No voice, no choice
A joint review of adult community
mental health services in England
Summary report
A joint review
This is a summary of the full report:
No voice, no choice: A joint review of
adult community mental health services
in England
First published in July 2007
© 2007 Commission for Healthcare Audit and
Inspection
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Commission for Healthcare Audit and Inspection
with the title of the document specified.
Applications for reproduction should be made in
writing to: Chief Executive, Commission for
Healthcare Audit and Inspection, Finsbury Tower,
103-105 Bunhill Row, London, EC1Y 8TG.
ISBN 978-1-84562-153-7
The pictures on the front cover are from www.johnbirdsall.co.uk
Contents
Foreword
2
Introduction
3
About the review
4
Overall results
6
Key findings
7
Theme 1: Whether people can access the right type of care and treatment for them
7
Theme 2: Whether people have a say in how they are being treated
7
Theme 3: Whether the type of treatment that is being provided actually helps people to recover, and to become part of their community again
8
Recommendations
Conclusion
Further information
11
12
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Healthcare Commission No voice, no choice Summary report
1
Foreword
One in six people in the UK experiences mental health problems at some stage of their lives.
Many receive services of a high standard that meet their individual needs, but a significant number
do not.
Despite more inclusive social attitudes, people with mental health problems continue to face
exclusion from areas of life that many of us take for granted – from jobs, security, family support,
community involvement and from the choices and decisions about their care and treatment. The
cost and burden to individuals, their families and the community are immense, and disadvantage
can often cross from one generation to the next.1
This report is welcomed by both Commissions as a way of highlighting the importance of effective
community mental health services in breaking the cycle of social exclusion. These services cover
health, social care and the third sector, and are crucial in maintaining people within their
communities, in employment and training, and ultimately, out of hospital.
The report reflects what we found when we reviewed community mental health services and
provides a commentary on current provision. Our most significant finding is the wide variation in
the quality of services. We hope it therefore prompts local implementation teams (LITs), and
mental health and social care professionals working in the sector to question the quality and range
of services on offer.
Crucial to this report are the views of people who use mental health services. They helped us to
develop our framework for assessment, they told us about their experiences of using services in
the communities we visited, and they have contributed to the recommendations in this report.
1
2
Anna Walker CB
Paul Snell
Chief Executive
Chief Inspector
Office of the Deputy Prime Minister, Social Exclusion Unit (2004) Mental Health and Social Exclusion.
Healthcare Commission No voice, no choice Summary report
Introduction The World Health Organization predicts that by
2020, depression will be the world’s leading
cause of disability. In the UK now, one in six
adults has some type of mental health problem.
In addition to the personal hardship caused by
poor mental health, the economic costs can be
high. In 2004, a Government report on mental
health and social exclusion stated that mental
health problems cost the UK around £77 billion
a year.
People with poor mental health often face
discrimination and social isolation. They also
experience physical ill health because of their
condition, which may partly be due to a poor
diet, smoking, poor housing, self-neglect and
the side effects of the medicines they may be
taking.1 So mental health services are a very
important part of modern healthcare. The
mental healthcare that is provided in the
community is supposed to be different from
1
traditional care because it treats people outside
hospital, around their own schedule, and with
their personal needs in mind.
It is because of the importance of community
mental health services that the Healthcare
Commission and the Commission for Social
Care Inspection (CSCI) decided to carry out this
joint review. We looked at the quality of
specialist adult mental health services that
were being provided in local communities in
England in 2005/2006. And we asked people
who use these services what they thought was
important to ensure that they received the
highest quality of care. We also looked at
whether the services that are being provided
are actually helping people to recover and to
become part of their local community again.
This summary presents some of the key
findings, conclusions and recommendations of
our review.
Office of the Deputy Prime Minister, Social Exclusion Unit (2004) Mental Health and Social Exclusion.
Healthcare Commission No voice, no choice Summary report
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About the review
Before we started our review, we brought
together health and social care professionals,
people who use mental health services, and key
advocacy groups, to develop a framework for
assessment. The factors that everyone
identified as important to providing successful
specialist mental health services were:
• access to services
• a ‘whole person’ or holistic approach
• addressing social exclusion
• ensuring that people who use services are
empowered to be involved in their own care
• enabling carers to be properly involved in the
care of those using the services
• empowering people who use services, their
carers and families to fully engage in the
planning of services
• organisations working in partnership
Every area in England has a local
implementation team (known as LITs) to
organise the health services in their area. They
are made up of all the main organisations
involved in local mental health services
including: primary care trusts; local councils
that have responsibility for social services; and
NHS trusts. People who use the services that
the LITs provide, and their carers, are also
expected to be members of the teams.
