Navigating Mental Health Services

1. Navigating Mental Health Services Manchester Mental Health & Social Care Trust

2. Aims of Session • To provide an overview of the professionals involved in the delivery of mental health services • To outline the development of the Care Programme Approach and its role in planning mental health services • To introduce the current Mental Health Act (1983) and also review the plans for the changes in Mental Health law

3. Objectives of the Session • For participants to have an increased awareness of the components of the delivery of mental health services and how to use this knowledge in practical situations. • For participants to be aware of the implications of the use of the Mental Health Act (1983)

4. Who might be involved ? General Practitioner (GP) • It is essential to be registered with a GP - at least as a ‘temporary resident’ • If the person is very unwell and deemed to be an emergency the GP can be asked to complete a home visit • GPs should be involved in discharge plans, to review repeat prescriptions, sick notes and any physical problems that might arise (Sim et al 2005)

5. Who might be involved? Psychiatrists • These are doctors who have trained to specialise in mental health • It is the psychiatrist who will make an initial diagnosis and manage treatment • A psychiatrist will see those who are admitted to in-patient care but will also often see people with a severe mental illness as out-patients • The psychiatrist might be a senior house officer, registrar, a senior registrar or a consultant

6. Who might be involved? Mental Health Nurses • Qualified nurses are often referred to as RMNs (Registered Mental Nurses) or CPNs (Community Psychiatric Nurses) • CPNs works in a community team. They make home visits to assess, manage, co-ordinate care and treat those who are referred to them • The CPN might also be involved in giving medication and injections

7. Who might be involved? Social Workers (SWs) • In Mental Health Trusts the social workers and health service workers often work very closely together. A social worker might often be the clients’ care coordinator • SWs are experts on social matters such as money, benefits, housing issues & child care • Approved Social Workers have specific training to assess those clients who might need to be cared for under the Mental Health Act (1983)

8. Who might be involved? Occupational Therapists (O.T) • O.T.s will focus on developing and maintaining individuals’ roles and personal functioning in activities of daily living • OTs will often support clients to attain the maximum level of independence, either in supported or independent accommodation • The development of meaningful activities is central in the role of the O.T. • The O.T might work from the in- patient unit or from community teams • The O.T. might be the care-coordinator

9. Who might be involved? Clinical Psychologists • Psychologists have extensive training in specific psychological treatments - cognitive therapy, psychotherapy or family work • Psychologists generally arrange appointments to see clients in clinics rather than in their own homes • A few psychologists specialise in psychotic illnesses but referrals to them are generally for less serious mental health problems

10. Who might be involved? Support Workers • They support people with practical matters such as shopping. • Sometimes they are someone for the client to talk to. They often build up very important relationships with clients • They generally visit every week and might be employed by an NHS Trust or a voluntary or independent mental health service • Supports workers often have a lot of experience. They do not hold a professional qualification but many of them have extra training through the NVQ system

11. Specialist Mental Health Services: The Care Programme Approach • All specialist (sometimes called ‘secondary’) mental health services MUST deliver co-ordinated mental health care using the Care Programme Approach (CPA) • The aims of the CPA are to deliver a ‘holistic’ approach to organising care (Rethink 2005) • The aim of the CPA is to develop an organised system to ensure that people with severe mental illness are assessed, treated and supported in the community (RCP 2004)

12. The Care Programme Approach • The CPA is based on four principles: • Assessment – Of mental and physical health needs, social and environmental needs and also an an assessment of risk to self and/or others or a risk of neglect • Allocation of a care co-ordinator - A professionally qualified key worker • Development of a care plan - This is a co-coordinated plan of all the arrangements with all those involved in the care of the individual • Regular review - The CPA is ideally reviewed every six months in collaboration with the client and involving all aspects of care

13. Care Programme Approach • The CPA care plan can be delivered by a range of ‘multi-disciplinary’ teams: e.g. community mental health teams, early intervention teams, assertive outreach (ACT) teams or crisis resolution teams. These teams specialise in intensive services for different groups of people. They all aim to work with people in the community • Often there is a need for the involvement of more than one team as needs are complex

14. Care Programme Approach Care Coordinators Role • To develop, plan, manage, co-ordinate and integrate an individual’s care between all specialist services, social services and primary care. • Must be a qualified professional in mental health - nurse, occupational therapist, social worker. Sometimes the role is undertaken by a psychiatrist • Most often the role is assumed by a member of the Community Mental Health Team (CMHT) as they have a long term commitment to continuous care of the client

15. Specialist Mental Health Services Community Mental Health Teams (CMHTs) • CMHTs provide the core of local specialist services. They offer assessment, treatment and social care to adults in the community with mental health problems • They tend to be based in local resource centres away from hospitals, to be more accessible to clients and families • In many areas the CMHT is the gateway to more specialist services • Referrals to CMHTs are given an initial assessment. The most suitable service is then agreed by referrer, client and service

16. Specialist Mental Health Services Early Intervention Teams • These teams are specifically for those who are experiencing a first episode of a psychotic illness and are for people aged 14 – 35 • They provide the best mix of specialist medical, psychological, social, occupational and educational interventions at the earliest possible opportunity • Although not available yet in all areas, the government proposes at least 50 services to be developed (SCMH 2003)

17. Early Intervention Teams Aims of Early Intervention Teams might include the following: • To reduce the duration of untreated psychosis • To provide a comprehensive assessment, treatment and rehabilitation • To prevent relapse • To minimise loss of functioning and social skills • To educate the young person and family/carers

