local providers of supported – clients' families and informal carers homes (both local and out of area) for accommodation, education and clients who are ready to move to a less – staff in supported accommodation to vocational rehabilitation services and supported, community based setting.
increase their confidence in managing other community resources people with complex mental health The main functions of community • work closely with commissioners rehabilitation services are to: to scope and review the ongoing • managing safeguarding assessments.
• care co-ordinate – around 15% of supported accommodation needs of community rehabilitation teams provide the local population out of area placement review
full CPA care co-ordination21, or this • have expert knowledge of the function is provided by the This can be effected through a dedicated availability, referral and funding local community mental health team team, or individuals within a community processes required to access supported (the care co-ordinator provides rehabilitation service, depending on the continuity of care, will often have number of clients placed out of area. known the client for many years, and • keep clear discharge criteria to ensure The aims of the review are to: will remain in contact if the client is ongoing access for new clients • ensure that the placement continues to admitted to hospital and are involved • review clients placed out of area.
meet the person's needs in making referrals to appropriately supported accommodation prior to The specific interventions provided by • identify an appropriately supported, discharge, facilitating the person's access community rehabilitation services include: (ideally more independent) placement to appropriate welfare benefits, adult • holistic multidisciplinary assessment for the client to move-on to in the protection procedures, other legal issues and formulation of individualised, future, ideally in their area of origin including use of the Mental Health collaborative care plans that enable (where desired and clinically indicated) Act and Mental Capacity Act where recovery and social inclusion • identify with the client and the staff necessary, and in all aspects of care of the out of area placement, clear planning required on discharge to the • clinical interventions to minimise goals for progression through the symptoms (e.g. psychological interventions and support with pathway being identified (e.g. managing • provide support to clients as they medication management) medication more independently, move from hospital to supported accommodation and from higher to • practical support to enable clients to • facilitate assessment by the potential less supported accommodation maintain their placement/tenancy (e.g. access to appropriate welfare benefits, move-on accommodation provider at an • enable clients to gain confidence help with budgeting, paying bil s, in their everyday living skills, their assistance with activities of daily living • liaise with all parties, including family self-management of their illness and such as shopping, cooking and cleaning) members, and support the client and medication, and their day to day life • supporting clients to: family practically and emotionally • widen clients' social networks through the assessment and move-on – access appropriate physical and process, including visits, transitional • support clients to build "meaningful dental health care including attending leave and final move occupation" into their daily routine primary and secondary medical care appointments • continue to review the new placement if out of area, or hand over case to local – access social, cultural and leisure community mental health/rehabilitation activities, education and vocational service after an appropriate settling period.
Guidance for commissioners of primary mental health care services 15 TReATMeNTS ANd INTeRVeNTIoNS
the team may be involved in promoting delIVeRed By INPATIeNT ANd
healthy living, but medical team members CoMMuNITy MeNTAl HeAlTH
Psychological therapies (such as cognitive lead on physical health assessment and ReHABIlITATIoN SeRVICeS
behaviour therapy for psychosis and family appropriate referral and treatment for interventions) promote communication and Mental health rehabilitation inpatient co-morbid physical health problems. understanding of an individual's mental and community services are staffed by This is especially relevant in relation to health problems and identify strategies multidisciplinary teams with the expertise to regular screening for known side effects that can be helpful in reducing distress and address the complex and diverse treatment of medication. As individuals progress unhelpful interaction patterns. Individualised needs of their clients. Ideal y, some staff towards community living, liaison with problem solving and goal setting are also provide continuity of care by working general practitioners becomes increasingly crucial parts of the rehabilitation programme. across inpatient and community settings. relevant to ensure adequate monitoring Clinical psychologists also offer consultation Al staff deliver their specialist interventions and treatment of physical health to the staff team to develop psychological within the col aborative framework of the problems continues outside the inpatient formulations of the clients' difficulties, which recovery approach. Given the complexity support positive relationships between of the client group, the team should have staff and clients, therapeutic optimism