Guidance for commissioners of rehabilitation services
Guidance for commissioners of rehabilitation services for people with complex mental health needs 1VolumeTwo:Practicalmental healthcommissioningGuidance for commissioners ofrehabilitation servicesfor people with complexmental health needsJoint Commissioning Panelfor Mental Healthwww.jcpmh.info
Guidance for commissioners of rehabilitation services for people with complex mental health needs 3Ten key messages for commissioners1 Mental health rehabilitation servicesspecialise in working with peoplewhose long term and complex needscannot be met by general adult mentalhealth services. Rehabilitation services:• provide specialist assessment,treatment, interventions andsupport to help people to recoverfrom their mental health problemsand to (re)gain the skills andconfidence to live successfully inthe community• always work in partnership withservice users and carers, adoptinga recovery orientation that placescollaboration at the centre of allactivities• work with other agencies thatsupport service users’ recovery andsocial inclusion, including supportedaccommodation, education andemployment, advocacy and peersupport services.2 Rehabilitation services are not thesame as recovery services. A recovery orientation should be atthe centre of all health and social careservice provision to people with mentalhealth problems and is not limited torehabilitation services.3 There is an ongoing need forspecialist rehabilitation services. Despite the investment in communitymental health services in recentdecades, there remains a group ofservice users with very complex needswho require specialist inpatient andcommunity rehabilitation. Around 10%of service users presenting to mentalhealth services for the first time with apsychotic illness will go on to requirerehabilitation services due to theseverity of their functional impairmentand symptoms1.4 People using rehabilitationservices are a “low volume, highneeds” group:• 80% have a diagnosis of apsychotic illness (schizophrenia orschizoaffective disorder), and manywill have been repeatedly admittedto hospital prior to referral torehabilitation services2• many experience severe“negative” symptoms that impairtheir motivation, organisationalskills and ability to manageeveryday activities (self-care,shopping, budgeting, cooking etc)and place them at risk of seriousself-neglect3,4,5• most have symptoms that have notresponded to first-line medicationsand require treatment withcomplex medication regimes• around 20% have co-morbiditiessuch as other mental disorders,physical health problems andsubstance misuse problems thatcomplicate their recovery further6,7• most require an extendedadmission to inpatient rehabilitationservices and ongoing support fromspecialist community rehabilitationservices over many years.5 People with complex mental healthproblems often require a largeproportion of mental health resources. Around one half of the total mentalhealth and social care budget isspent on services for people withlonger term mental health problems.Half of this (one quarter overall) isspent on rehabilitation services andspecialist mental health supportedaccommodation8.6 There is good evidence thatrehabilitation services are effective:• around two-thirds of peoplesupported by rehabilitation servicesprogress to successful communityliving within five years, and around10% achieve independent livingwithin this period9• people receiving support fromrehabilitation services are eighttimes more likely to achieve/sustain community living,compared to those supported bygeneric community mental healthservices10.7 Investment in a local rehabilitationcare pathway is cost-effective:• local provision of inpatient andcommunity rehabilitation servicesensures that service users withcomplex needs do not become“stuck” in acute mental healthinpatient wards• historically, where there is a lackof local provision, service users withcomplex needs have been placedoutside the local area in hospital,nursing or residential care. Out ofarea placements cost around 65%more than local placements, aresocially dislocating for service usersand are of variable quality11• recent guidance for commissionerson out of area placementsemphasises the importance ofprovision of local care pathways forpeople with complex mental healthneeds to minimise the use of out ofarea placements12.
