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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
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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
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