and Self-care, everyday living skills and access to regular group and individual creative interventions. Whenever possible, supervision to share concerns and staff work with clients to help them develop problem solve. Wherever possible, specific Nurses, support workers and occupational self-management strategies. Clinical interventions are delivered in accordance therapists are key to helping service users psychologists may also provide training with NICE guidance37,38. gain/regain the confidence and routine and supervision to other staff to provide involved in managing their medication "low intensity" psychological interventions, and activities of daily living (self-care, such as behavioural activation, anxiety Many people are referred for rehabilitation keeping their living space clean, laundry, management and relaxation techniques, because they have not responded shopping, budgeting, cooking). They relapse prevention, and motivational adequately to medications, often including also support service users to access and interviewing for co-morbid substance those prescribed for ‘treatment resistance'. engage with community leisure activities The ability to find the best medication (e.g. cinema, sport) and vocational regime to minimise symptoms without Arts Therapies rehabilitation activities (e.g. education, producing distressing or physically harmful training and employment). Occupational Arts Therapies (art, drama, music, side-effects is a key skill for rehabilitation therapists can identify specific functional dance) are delivered in around one third psychiatrists. Special expertise in the use problems that the service user may have of inpatient rehabilitation units across of clozapine, other atypical antipsychotic and contribute to care plans to address England21. Arts therapies combine art and medications and mood stabilisers and the these. They will often organise and psychotherapeutic techniques to enable use of combination of therapies is a key facilitate individual and group activities on service users' communication, expression competence. Their expertise in managing inpatient and community rehabilitation and understanding in the context of an treatment resistant conditions means that units and develop links with local interpersonal therapeutic relationship rehabilitation psychiatrists are also called resources to facilitate community based as part of the recovery process. Arts on to review patients in other parts of activities. Techniques such as motivational Therapies for the treatment of negative the service and to advise colleagues on interviewing and behavioural programs, symptoms of schizophrenia are supported treatment. They also identify when referral supervised by clinical psychologists, can by NICE Guidelines38.
to a tertiary service for very specialist be particularly helpful in assisting staff advice and treatment is required (such as Healthy living to engage clients with severe negative the National Psychosis Unit).
Guidance and support to improve symptoms who struggle with motivation.
unhealthy lifestyles (such as exercise, smoking cessation and dietary advice) and monitoring of physical health are an essential component of a high quality rehabilitation service. All members of 16 Practical Mental Health Commissioning What would a good rehabilitation service look like? (continued) SuPPoRTed ACCoMModATIoN
Although, historically, nursing care each service annually. This study called has been considered an NHS financial for further research into the effectiveness responsibility and other forms of supported of different models of supported People with mental health problems need accommodation were considered the accommodation since they appear to have good quality housing and appropriate responsibility of Local Authorities, the developed without an evidence base. support to facilitate their recovery and mixed economy of provision and greater ability to manage independent living in Most supported accommodation pathways integration of mental health and social the future. People with mental health are designed for service users to move care services in general, has led to a conditions are twice as likely as those to more independent settings as their blurring of this distinction. Many service without to be unhappy with their housing skills improve. This allows for graduated users require care packages that include and mental ill health is frequently cited "testing" but many users dislike repeated health and social care inputs and local as a reason for tenancy breakdown39.
moves. Recently, there has been increased mental health services provide care Housing problems often contribute investment in supported flats rather than co-ordination and additional support to the stresses that lead to relapse of group settings since many services users to the residents and staff of supported mental health problems and admission prefer their own independent living space, accommodation projects through the to hospital, and lack of availability of though some service users and family Care Programme Approach. It is therefore suitably supported accommodation often members have reported that independent not meaningful to separate "health" and contributes to delayed discharges. The tenancies are socially isolating. "social care" investment in mental health provision of supported housing is therefore supported accommodation services. Evaluations of American models of mental an important factor in enabling the social health supported housing have shown inclusion of this group39.