LITs plan and commission community mental
health services and there are 174 of them
across England. We looked at how well LITs are
providing services for people with mental
health problems. To assess the quality of their
services, we looked at the data that each LIT
kept in its records, and then asked them to
collect extra information if we wanted
something that they didn’t keep.
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Healthcare Commission No voice, no choice Summary report
We collected information about all 174 LIT
areas, which was supplied by:
• 82 NHS trusts
• 149 councils with social service
responsibilities
• 303 primary care trusts
We also checked to see whether the National
Institute for Health and Clinical Excellence
(NICE) guidelines for schizophrenia (2002) were
being followed. These important guidelines are
designed to reduce inequalities in health and
social care, and to ensure that people receive
consistent standards of care and support. We
chose to use these guidelines because they
were the first NICE guidelines to be published
for mental health, and we believe that
healthcare services should have had time to
apply them.
We used a scoring system, which was designed
to give each LIT one simple award of
“excellent”, “good”, “fair” or “weak”.
• “excellent” – meant that its performance
went well beyond minimum requirements
and the reasonable expectations of patients
and the public
• “good” – meant that its performance went
beyond minimum requirements and the
reasonable expectations of patients and the
public
• “fair” – meant that its performance only met
minimum requirements and the reasonable
expectations of patients and the public
• “weak” – meant that its performance did not
meet the minimum requirements or the
reasonable expectations of patients and
the public
When our initial review was over and we had
analysed the results, the Healthcare
Commission and CSCI went into 11 of the LITs
that had performed the worst, to do additional
fieldwork. The reason for this fieldwork was to
explore our findings from the data analysis and
to help these LITs plan how to improve their
performance in the future.
Overall results
This is how the LITs in England scored:
• 9% scored “excellent”
• 45% scored “good”
• 43% scored “fair”
• 3% scored “weak”
The LITs that scored “excellent” or “good” were
performing consistently well across the majority
of the areas that we assessed in this review.
They also displayed evidence of progress
towards meeting the standards and delivering
the services that provide the best outcomes for
the people who use services and their carers.
For example, these LITs provided a range of
services, such as help in a crisis, assessment of
people’s physical health needs, and
empowerment of people who use services to be
more involved in the planning of their own care.
Those that scored “fair” were showing evidence
of progress but they must improve their
performance to achieve a higher standard.
LITs that scored “weak” were performing poorly
in a number of areas and showed very little
evidence of progress towards meeting the
standards of care.
Healthcare Commission No voice, no choice Summary report
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Key findings
In this section, we describe some of the key
findings from our analysis of all the information
that we collected. If you would like to see all of
our findings or read the full report, you can visit
the Healthcare Commission website, the
address of which is shown at the bottom of
the page.2
many people still cannot use it. We found that
the percentage of people who could access this
service ranged from 25% to 83%, across mental
health trusts. This shows that people in nearly
a third of LITs had levels of access to services
out of hours significantly lower than the
national average.
We arranged our findings under three themes:
Crisis resolution teams provide intensive home
or crisis home-based support for people with
mental health problems, or for people who are
in distress. We found that 87% (151) of LITs had
ensured that their crisis resolution teams were
able to provide out-of-hours services. In March
2006, 12% (21) of LITs reported that they had
no crisis resolution teams providing out-of­
hours services. The review also found that 59%
of LITs (102) had no crisis accommodation for
their area on a 24-hour basis, and that 94 of
these said that they had no crisis
accommodation at all.
1 whether people can access the right type of
care and treatment for them
2 whether people have a say in how they are
being treated
3 whether the type of treatment that is being
provided actually helps people to recover,
and to become part of the community again
Theme 1: Whether people can access the
right type of care and treatment for them
Out-of-hours crisis services vary widely
Greater access to key talking therapies
is needed
Most of the LITs (77% of them) provided people
in their local area with access to specialist
mental health services at all times. Those
organisations providing this particular service
said that the people who were being treated and
were part of the Care Programme Approach3 or
who were urgently referred to them, could see a
mental health professional at any time of the
day or night, on any day of the year.
The review looked at two forms of talking
therapy – cognitive behavioural therapy (CBT),
which is the most widely accepted form of
talking therapy, and family interventions.