4 Practical Mental Health Commissioning8 Commissioning a ‘good’ rehabilitationservice includes components of careprovided by the NHS, independentand voluntary sector:• inpatient and community basedrehabilitation units – for voluntarypatients and those requiringdetention under the Mental HealthAct (1983)• community rehabilitation teams– support service users whenthey leave hospital and/or moveto supported accommodation;support supported accommodationproviders; liaise with providers toensure that vacancies are matchedwith clinical priorities; facilitateservice users’ move-on to lesssupported accommodation• supported accommodationservices – these provide day today support for service users tolive in the community, and includenursing/residential care; supportedtenancies; and floating outreachservices• services that support service users’occupation and work; advocacyservices and peer support services;and any services that supportservice users’ social inclusionand rights.9 Mental health rehabilitation servicesrequire multidisciplinary staffing. Multidisciplinary teams are required ininpatient and community rehabilitationservices with the expertise to addresstheir service users’ complex and diverseneeds including: complex medicationregimes; physical health promotion;psychological interventions, artstherapies; self-care; everyday livingskills; and meaningful occupation.10 The quality and effectiveness ofrehabilitation service provision can beassessed with simple indicators andstandardised outcome tools.This guidance recommends outcomemeasures and indicators that can beused to monitor the quality of services,flow through the care pathway andbetter service user outcomes.Ten key messages for commissioners (continued)
The Joint Commissioning Panelfor Mental Health (JCP-MH)(www.jcpmh.info) is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• Service users and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.IntroductionThe JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health.13The JCP-MH has two primary aims:• to bring together service users, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioning• to integrate scientific evidence,service user and carer experience andviewpoints, and innovative serviceevaluations in order to produce the bestpossible advice on commissioning thedesign and delivery of high quality mentalhealth, learning disabilities, and publicmental health and wellbeing services.The JCP-MH:• has published Practical MentalHealth Commissioning,14a briefing onthe key values and principles for effectivemental health commissioning• has so far published six other practicalguides on the commissioning of primarymental health care services15, dementiaservices16, liaison mental health servicesto acute hospitals17, transition services18,perinatal mental health services19, andpublic mental health services20• provides practical guidance and adeveloping framework for mental health• will support commissioners to deliverthe best possible outcomes for communityhealth and wellbeingWho is this guide for?This guide is about thecommissioning of good qualitymental health interventions andservices for people with complexand longer term problems tosupport them in their recovery.It should be of value to:• Health and Wellbeing Boards whowill have a key role in transforminghealth and care and achieving betterpopulation health and wellbeing throughtheir responsibility for preparing JointStrategic Needs Assessments (whichshould take account of the current andfuture health and social care needs ofthe entire population), Joint StrategicAsset Assessments, and Joint Health andWellbeing Strategies• Clinical Commissioning Groups and LocalAuthorities as they will jointly lead thelocal healthcare system, through Healthand Wellbeing Boards and in collaborationwith their communities• The NHS Commissioning Board as this willsupport and hold to account the work ofClinical Commissioning Groups• Service providers including those inprimary and secondary care, social care,local authorities and third-sector providersof supported accommodation and otherservices that promote social inclusionincluding supported employment andother meaningful occupation• Public Health England as reducing mentaldisorder and promoting well-being isan important part of their role and alsocontributes to a range of other publichealth priorities.Guidance for commissioners of rehabilitation services for people with complex mental health needs 5