Despite the economic cost of supported some benefits in reducing other welfare accommodation, there has been very In England, a considerable proportion of and health system costs, through lowering little research to investigate the types of working age adults with severe mental the frequency of unplanned psychiatric support delivered and their effectiveness. health problems reside in supported admissions, reducing homelessness The only survey of mental health accommodation provided by health and and contacts with the criminal justice supported accommodation to be carried social services, voluntary organisations, out in England sampled 250 services housing associations and other and over 400 service users from 12 In the absence of a clear evidence base, independent providers. These include geographically representative regions41. most localities provide a spectrum of nursing and residential care homes, group They found few differences in service user supported housing designed to meet local homes, hostels, blocks of individual or characteristics between those residing in needs. These need to be developed in shared tenancies with staff on site, and nursing/residential care homes, supported partnership with health, local authorities, independent tenancies with "floating" (staffed) housing and floating outreach independent and third sector providers and or outreach support from visiting staff. projects: the majority were male, 80% in reference to the Joint Strategic Needs Around half of all clients with disabilities had a diagnosis of a psychotic disorder Assessment and will include: accessing housing support through the and 48% also had a substance misuse "Supporting People" programme in • nursing and residential care homes history. Around 40% of those in supported 2008/09 defined themselves as having a housing or receiving floating outreach • supported housing; group, shared or mental health problem and half of these were participating in some form of individual tenancies with staff on-site were subject to the Care Programme community activity (compared to 25% of Approach (CPA), indicating high mental • floating outreach services that provide those in residential care) but only 3% were health needs40.
visiting (off-site) support to individuals in open employment. Although residential in independent tenancies.
care settings had a higher proportion of trained mental health staff than the other services, almost all service users in all types of setting were prescribed medication and all services provided support with personal care and activities of daily living. Between 18 and 25% of residents moved on from Guidance for commissioners of primary mental health care services 17 SeRVICeS THAT SuPPoRT
Individual Placement and Support (IPS)
AdVoCACy SeRVICeS
oCCuPATIoN ANd WoRK
aims to get people with mental health These provide independent advice and problems into competitive employment Supporting people with mental health support to people with mental health through training and support on the problems to access meaningful occupation problems to get their voice heard and job. Some IPS services also help clients and work is important in helping to have their rights protected. Advocacy develop their CVs, conduct mock maximise their recovery since occupation can be paid for or provided voluntarily. interviews (including ‘how to' disclose forms an important part of everybody's It can be provided on an individual, one a mental health problem), and provide personal and social identity. Although to one basis, or through self-advocacy, longer term support such as mentoring occupation is often equated with work, group or peer advocacy. Some people who and coaching, whereas in other areas employment rates for people with severe are subject to either the Mental Health these supportive functions are carried out mental health problems are very low. Capacity Act or Mental Health Act are by other specialist employment services This is due to many reasons including the entitled to access formal advice from an for people with mental health problems.
functional impairments associated with the Independent Mental Capacity Advocate illness, discrimination by employers, and • prevocational training programmes
(IMCA) or Independent Mental Health the "benefits trap" that can make part- provide preparatory work training in a Advocate (IMHA). time and graduated working financially sheltered environment to help service unviable. A major focus of rehabilitation users become re-accustomed to working PeeR SuPPoRT SeRVICeS
services is the facilitation of service users' and to develop the skills necessary for This involves the use of people with meaningful occupation, including hobbies, later competitive employment. Some experience of mental health problems leisure activities and social engagements, services (particularly the "Clubhouse" to provide individualised support and through to educational and vocational model) offer transitional employment expertise about treatment and care to courses, voluntary, supported and paid schemes which provide time limited people with mental health problems. employment. Occupational therapists play work experience in a mainstream This is an evolving field which is a key role here in making links with local employment setting. recognised within policy as having the community resources (e.g. cinemas, gyms, • welfare benefits advice services should
potential to transform the outcomes of colleges and employment organisations) be available to provide independent people with mental health problems, and and, along with nursing staff, support and free benefits advice to address where a number of services are already workers and activity workers, in supporting service users' concerns about the reporting positive experiences45. The service users to access and engage with impact on their benefits of entering into evidence base for peer support reflects these. It is vital that occupational care employment, and to ensure they are the fact that this is an initiative in its plans are developed with service users to claiming all the benefits they are eligible early stages in the UK, with some studies reflect their interests and goals and that for. Access to debt advice can also be concluding that peer support may lead there is a recognition that not all service beneficial for some service users.