However, in 2006, when the Healthcare
Commission asked people who use mental
health services whether they actually had the
phone number of someone they could contact
out of hours, only 49% of people said that they
did. So even though the service is available,
CBT is a way of talking about how you think of
yourself, the world and other people, and how
this affects your thoughts and feelings. The
NICE guidelines state that, “100% of individuals
with schizophrenia who are experiencing
persisting psychotic symptoms should be
We found that for people with schizophrenia,
levels of access to key talking therapies in the
majority of areas were well below the standard
advised in the NICE guidelines.
www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/improvementreviews/
adultcommunitymentalhealthservices.cfm
3
A Department of Health framework for the assessment and planning of care for people who use mental health
services (1990).
2
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Healthcare Commission No voice, no choice Summary report
offered CBT”. Our review found that out of
approximately 7,500 people who we surveyed,
only 46% had received or been offered CBT in
the 12 months to March 2006.
Family interventions are aimed at helping
people by providing support to those who know
them, and can include: educating relatives
about an individual’s mental health condition;
family assessment and family sessions to
address any issues; and providing support for
carers. The NICE guidelines state that: “Family
intervention is to be offered to 100% of families
of individuals with schizophrenia who have
experienced a recent relapse, are considered to
be ‘at risk’ of relapsing, or who have persisting
symptoms, and are living with or in close
contact with their family”. Our review found that
out of approximately 2,200 people for whom
family intervention was appropriate, only 53%
had received it in the 12 months to March 2006.
Theme 2: Whether people have a say in
how they are being treated
Users are not fully involved in decisions
about their own care
It is very important that people who use
services are offered a choice of treatments so
that they can choose the one that suits them. It
is also important that there are policies in place
to support this involvement. However, we found
that in some areas of England, people who use
services still do not always feel properly
involved in the decisions about their care, or
are offered real choices.
schizophrenia. Advance directives are written
instructions about a person’s choice of the type
of treatment they would like to receive if they
become ill. Having their wishes written down in
advance is very important, especially as the
person may become too ill to say what their
choice is.
The guidelines recommend that: “The Care
Programme Approach documentation care plan
for all people with schizophrenia or suspected
schizophrenia should contain an advance
directive that describes preferred treatment
choices in the event of the individual
experiencing an acute episode of illness,
including the agreed choice of anti-psychotic
medication”.
As part of our review, we saw a sample of care
plans and checked them against the standards
set out in the 2002 NICE guidelines for
schizophrenia, we looked at how many of these
plans included:
• an advance directive or crisis and
contingency plan
• a reference to the agreed choice of anti­
psychotic medication in case of acute illness
(in those where there was an advance
directive or crisis and contingency plan)
Out of approximately 7,500 people that we
sampled nationally, 82% had an advance
directive or a crisis and contingency plan in
their care plans. The range of results varied
between 49% and 100% across the trusts
providing the services.
To check whether people’s choices about
treatment were being written down in their care
plans* we used recommendations on advance
directives in the 2002 NICE guidelines for
* Care plans are a record of the agreements made between the person who uses services and the mental health team
about the help they have been offered.
Healthcare Commission No voice, no choice Summary report
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Key findings continued
However, the proportion of people who had a
care plan containing both an advance directive
(or crisis and contingency plan) and a reference
to an agreed choice of anti-psychotic medication
was much lower in comparison. A national
average of only 29% of care plans contained
both, and results by trust varied from 0% to
83%. This must improve if people are to feel that
services are truly built around their needs.
People are not given enough choice about the
type of medicines they take
Nationally, only 42% of people reported that
they “definitely” had a say in decisions about
the medication that they take.
Only 38% of people reported that they were
“definitely” told about the possible side effects of
medication, while 34% reported that they were
not told at all. Ninety-three per cent of people
receiving secondary care services (i.e. those not
provided by a GP) have medication as a key
treatment. So there is a clear and urgent need
for the recommendations of the Healthcare
Commission’s 2007 audit, Talking about
medicines,4 to be put in place by the providers of
local mental health services.
Theme 3: Whether the type of treatment
that is being provided actually helps
people to recover, and to become part of
their community again
More focus is needed on physical health
Physical health checks are very important for
people with long-term mental health problems,
as they have an increased risk of physical illhealth and early death. According to a
Government report, a person with
schizophrenia will usually die 10 years before
someone who does not have a mental health
problem.5 A poor diet, smoking, poor housing,
self-neglect and the side effects of medication
may contribute to this statistic.