How will this guide help you?This guide has been writtenby a group of rehabilitationservice experts.The content is primarily evidence-basedbut ideas deemed to be best practiceby expert consensus have also beenincluded.By the end of this guide, readers shouldbe more familiar with the conceptof rehabilitation services and betterequipped to understand:• the policy context for rehabilitationservices• the importance of joined up healthand social care commissioning ofrehabilitation services• the centrality of the service userand carer voice in the commissioningof rehabilitation services• the importance of having a“whole system approach” in thecommissioning of mental healthrehabilitation services• the importance of providing alocal rehabilitation care pathway forpeople with complex mental healthneeds, from inpatient care throughto supported housing and vocationalrehabilitation services• the key components of acomprehensive rehabilitation serviceand the need for local tailoring ofthe rehabilitation care pathway tomeet local need• the range of providers needed todeliver such a care pathway.What are mental healthrehabilitation services?This guide defines mental healthrehabilitation as:A whole systems approach torecovery from mental illnessthat maximises an individual’squality of life and socialinclusion by encouraging theirskills, promoting independenceand autonomy in order to givethem hope for the future andleading to successful communityliving through appropriatesupport21.A mental health rehabilitation serviceprovides specialist assessment, treatment,interventions and support to enable therecovery of people whose complex needscannot be met by general adult mentalhealth services.These services aim to work with peopleto help them acquire or regain the skillsand confidence to live successfully in thecommunity. They focus on addressing andminimising the symptoms and functionalimpairment that people may have, with anemphasis on achieving as much individualautonomy and independence as possible.This includes optimal management ofsymptoms, promotion of activities ofdaily living and meaningful occupation,screening for physical health problems andpromoting healthy living, and providingsupport and evidence based interventionsto support carers.Rehabilitation services adopt a “recovery”approach that values service users aspartners in a collaborative relationshipwith staff to identify and work towardspersonalised goals. The concept ofrecovery encompasses the values of hope,agency, opportunity and inclusion, themesthat resonate well with the aims of mentalhealth rehabilitation.6 Practical Mental Health CommissioningRehabilitation services operate as awhole system that includes a rangeof inpatient and community services,supported accommodation and vocationalrehabilitation services provided bystatutory, independent and voluntarysector organisationsThe specific components required inany locality will vary according to localpsychiatric morbidity and need and aredescribed on pp.12-17.These pages also describe the functions ofthese components and the interventionsdelivered by staff.Users of rehabilitation services often haveco-morbid physical health problems andclose liaison with primary care servicesand, where appropriate, secondarycare medical services is a key role forrehabilitation practitioners.THE REHABILITATION CARE PATHWAYPeople who do not recover adequatelyafter acute admission to a mental healthunit to be able to be discharged home arereferred to rehabilitation services. Thereforemost referrals come from general adultinpatient services. Rehabilitation servicesalso provide step-down for those patientsmoving on from secure mental healthservices who have longer term and complexmental health needs.Around 10% of people receiving carefrom Early Intervention Services havelonger term and complex needs that willrequire input from rehabilitation services1.However, most of these will be inpatientsin a general or secure mental healthinpatient ward at the point of referral.Figure 1 (p.8) illustrates a typicalrehabilitation care pathway, showing the“direction of travel” for service users withcomplex and longer term mental healthproblems, from inpatient services throughto community living. The specifications ofeach are described in detail on pp.12-17.Introduction (continued)
A recent national survey of inpatientrehabilitation services2has found that almostall NHS Trusts in England have at leastone type of inpatient rehabilitation unitaccepting referrals from acute admissionwards and secure mental health services,but 60% of these units are actually sited inthe community. Only 11% are wards withina mental health unit and 29% are separateunits within the mental health unit’sgrounds. Around one third of Trusts alsohave a low secure rehabilitation unit22.The exact configuration of inpatientrehabilitation services varies in differentlocalities according to need. Inner cityareas, for example, tend to have greaterneed for a high dependency inpatientrehabilitation unit within the mentalhealth unit. Taking this approach allowsservice users to generally move on to acommunity based rehabilitation unit inpreparation for more independent, butsupported community living. Most (67%)people who require inpatient rehabilitation,whether delivered in a hospital orcommunity based unit, are able to moveon successfully to some form of supportedaccommodation within five years9.Community rehabilitation services workclosely with supported