to a reduction in admissions and health users are able, or wish, to work.
volunteering services can also assist
There are two main types of vocational people in getting back into employment rehabilitation service - prevocational through part-time, flexible posts training and supported employment. The that help them learn new skills, gain National Institute of Clinical Excellence confidence and reduce social isolation.
recommend that supported employment programmes should be provided for people with schizophrenia who wish to return to work or gain employment. However, they should not be the only work-related activity offered when individuals are unable to work or are unsuccessful in their attempts to find employment38.
18 Practical Mental Health Commissioning What would a good rehabilitation service look like? (continued) ASSeSSINg THe effeCTIVeNeSS
B the Camberwell Assessment of Needs
The Quality Indicator for Rehabilitative
ANd QuAlITy of MeNTAl HeAlTH
Short Appraisal Schedule (CANSAS).
Care (QuIRC) is a web based self-
This is a widely used, brief and easily assessment tool for mental health Metrics that can be used to assess the completed measure which has good rehabilitation wards and community based demand for mental health rehabilitation psychometric properties. It reports rehabilitation facilities that provide 24 services and the quality of response to on met, unmet and total needs in hour support to people with longer term referrals, include the number of referrals, 22 domains and may be especially mental health problems. It is completed by time from referral to assessment and time important for rehabilitation services the manager of the facility and has been from acceptance to transfer to a mental to evidence the degree to which they validated against service user experiences health rehabilitation facility.
are addressing service users' complex of care. It has excellent psychometric problems (i.e. by increasing the properties is free to use and takes around Length of stay in each component of the proportion of met to unmet needs) even 60 minutes to complete. It provides an inpatient rehabilitation care pathway and when total needs don't change (as is accessible report of the unit's performance supported accommodation will help assess often the case for people with complex showing its percentage scores, and those whether the whole system is working of similar units across England, on seven domains of care (Living Environment; Similarly, readmissions and placement SeRVICe QuAlITy
Therapeutic Environment; Treatments breakdowns will identify where discharge The Royal College of Psychiatrists'' Centre and Interventions; Self-management plans have not provided adequate support.
for Quality Improvement has recently and Autonomy; Human Rights; Social Inclusion; Recovery Based Practice). The In addition to the Health of the Nation established an accreditation programme QuIRC has been incorporated into the Outcome Scale (HoNOS), and service for inpatient mental health rehabilitation AIMS-Rehab programme and the REAL user satisfaction scales used across all units, along the same lines as its other study. Thus, national quality benchmarking mental health services, two staff-rated "AIMS" (Assessment of Inpatient data are now available for inpatient mental standardised outcome measures have Mental Health Services) Programmes. health rehabilitation units across England. been recommended by the Royal College The AIMS-Rehab programme provides
Later phases of the REAL study will help to of Psychiatrists for the clinical assessment a comprehensive quality assessment identify the aspects of care that are most of mental health service users that can be of units registered with them, that clinically and cost-effective48,49.
used at the individual and group level47. includes assessment of quality standards Both are free to use: agreed by an expert reference group through review of policies, processes and A the Social functioning Questionnaire
protocols, interviews and assessments (SFQ). This measure was developed with staff, service users and carers originally by Paul Clifford and Isobel and a visit by a peer assessment team Morris for the assessment of mental (rehabilitation practitioners from another health rehabilitation service users. It has organisation). It is possible that the Care only recently undergone psychometric Quality Commission will increasingly assessment but appears to have good use AIMS accreditation as a key part of reliability and validity, is quick to the evidence for registering inpatient complete and provides a useful graphical units. (www.rcpsych.ac.uk/quality/ presentation of the results. Guidance for commissioners of rehabilitation services for people with complex mental health needs 19 Supporting the delivery of the mental health strategy The Joint Commissioning Panel Shared objective 3: Shared objective 5: for Mental Health believes that Fewer people with mental People receiving care and commissioning which leads to health problems will die support should have confidence effective rehabilitation service prematurely, and more people that the services they use are provision will support the will physical ill health will have of the highest quality and at delivery of the Mental Health better mental health.