Overall in our review, a high number of LIT
areas performed well when it came to providing
physical health checks, with 17% of them
scoring “excellent” and 52% scoring “good”.
Nationally, 81% of people with schizophrenia or
suspected schizophrenia had a physical health
check in the year up to 31 March 2006. Ninetyone per cent of people with severe long term
mental health problems were reported to have
had a physical health review with their GP in
the 15 months to March 2006.6
However, LITs scored poorly in reporting
whether physical health checks had been
formally recorded at local level. Eight per cent
of LITs reported that there was no formal way
to record whether physical health checks were
taking place.
We are concerned that a large number of
community mental health services have no
formal system of recording whether physical
health checks are routinely included in
care plans.
Very few people are using direct payments
Direct payments are payments from the local
council for people who have been found to need
help from social services. The payments allow
people to arrange and pay for their own care
and support services, instead of receiving the
services directly from the local council.
Healthcare Commission (2007) Talking about medicines: the management of medicines in trusts providing mental health
services.
5
Office of the Deputy Prime Minister, Social Exclusion Unit (2004) Mental Health and Social Exclusion, p 172.
6
Department of Health (2006) Quality and Outcomes Framework.
4
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These payments help people to choose the type
of services that they receive and can also help
providers of services to deliver more individual
and culturally appropriate care. However,
progress on the use of direct payments remains
worryingly slow.
The national director for mental health
reported in his five-year review of the National
Service Framework for Mental Health (1999) that
the take-up of direct payments by people who
use mental health services had been very low –
with only 131 people receiving payments in
March 2002.
Local councils are responsible for providing
direct payments within each LIT area. We found
that of the 147 councils who provided us with
data, 29 of them (or 20%) made no direct
payments at all. With the exception of two
councils, who reported 148 and 92 direct
payments respectively, the remaining 116
reported 52 payments, or fewer, in 2004/2005.
So although the provision of direct payments
is generally poor, it is far worse for people
with mental health problems than for those in
other groups.
People are not getting enough help with
employment
People who use mental health services are one
of society’s most excluded groups and have the
lowest employment rate out of all the main
groups of disabled people.7 Health and social
care services play a critical role in enabling
these groups to work and maintain social
contacts – two factors that are associated with
better mental health and a reduced reliance on
services.8 Yet, these factors are not given
sufficient prominence in the provision of
community mental health services currently.
7
8
Nationally, an average of 50% of people who
said that they needed assistance with finding
employment received it. The performance of
individual trusts varied considerably, ranging
from assisting 29% to 64% of people.
The Healthcare Commission’s 2006 survey of
mental health patients found that 68% of them
were not in paid work, voluntary work or
studying. Only 21% of people who use mental
health services reported that they were in paid
work. This is an exceptionally low figure
compared with the national employment rate
for all people of working age, which was 74.5%
in December 2006.
More emphasis on delivering equality
Community development workers (CDWs) are
central to providing community mental health
services that are culturally appropriate. These
workers support communities and ensure that
their views are represented when services are
being planned.
Community development workers are also a
large part of the 2005 Delivering Race Equality
in Mental Health Care action plan, which aims
to tackle the unacceptable inequalities in
services for black and minority ethnic groups.
In autumn 2005, 66% of LITs scored “weak” on
the numbers of CDWs they had in place,
reporting that they had less than half the target
number, with no plans to change this by
December 2006.
We used information from the Healthcare
Commission national survey of NHS staff (2005)
to assess the levels of training in diversity
awareness. We checked to see if each member
of staff had received diversity awareness
training since they started working for their
specialist mental health trust. The types of
training we checked for were:
Office for National Statistics (2006) Labour Force Survey.
Office of the Deputy Prime Minister, Social Exclusion Unit (2004) Mental Health and Social Exclusion, p10.
Healthcare Commission No voice, no choice Summary report
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Key findings continued
• equal opportunities
• racial awareness
• gender awareness
• disability awareness
• religious awareness
• bullying and harassment awareness
Of all the staff in specialist mental health trusts
that we surveyed, only 32% reported receiving
any diversity training since they started work
for their employer. In some trusts, only 19%
said they had been trained. The highest
percentage was 55%.