accommodationservices to provide comprehensivesupport to service users as they continuetheir recovery in the community. Whenservice users are able to manage with lesssupport they move on to less supportedaccommodation. Once they are able tomanage more independent living, theircare is transferred from the rehabilitationservice to a standard community mentalhealth service. However, only around 10%of service users will achieve and sustainfully independent living within five years ofreferral into rehabilitation services9.It takes a number of years for service usersto move successfully through each step ofthe rehabilitation care pathway due to theseverity and complexity of their mentalhealth needs. Service users often need tomake repeated attempts to successfullytransition from a higher to a lowerlevel of support. Those commissioningrehabilitation services need to be awarethat a “long term view” has to be held forthis service user group.WHO USES MENTAL HEALTHREHABILITATION SERVICES?Despite developments in mental healthinterventions and services that provideearly intervention to people presentingwith psychosis, around 10% of peopleentering mental health services will haveparticularly complex needs that requirerehabilitation and intensive support frommental health services over many years1.At any time, around 1% of people withschizophrenia are in receipt of inpatientrehabilitation6.A recent national survey of inpatientmental health rehabilitation servicesacross England found that 80% of thoseusing these services had a diagnosis ofa psychotic illness, usually schizophreniaor schizoaffective disorder. Two-thirds ofservice users were male, reflecting the factthat men diagnosed with schizophreniatend to have a poorer prognosis thanwomen. On average, service users hadexperienced mental health problemsfor 13 years and had been recurrentlyadmitted to hospital prior to referral forrehabilitation2.Mental health rehabilitation serviceusers often have prominent “negative”symptoms that impair their motivationand organisational skills to manageeveryday activities3,4,5. This places themat risk of self-neglect. Many also haveongoing “positive” symptoms (such asdelusions and hallucinations) which havenot responded fully to medication and canmake communication and engagementdifficult6. It is estimated that aroundone third of people with a diagnosis ofschizophrenia do not respond adequatelyto antipsychotic medication23.As well as “treatment resistant” positivesymptoms and severe negative symptoms,many people who use rehabilitationservices have co-existing problemsthat make their presentation especiallycomplex and difficult to manage. Theseinclude other mental health issues (suchas depression and anxiety), long termphysical health conditions (such aschronic obstructive pulmonary diseaseand cardiovascular disease), pre-existingdisorders (such as learning disability anddevelopmental disorders including thoseon the Autistic Spectrum) and substancemisuse. These problems mean that manyservice users present with challengingbehaviours including aggression to others6.Most have considerable disability andimpaired mental capacity to makeeveryday decisions. They can be vulnerableto exploitation and abuse by others andmay require safeguarding.In short, mental health rehabilitationservice users are a “low volume, highneed” group.It is likely that, in addition to those patientsthat receive support from mental healthrehabilitation services, there is a largergroup of people living in the community,diagnosed with schizophrenia, who havenot been adequately supported to achievetheir full recovery potential. Sometimesthese people will be receiving supportfrom general adult mental health servicesbut considered “stable”. Some may notbe receiving care from secondary mentalhealth services but are known to theirGP. A large “clinical iceberg” of undertreatment is suspected. There is goodevidence that clozapine, a medicationprescribed for people with “treatmentresistant” symptoms, is under used in thecommunity. It is likely that communitymental health teams have not been ableto focus on this group due to many othercompeting priorities. Improving access toappropriate multidisciplinary and multi-provider resources, including rehabilitationservices, is needed to maximise recoveryfor this group.Guidance for commissioners of rehabilitation services for people with complex mental health needs 7
