One in four people experience mental health problems during their lifetime. Mental health is one of the Government's core national priorities, with new services and staff being introduced as a result of the NHS Plan.
Organising mental health services
Mental health services are provided as part of primary and secondary care, with responsibility split between the NHS, social services and the independent and voluntary sectors. However, PCTs are responsible for commissioning all mental health services. There are 43 specialist mental health trusts that provide acute inpatient care, community and rehabilitation services, residential care centres, day hospitals and drop-in centres. Some PCTs provide mental health services; their future role in this will evolve as Commissioning a Patient-led NHS and 'Our health, our care, our say' are implemented. About 80,000 staff work in statutory mental health services.
Primary and community services
Ninety per cent of people who receive help for mental health problems are dealt with in primary care. In a typical PCT of 200,000 people, about 25,000 will suffer from depression, anxiety or other so-called mental disorders. Another 500 will suffer from a psychotic illness such as schizophrenia. Of GP consultations, 30 per cent have a significant mental health component.
Nevertheless, 80 per cent of NHS spending on mental health is devoted to inpatient services. Less than half of GPs have postgraduate training in psychiatry and only two per cent of practice nurses have mental health training, although about half of GP surgeries provide counselling.
The new GMS contract gives GPs an incentive to provide care for the physical health of people with severe mental illness. GPs usually refer patients they cannot help directly to the local community mental health team (CMHT) or to a psychiatric outpatient clinic.
CMHTs - sometimes known as primary care liaison teams - are the main source of specialist support for those suffering severe and enduring mental health problems. They assess and monitor mental health needs using two specialist systems - the care programme approach or care management. These require that everyone seen by specialist mental health services should have their need for treatment assessed, a care plan drawn up and a named mental health worker to co-ordinate their care, including a regular review of their needs. They aim to provide continuity of care across services, promote multi-professional and inter-agency working, and ensure suitable care for people diagnosed with serious mental illness on discharge from hospital.
CMHT members include community psychiatric nurses, social workers, psychologists, occupational therapists, doctors and support workers. Patients will regularly meet the psychiatrist from their mental health team at a psychiatric outpatient clinic for review of their treatment.
Providing mental health services in the community has prompted new approaches to care to avoid hospital admission, such as:
- early intervention teams, which aim to treat psychotic illness as quickly and effectively as possible, especially during the critical period after its onset
- assertive outreach teams to provide intensive support for severely mentally ill people who are difficult to engage in more traditional services
- home treatment and crisis resolution to provide flexible acute care in patients' own homes with a 24-hour service to help with crises.
Further information
Leading edge 17: Adult mental health services in primary care, NHS Confederation, November 2005
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Hospital services
Psychiatric hospital services have been progressively scaled down over the past 30 years, as many services once provided in hospitals are now provided in the community. However, numbers of patients detained under the Mental Health Act have been rising, intensifying pressure on beds and stress on staff. One result of fewer beds and rising demand has been a significant increase in pressure on hospital services, with psychiatric beds experiencing high occupancy rates - more than 100 per cent in about half of wards. Acute inpatient services deal mainly with patients suffering severe mental illness.
Child and adolescent mental health services
Child and adolescent mental health services (CAMHS) cater for young people and children with all types of mental disorder including hyperkinetic disorders.
Services are arranged into four tiers, which should be closely linked in any area:
- tier 1 includes services contributing to mental healthcare of children and young people, but whose primary function is not mental healthcare (for example, schools and GPs)
- tier 2 includes mental health professionals assessing and treating those who do not respond at tier 1
- tier 3 includes teams of mental health professionals providing multi-disciplinary interventions for more complex problems
- tier 4 includes the most severe and complex problems that cannot be dealt with at tier 3, including inpatient and specialist services such as eating disorders.
All areas are required to have 'comprehensive CAMHS' by the end of 2006. This includes out-of-hours emergency cover as well as adequate provision for all young people up to age 18, with mental health problems.
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Forensic services
Forensic mental health services deal with mentally ill people who may need a degree of physical security and have shown challenging behaviour beyond the scope of general psychiatric services. Some may be mentally disordered offenders.
Services fall into three categories:
- low-security services tend to be based near general psychiatric wards in NHS hospitals
- medium-secure services often operate regionally and usually consist of locked wards with a greater number and a wider range of staff
- high-security services are provided by the three special hospitals (Ashworth, Broadmoor and Rampton), which have much greater levels of security and care for people who pose an immediate and serious risk to others.
In addition, new services are developing to meet the needs of mentally disordered offenders in the community.
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Modernising services
The National Service Framework for mental health, published in 1999, sets out a 10-year programme to introduce new standards of care that people will be entitled to expect in every part of the country. It emphasises:
- mental health promotion - to ensure health and social services promote mental health and reduce discrimination and social exclusion associated with mental illness
- primary care and access to services - to deliver better primary mental healthcare and ensure consistent help for people with mental health needs, including primary care services for those with severe mental illness
- effective services for people with severe mental illness - to ensure each person gets the services they need, that crises are anticipated or prevented, that help is prompt and effective if a crisis does occur, and that timely access to an appropriate and safe mental health place or hospital bed, as close to home as possible, is available
- caring about carers - to ensure health and social services assess carers' needs and provide care to meet their needs
- preventing suicide - to ensure that health and social services play their full part in reducing the suicide rate by at least one-fifth by 2010
In a five-year assessment of progress, the national director for mental health indicated a need to focus on whole-community mental health.
Further information
DH website - National Service Framework for mental health: modern standards and service models, DH, September 1999
The National Service Framework for mental health - five years on, NHS Confederation, March 2005
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Delivering race equality in mental health care
This initiative was launched in 2005 and outlines a five-year action plan for achieving equality and tackling discrimination in mental health services in England for all people of black and minority ethnic (BME) status. Delivering race equality (DRE) is part of a wider programme of action to develop greater equality in health and social care. The programme is based on three building blocks:
- providing more appropriate and responsive services and improving clinical services for specific groups, such as older people, asylum seekers, refugees and children
- engaging communities in planning services, supported by 500 new community development workers (CDW)
- improving ethnicity monitoring, dissemination of information and knowledge about effective service, including a regular census of mental health patients.
The vision for DRE is that by 2010 there will be: a service characterised by 'less fear' among BME communities and service users; increased satisfaction with services; a reduced rate of admission of people from BME communities to psychiatric inpatient units; a reduction in the disproportionate rates of compulsory detention of BME service users in inpatient units and a more balanced range of culturally appropriate and effective therapies.
Focused implementation sites have been established to help identify and spread best practice. The evaluation of these sites in 2008 will inform national implementation. A BME mental health programme board, directly accountable to ministers, is overseeing this action plan and the wider BME mental health programme.
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Revising mental health law
After wide consultation, the Government has decided to amend the 1983 Mental Health Act rather than introduce new legislation. It intends to include provisions on which it previously consulted, such as community treatment orders, improved patient safeguards concerning tribunals and a new definition of mental disorder. It will also remedy any incompatibility with other Acts such as human rights and civil partnership. The Government will make these amendments when parliamentary time permits.