least as safe as any other public Strategy by contributing to the Commissioning high quality rehabilitation following shared objectives.
services will help achieve this objective Commissioning high quality rehabilitation since more people with complex mental services will help achieve this objective as Shared objective 1: health needs will be properly cared for in it requires systems to be in place which More people will have settings which are appropriate.
continually monitor the appropriateness of good mental health.
care settings and treatments.
Shared objective 4: A coordinated system that can provide Care and support, wherever Shared objective 6: appropriate rehabilitation for people with the most severe mental health problems it takes places, should offer Public understanding of mental results in gradual recovery and successful access to timely, evidence-based health will improve and, as a community living.
interventions and approaches result, negative attitudes and that give people the greatest behaviours to people with Shared objective 2: choice and control over their mental health problems will More people who develop own lives, in the least restrictive decrease.
mental health problems will environment, and should ensure have a good quality of life Commissioning high quality rehabilitation that people's human rights are services will help achieve this objective as – greater ability to manage it will help to end the stigmatising ‘out of their own lives, stronger social sight, out of mind' approach to the care of relationships, a greater sense Commissioning high quality rehabilitation people with complex mental health needs.
services will help achieve this objective as of purpose, the skills they people will receive recovery-oriented care need for living and working, in settings which are appropriate for their improved chances in education, level of need.
better employment rates, and a suitable and stable place to live.
Commissioning high quality rehabilitation services will make a significant impact on achieving this objective as it encapsulates the core business of mental health rehabilitation.
20 Practical Mental Health Commissioning Quality Indicator for Rehabilitative 1 Craig, T., Garety, P., Power, P., et al Care (QuIRC) www.quirc.eu (2004) The Lambeth Early Onset (LEO) Team: randomised controlled trial of the National Mental Health Development effectiveness of specialised care for early Unit – toolkit to reduce the use of psychosis. BMJ, 329, 1067–1071.
out of area mental health services 2 Killaspy, H., Marston, L., Omar, R This guide was collectively written et al (2012) Service Quality and Clinical by Helen Killaspy, Richard Meier, Outcomes: an Example from Mental Social Care Institute for Excellence Shawn Mitchell, Charlotte Harrison, Health Rehabilitation Services in England. – personalisation resources Sridevi Kalidindi, Tom Edwards, Chris British Journal of Psychiatry. In Press.
Fitch, David Jago (Royal College of 3 Green, M.F. (1996) What are the Psychiatrists), Mel Bunyan (British functional consequences of neurocognitive Psychological Society), Julie Kerry Royal College of Psychiatrists – deficits in schizophrenia? American Journal (Associate Director, Mental Health Accreditation for Inpatient Mental of Psychiatry, 153, 321–330
& Learning Disability, NHS South of Health Services: rehabilitation England), and Vicki Nash (Mind).
4 Wykes, T. & Dunn, G. (1992) Cognitive deficit and the prediction of rehabilitation Input from representatives of the success in a chronic psychiatric group. following organisations is gratefully Psychological Medicine, 22, 389–398.
Social Functioning Questionnaire 5 Wykes, T., Katz, R., Sturt, E., et al (1992) College of Occupational Therapists; Abnormalities of response processing in Forum for Mental Health in Primary a chronic psychiatric group. A possible predictor of failure in rehabilitation We would like to thank the service user programmes? British Journal of Psychiatry, and carer representatives of the Faculty of Rehabilitation and Social Psychiatry, 6 Holloway, F. (2005) The Forgotten Royal College of Psychiatrists for their Need for Rehabilitation in Contemporary helpful comments on this document.