18. Principles of Early Intervention Teams • Early detection and assessment of psychosis • The team aims to instill optimism about each young person’s chances of recovery • Acceptance that a clear diagnosis is not always possible yet a wide range of pharmacological and psychosocial interventions should be offered • Acknowledging that families need support as well as clients • Services need to forge strong working partnerships with a range of statutory and non-statutory services (SCMH 2003)

19. Specialist Mental Health Services Assertive Outreach (Community) Teams - (AOT or ACT) • Deliver intensive treatment and rehabilitation in the community for the severely mentally ill • Provide rapid help in crisis and offer long term support • Staff act as advocates and liaise with other services (GP, social services) • These teams are specifically for those with complex needs who are reluctant to engage with mental health services (Philips et al 2001)

20. Specialist Mental Health Services Crisis Resolution/ Home Treatment Teams • An alternative to hospital admission during an acute phase of illness • Different service models exist throughout UK • A 24 hours / 7 day a week service to assess and provide treatment by an Multi Disciplinary Team (MDT) to clients and support to carers • CMHTs remain involved with clients • Often the first experience of mental health services for those experiencing a first episode of psychosis

21. Specialist Mental Health Services Acute In- Patient Care • When a rapid assessment and stabilisation during an acute episode is necessary • Used for clients who need to be compulsorily detained under the Mental Health Act (1983) • Admission period varies from a few days to several months depending on need • MDT meets weekly on the ward to discuss care plans with clients • Some in- patient care units detain clients in secure environments

22. Specialist Mental Health Services Child & Adolescent Mental Health Services (CAMHS) • Offer services for children and young people in hospital settings, GP clinics, health centres and sometimes in schools and further education (McGlynn 2001) • CAMHS offer a wide range of interventions by an MDT. They often include family therapy (Charman 2004) • Age group depends on the model of service delivery

23. Specialist Mental Health Teams Other teams that might be involved: • Substance misuse teams (alcohol & drugs teams) • Psychotherapy services • Eating disorders services • Self harm services • Family Intervention Teams • Voluntary or independent groups offering support groups, drop-ins and counselling • Employment projects and training schemes

24. Pathways to Care Access routes to Early Intervention Services include : • Primary care • Youth services • Acute care (A&E, walk-in clinics etc) • Specialist early detection teams Ideally a mixture of routes should be available but service designs often mean accessibility varies considerably

25. Group Exercise • Divide into small groups to represent all stakeholders of care • Each group will be given one stakeholder: either the client, carers and family, mental health services or the general public • Each group is then asked to consider the the advantages and disadvantages of the mental health law in the UK

26. Mental Health Act (MHA 1983) • Many people will enter hospital for treatment voluntarily. The MHA is only used when detainment in hospital is considered necessary for the health and safety of the person with psychosis or for the protection of others • Often needed when people do not realise they are ill – this is often termed ‘lack of insight’ by professionals

27. What is the Process? • In order for anyone to be admitted to hospital for admission and treatment under the MHA the recommendations must be made by two doctors – one of whom is often the GP . In addition, a social worker with special training to make the decisions is involved • If the person or their relative is admitted to hospital for assessment or treatment they can appeal against the section to the Mental Health Review Tribunal (MHRT)

28. Terms used …… • The MHA is divided into a number of different ‘sections’. This is where the term to ‘section someone’ is derived • Doctors, often the GP and a psychiatrist must make medical recommendations for the person to be detained • Once the recommendations have been made an Approved Social Worker (ASW) must then make an application to the hospital manager to admit the person to hospital

29. The Sections of the MHA • Section 136– The moving of someone to a place of safety made by the police • Section 2– For the assessment of someone for up to 28 days • Section 3– To provide treatment following assessment lasting for up to 6 months • Section 4– An emergency admission lasting for 72 hours, often transferred to a Section 2 • Section 5 (2)– If a voluntary in-patient needs to be detained and they wish to leave – lasting for 72 hours

30. The Mental Health Act • Sections 2 & 3 require that two medical recommendations must be made, usually from a consultant psychiatrist and a GP • The medical recommendations should know the patient already and can judge what is ’normal’ for that person

31. Section 117 - Aftercare • This section requires that when a client is discharged from a ‘treatment section’ all their needs are provided for • Clients should agree to the plan prior to discharge • The 117 meeting may include advising the client where they should live

32. Proposed Changes in the MHA • The draft Mental Health Bill was released for consultation in 2004 • Changes are to be made concerning the duration of enforced admission. A period of no longer than 28 days should elapse before a review is conducted • Changes in support systems for detained clients - a clinical supervisor will be appointed to provide a care plan within 5 days of allocation • Allows community teams to care for detained clients as an alternative to inpatient admission

33. Changes that will affect young people • Both 16 and 17year olds will be treated as adults with a choice to agree or refuse intervention which cannot be overridden by parents • If children under 16yrs require treatment and parental consent is not gained, safeguards are in place to ensure they obtain the treatment they need

34. Case Study Exercise • In small groups read through section one of the case study • Write the answers down in your group • As a large group discuss your answers from the first section before moving onto the next section • There are no ‘right or wrong’ answers, just possibilities

35. Conclusion • Mental health services involve a comprehensive range of professionals and support staff who have a wide range of skills and experience • The CPA is the standard method of co-ordinating the services available to clients and their carers • Government guidance shapes the development of services locally and nationally • The MHA (1983) legislation also influences the delivery of services. This legislation is due to be modified