The featured document is a 1999 Department of Health Document titled ‘A National Service Framework for Mental Health’ and freely available here. This is a lengthy document which runs to 153 pages (in the PDF) and is divided into an introduction, a section on standards, interventions, evidence and service models, local implementation, ensuring progress and national support for local action.
There is an introduction from Frank Dobson, former secretary for state in which he outlines the government’s drive to modernise mental health service in keeping with the White Paper ‘Modernising Mental Health Services’ and which his been validated by an External Reference Group led by Professor Graham Thornicroft.
There follows the introduction – ‘The National Service Framework for Mental Health’. In this section a number of other papers of importance are discussed including ‘The new NHS’ and ‘Modernising Social Services’ which set goals which would reduce variation in practice and ensured that services were sensitive to the needs of individuals. Other documents referred to include ‘A First Class Service’ identifying the roles of the National Institute of Clinical Excellence and the National Service Framework in setting standards as well as ‘A New Approach to Social Services Performance’, ‘Saving Lives: Our Healthier Nation’, ‘Modernising Health and Social Services: National Priorities Guidance for 1990/00-2001/02’. This section covers the National Service Frameworks, goes on to discuss how these can be developed using an evidence-based approach. The need for National Standards is discussed and these are identified as mental health promotion, primary care and access to services, effective services for people with severe mental illness, caring about carers and preventing suicide. The need to monitor progress is discussed and the mechanisms for measuring the delivery of standards is described as being set out in ‘The NHS Performance Assessment Framework’. The new vision for mental health is outlined and covers safe, sound and supportive services. The role of ‘Modernising Mental Health Services’ in commissioning mental health services and providing integrated services is then discussed.
The second section focuses on the National Standards. The first standard is mental health promotion. The rationale is explained including a citation of a 1999 WHO report in which it was found that neuropsychiatric conditions were the most common cause of premature death. Mental Health Promotion strategies are discussed including the Mental Health Foundation Report ‘Bright Futures – promoting children and young people’s mental health’. Vulnerable populations are then discussed. Following this are a number of examples of successful campaigns or resources available for mental health promotion. The second standard relates to primary care and states that
‘any service user who contacts their primary health care team with a common mental health problems should
have their mental health needs identified and assessed
be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it‘
This is covered together with section three which similarly states that
‘any individual with a common mental health problem should:
be able to make contact round the clock with the local services necessary to meet their needs and receive adequate care
be able to use NHS Direct, as it develops, for first-level advice and referral on to specialist helplines‘
Again the evidence base and rationale are examined for both standards and vulnerable groups such as those with eating disorders, anxiety disorders or people accessing Accident and Emergency are discussed. A number of examples of services relevant to these standards are then outlined briefly – from Liaison services to services for young men with mental health problems. Methods for assessing performance are included at the end of the section.
Standard four looks at mental health service users on CPA and notes that they should
‘receive care which optimises engagement, anticipates or prevents a crisis, and reduces risk
have a copy of a written care plan which:
– includes the action to be taken in a crisis by the service user, their carer and their care co-ordinator
– advises their GP how they should responds if the service user needs additional help
– is regularly reviewed by their care co-ordinator
– be able to access services 24 hours a day, 365 days a year‘
Of particular relevance is the recent change in CPA such that enhanced CPA continues but standard CPA does not exist formally. Instead it is expected that all contact with services meets the standards set out in CPA. Thus by inference, standard four could be argued to apply in such instances.
Standard 5 applies to people receiving care away from home and states that the person should have
‘timely access to an appropriate hospital bed or alternative bed or place, which is:
– in the least restrictive environment consistent with the need to protect them and the public
– as close to home as possible
a copy of a written after care plan agreed on discharge which sets out the care and rehabilitation to be provided, identifies the care co-ordinator, and specifies the action to be taken in a crisis‘
The principle of least restriction is emphasised in the 2007 amendment to the Mental Health Act for example and the relationship between the National Service Framework and the Mental Health Act is discussed earlier in the document. These two standards are reviewed together and following on from this are sections on the rationale and evidence base. Brief descriptions of service models and examples of good practice follow.
Standard six is ‘caring for carers’ and states that
‘All individuals who provide regular and substantial care for a person on CPA should:
– have an assessment of their caring, physical and mental health needs, repeated on at least an annual basis
– have their own written care plan which is given to them and implemented in discussion with them‘
The rationale includes a reference to the national strategy ‘Caring about Carers’ and there is a focus on the three principles of ‘information, support and care’. The evidence base is covered which includes assessing carer’s needs, needs assessment and the carer’s plan. A number of service models and examples of good practice are included.
Standard seven is preventing suicide and includes references to the previous six standards as well as developing ‘local systems for suicide audit to learn lessons and take any necessary action’ as well as focusing on at risk groups. As with the previous sections, the rationale, evidence base, service models and examples of good practice are included.
The next section focuses on local implementation and looks at ‘ownership of standards’, performance assessment as well as national/regional support. A number of previous points are reiterated and the roles of the national Mental Health Implementation Group and Team are discussed. There is a useful section on how good practice will be shared including the Learning Zone. National support resources are identified. Six phases of development of local implementation are outlined.
The fourth section looks at ensuring progress and covers assessment of performance and national milestones. National assessment includes coverage of performance indicators and there is a further section on national milestones. The fifth section – the National support for local action is divided into sections on finance, workforce planning/education/training, research and development, clinical decision support systems and information. In the section on finance, there is a discussion of funding resources. In the section on workforce planning, education and training there is a discussion of the challenges facing the workforce, a national training strategy for the workforce and then a complex outline of the various recommended strategies in the categories of recruitment and retention, developing and supporting leadership, education and training and workforce planning. In the section on research and development, there is a focus on three areas – new and emerging applications of technology, service delivery and organisation and Health Technology and Assessment (HTA). Commissioned papers on mental health research and recommendations of the Mental Health Topic Working Group are discussed under National Action. In clinical decision support systems, various resources including the Cochrane collaboration, the NHS centre for reviews and dissemination, PRODIGY (a computerised prescribing decision support system) as well as clinical evidence, clinical guidelines and audit are discussed. The National Action references the NICE guidelines. The final part of this section is on the information strategy. Difficulties with information management are discussed. Urgent development areas are mentioned – ‘the clinical and practice evidence base needs to be more easily available to busy frontline staff’ and ‘staff responsible for planning and monitoring services do not have some fo the basic information they need’. A National Action plan is discussed which includes a mental health information strategy. This is developed further.
‘A National Service Framework for Mental Health’ is clearly an important document for mental health in the UK and while this is a complex document it contains many useful resources and acts as an orienting document that merits close study.
STT1 (Policy document)
Steps To Treatment (STT)
STT = Steps To Treatment. An estimate of the number of steps between the results and translation into practice i.e. treatment. This is an opinion. A policy statement would have a value of 1 as this a guide for practice whereas a speculative model would get a much higher score as there are more steps between statement of the model and treatment (which would involve testing the model, informing treatment approaches and trialling these approaches for instance).
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