Mental Health Services: A Position Statement from the Executive Committee of the Faculty of Rehabilitation and Social This guide has been written by a group Psychiatry. Royal College of Psychiatrists of rehabilitation mental health service experts, in consultation with patients and carers. Each member of the Joint 7 Killaspy, H., Rambarran, D. & Bledin, Commissioning Panel for Mental Health K. (2008) Mental health needs of clients received drafts of the guide for review of rehabilitation services: a survey in and revision, and advice was sought one trust. Journal of Mental Health, 17,
from external partner organisations and individual experts. Final revisions to the guide were made by the Chair 8 Mental Health Strategies (2010) The of the Expert Reference Group in 2009/10 National Survey of Investment collaboration with the JCP's Editorial in Mental Health Services. London: Board (comprised of the two co-chairs Department of Health of the JCP-MH, one user representative, one carer representative, and technical and project management support staff).
Guidance for commissioners of rehabilitation services for people with complex mental health needs 21 9 Killaspy, H.and Zis, P. (2012) Predictors 17 Joint Commissioning Panel for Mental 26 Trieman, N. & Leff, J. (2002) Long- of outcomes of mental health rehabilitation Health (2012) Guidance for commissioners term outcome of long-stay psychiatric services: a 5-year retrospective cohort of liaison mental health services to acute in-patients considered unsuitable to live in study in inner London, UK. Social hospitals. London: JCP-MH.
the community: TAPS Project 44. British Psychiatry and Psychiatric Epidemiology. Journal of Psychiatry, 181, 428–432.
18 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners 27 Department of Health (1999) National 10 Lavelle, E., Ijaz, A., Killaspy, H.et al of mental health services for young Service Framework for Mental Health. (2011) Mental Health Rehabilitation people making the transition from child TSO (The Stationery Office).
and Recovery Services in Ireland: a and adolescent to adult services. London: 28 Davies, S., Mitchell, S., Mountain, D., multicentre study of current service et al (2005) Out of Area Treatments for provision, characteristics of service users 19 Joint Commissioning Panel for Mental Working Age Adults with Complex and and outcomes for those with and without Health (2012) Guidance for commissioners Severe Psychiatric Disorders: Review of access to these services. Final Report of perinatal mental health services. Current Situation and Recommendations for the Mental Health Commission of London: JCP-MH.
for Good Practice (Faculty of Rehabilitation and Social Psychiatry 20 Joint Commissioning Panel for Mental 11 Killaspy, H & Meier, R.A (2010) Fair Working Group Report). Royal College Health (2012) Guidance for commissioners Deal for Mental Health Rehabilitation of Psychiatrists. www.rcpsych.ac.uk/pdf/ of public mental health services. London: Services. The Psychiatrist, 34, 265-267.
12 National Mental Health Development 29 Poole, R., Ryan, T. & Pearsall, A. (2002) 21 Killaspy, H., Harden, C., Holloway, Unit (2011) In sight and in mind: A The NHS, the private sector, and the F., et al (2005) What do mental health toolkit to reduce the use of out of area virtual asylum. BMJ, 325, 349–350.
rehabilitation services do and what are mental health services. Royal College of they for? A national survey in England. 30 Ryan, T., Pearsall, A., Hatfield, B., et al Journal of Mental Health, 14, 157–165.
(2004) Long term care for serious mental illness outside the NHS: a study of out 22 Mountain, D., Killaspy, H. Holloway, 13 Department of Health (2011a) No of area placements. Journal of Mental F. (2009) Mental Health Rehabilitation Health Without Mental Health; a cross Health, 13, 425–429.
Services in the UK in 2007. Psychiatric government mental health outcomes Bulletin, 33, 215-218.
31 Ryan, T., Hatfield, B., Sharma, I., et strategy for people of all ages. www.
al (2007) A census study of independent 23 Meltzer, H. (1997) Treatment-resistant mental health sector usage across seven schizophrenia: the role of clozapine. strategic health authorities. Journal of Current Medical Resident Opinion, 14,
Mental Health, 16, 243–253.