The highest levels of training were in equal
opportunities, with a national average of 38% of
staff receiving it. The lowest levels were in
religious awareness, with a national average of
24%. When the results by trust were brought
together at LIT level, 41% of LITs were found to
be “weak”, in comparison to an already low
national average of 38%.
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Healthcare Commission No voice, no choice Summary report
Recommendations
We used a set of principles to help us decide
what our recommendations should be. These
principles were based on the things that people
who use mental health services said were vital
to ensuring that services were of a high quality
and actually helped them to recover. The
principles were also based on the further
fieldwork we did with some of the LITs who had
performed poorly in our review. (We looked at
what these LITs could have done to perform
better and used that information.)
The principles are:
• robust and committed leadership is
essential, as well as clear, explicit lines of
accountability. Accountability is especially
important because care now comes from a
number of different providers
• people who use services need to have higher
expectations and a better understanding of
the importance of their involvement in the
planning of their care, and in the design of
the services that they use
• health and social care professionals need to
have higher expectations of what people
with mental health problems can achieve
and what they have a right to expect. This is
central to creating services that are based
on people’s rights – a clear theme in current
Government thinking
• all professionals who work in community
mental health services must respect the
independence of the people using the
services
Our recommendations are intended to improve
the effectiveness of existing advice and policy
on community mental health services rather
than to replace it, and to ensure that these
services are delivered fairly across the country.
In this summary, we have arranged our
recommendations under two headings – those
that apply to people using services and those
that apply to the organisations which provide
the services. This is so that providers know
which area of poor performance the
recommendation is trying to improve.
People using services:
• should be told about all the different
treatment options available to them and
should be directly involved in making
decisions about their own care, treatment
and recovery
• should be told how to ask for a change of
care co-ordinator, and how to make a
complaint if they are unhappy
• should be routinely helped to create advance
instructions about the treatment, care and
medication they prefer to receive if they fall
ill, and staff should act on these instructions
(as appropriate) when crises occur
• should be given a copy of their care plan,
and where appropriate, their carers/family
must also be given a copy
• their carers, and family members, should be
told if there are any risks to them arising
from the treatment/care plan that has been
put together. For example, the risks of not
taking medication, or of missing
appointments with community mental health
professionals
Providers of mental health services should
make sure that:
• their services are designed to improve the
chances of recovery and social inclusion for
the people who use services – in particular
in areas such as education, employment,
housing and other community activities
Healthcare Commission No voice, no choice Summary report
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Recommendations continued
• they undertake and record employment
assessments
• they routinely assess and record the physical
health needs of people who use services
• they review existing employment schemes
and, where necessary, develop such
schemes. The most successful schemes are
those which prepare people for employment,
help them to find work in mainstream
occupations and provide ongoing support
as required
• they review existing direct payment
arrangements and put a system in place to
improve the take-up of direct payments by
people who use services. This system should
include training for staff, so that they are
well informed and confident about offering
direct payments to people. There should
also be an infrastructure that provides
support, advice and practical help to people
who receive them
• they provide better and more effective
diversity training, with particular emphasis
on cultural awareness and sensitivity.
However, training is not enough. Services
should develop systems to monitor the
impact of training on the design and delivery
of services, and on innovation
• they put in place a safe and effective service
for their entire local population and not just
some sections of it
• they involve people using services in
managing their own medicines and advise
them about the different choices they have.
They should also be given information about
possible side effects and about how and
when their treatments are reviewed
Conclusion
The majority of the LITs that we assessed
showed encouraging performance but there is
still much room for improvement in the basic
areas of care, such as:
• access to care and treatment
• management of care
• support for recovery and social inclusion
We are particularly concerned about how well
people who use services are involved in the
care that they receive. Independence is as
important an issue for people who experience
mental health problems as it is for those with
cardiac conditions or diabetes. Sadly, however,
many services still do not seem to realise this.
Providers of services must ensure that they
continue to improve. Using the key themes
from this review as a benchmark to measure
progress, and taking forward our
recommendations will help with these
improvements. However, good partnerships
with other agencies, particularly those in the
voluntary sector, are key to carrying out these
recommendations and meeting the various
needs of local communities.
Further information
If you want to find out more about how we carried
out our review and the fieldwork – the questions
we asked, how we collected the data, or how all
the LITs in England performed – please visit the
Healthcare Commission website at the address
at the bottom of the page.9
www.healthcarecommission.org.uk/serviceproviderinformation/reviewsandinspections/improvementreviews/
adultcommunitymentalhealthservices.cfm
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Healthcare Commission
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