14 Bennett, A., Appleton, S., Jackson, 32 Killaspy, H., Rambarran, D., Harden, C. (eds) (2011) Practical mental health 24 Harding, C., Brooks, G. , Asolaga, T., C., et al (2009) A comparison of service commissioning. London: JCP-MH. et al (1987) The Vermont longitudinal users placed out of their local area and study of persons with severe mental local rehabilitation service users. Journal of illness. 1: Methodological study sample 15 Joint Commissioning Panel for Mental Mental Health, 18,111–120.
and overall status 32 years later. American Health (2012) Guidance for commissioners Journal of Psychiatry, 144, 718–726.
33 NHS Confederation (2011) Housing of primary mental health services. London: and mental health. NHS Confederation 25 Harrison, G., Hopper, K., Craig, T., Mental Health Network.
et al (2001) Recovery from psychotic 16 Joint Commissioning Panel for Mental illness: a 15- and 25-year international Health (2012) Guidance for commissioners follow-up study. British Journal of of dementia services. London: JCP-MH.
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22 Practical Mental Health Commissioning References (continued) 34 Wolfson P, Holloway F, Killaspy H. 42 Tsemberis, S. Housing first: ending (2009) Enabling recovery for people with homelessness and transforming live (2010) complex mental health needs. A template Schizophrenia Research Volume 117(2):
for rehabilitation services. Faculty report FR/RS/1. Royal College of Psychiatrists 43 Culhane, D.P., Metrauxb, S. & Hadley, Faculty of Rehabilitation and Social T. (2002) Public service reductions associated with placement of homeless 35 Royal College of Psychiatrists, Mental persons with severe mental illness in Health Network, NHS Confederation & supportive housing. Housing Policy London School of Economics and Political Debate, 13(1): 107-163.
Science (2009) Mental Health and the 44 Metraux, S., Marcus, S.C., Culhane, Economic Downturn; national priorities D.P. Assessing the Impact of the New and NHS solutions. Occasional Paper 70, York/New York Supported Housing Royal College of Psychiatrists.
Initiative for Homeless Persons with Severe 36 Department of Health (2011c). No Mental Illness on Public Shelter Use in health without mental health: A cross Government mental health outcomes 45 Mental Health Foundation (2012) Peer strategy for people of all ages. Supporting support in mental health and learning document – the economic case for disability. Need2Know Briefing. improving efficiency and quality in mental health services. 46 Repper, J. & Carter, T. (2011) A review of the literature on peer support in mental 37 National Institute for Clinical Excellence health services. Journal of Mental Health, (2002) Schizophrenia: Core Interventions 20(4): 392-411.
in the Treatment and Management of Schizophrenia in Adults in Primary and 47 Royal College of Psychiatrists (2011) Secondary Care. Clinical Guideline 1. NICE.
Outcome Measures Recommended for Use in Adult Psychiatry. Occasional Paper 38 National Institute for Health and 78, Royal College of Psychiatrists. Clinical Excellence (2009) Schizophrenia: Core Interventions in the Treatment and 48 Killaspy, H., White, S., Wright, C. Management of Schizophrenia in Adults et al (2012) Association between service in Primary and Secondary Care. Clinical user experiences and staff rated quality Guideline 82. NICE.
of care in European facilities for people with longer term mental health problems. 39 Johnson, R., Griffiths, C., Nottingham, PLoS One, 7(6).
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49 Killaspy, H., White, S., Wright, C. et al (2011) The Development of the Quality 40 National Mental Health Development Indicator for Rehabilitative Care (QuIRC): Unit (2010) Factfile 2. Mental health and a Measure of Best Practice for Facilities for housing. London: NMHDU.
People with Longer Term Mental Health 41 Priebe, S., Saidi, M., Want, A., Problems. BMC Psychiatry, 11:35.
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Guidance for commissioners of rehabilitation services for people with complex mental health needs 25 A large print version of this document is available from www.jcpmh.info Published February 2013 Produced by Raffertys

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