8 Practical Mental Health CommissioningWhat are mental health rehabilitation services? (continued)WHICH “CLUSTERS” ARE RELEVANT?With reference to the Mental HealthClustering Tool (HoNOS), the majority ofpeople in receipt of inpatient mental healthrehabilitation services are likely to becategorised as Cluster 13:Cluster 13: Complex needs, High Support“This group will have a history ofpsychotic symptoms which are notcontrolled. They will present with severeto very severe psychotic symptoms andsome anxiety or depression. They have asignificant disability with major impact onrole functioning. They will have possiblecognitive and physical problems linkedwith long-term illness and medication.They may be lacking basic life skills andpoor role functioning in all areas”.As people’s symptoms and life skillsimprove over time, their “cluster” maybe re-categorised to reflect their changein needs. Those who are able to move tosupported accommodation successfully aremost likely to be categorised as Cluster 12and will require ongoing, flexible supportfrom community rehabilitation servicesand/or other community mental healthservices to sustain their recovery andaccommodation:Cluster 12: Complex needs, MediumSupport“Possible cognitive and physical problemslinked with long-term illness andmedication. May have limited survival skillsand be lacking basic life skills and poor rolefunctioning in all areas. This group havea history of psychotic symptoms with asignificant disability with major impact onrole functioning”.Those who achieve independent livingmay ultimately be categorised into Cluster11. This group will not need ongoingcommunity mental health rehabilitationservices. Some may continue to besupported by other community mentalhealth services with the aim of eventualdischarge from mental health services toprimary care services:Cluster 11: Complex needs, StandardSupport“This group has a history of psychoticsymptoms that are currently controlledand causing minor problems if any at all.They are currently experiencing a period ofrecovery where they are capable of full ornear functioning. However, there may beimpairment in self-esteem and efficacy andvulnerability. This group may have full ornear full functioning”.Services that makereferrals to localrehabilitation services• Medium secure forensicmental health units(regional)• Low secure forensic mentalhealth units (regional)• Psychiatric intensive careunits (local)• Acute inpatient units(local)Local inpatient mentalhealth rehabilitationservicesLow secure rehabilitationunit (30% of NHS Trustsprovide these locally)High dependencyrehabilitation unit(hospital based) Community based “inpatient” rehabilitation unitLonger term complex carerehabilitation unit (hospitalor community based)Community services that supportrehabilitation and recovery from complexmental health problemsPRIMARY CARESECONDARY COMMUNITY MENTALHEALTH AND SOCIAL CARE SERVICESCommunity Rehabilitation TeamAssertive Outreach TeamCommunity Mental Health/Recovery TeamPrimary Care Liaison TeamSupportedaccommodation• Nursing/residential care• Supported tenancies(support on-site)• Supported tenancies(floating outreach )Other services that supportsocial inclusion• Vocational rehabilitation(sheltered and supportedemployment, voluntarywork, welfare benefitsadvice)• Education• Advocacy services• Peer support• Cultural/leisure servicesIndependent tenanciesFigure 1: Components of a “whole system” rehabilitation care pathway
Assertive Outreach Teams (AOTs)are most likely to work with patientscategorised as Cluster 16 or 17 who maybe living independently or in supportedaccommodation. AOTs are specialistcommunity teams that offer intensivesupport to people living in independentor low support tenancies. They comprisean important component of the local carepathway for people with longer term andcomplex mental health needs. Many arecommissioned and managed as part ofthe local rehabilitation service, hence theirinclusion in this guide:Cluster 16: Dual diagnosis“This group has enduring, moderate tosevere psychotic or affective symptomswith unstable, chaotic lifestyle andco-existing substance misuse. Theymay present a risk to self and othersand engage poorly with services. Rolefunctioning is often globally impaired”.Cluster 17: Psychosis and affectivedisorder, difficult to engage“This group has moderate to severepsychotic symptoms with unstable, chaoticlifestyles. There may be some problemswith drugs or alcohol not severe enough towarrant dual diagnosis care. This group havea history of non-concordance, are vulnerableand engage poorly with services”.HOW EFFECTIVE ARE MENTALHEALTH REHABILITATION SERVICES?Due to the complex nature of theirproblems, mental health rehabilitationservices often work with their clients overmany years, enabling them to gain/regainconfidence and skills in everyday activitiesand in managing their mental healthsymptoms.Maintaining expectations of recovery overlong periods of time can be difficult forstaff, service users and carers. A majoraspect of the ethos of rehabilitationservices is the continuous promotion oftherapeutic optimism.Longer term studies of people with adiagnosis of schizophrenia have shownthat half to two-thirds significantlyimprove or recover over time24,25.There is also good evidence that evenamongst those with complex problems,with appropriate rehabilitation, themajority (two-thirds) are able to progresssuccessfully to supported communityliving within five years and around 10%will achieve independent living9,26. Thissuggests that therapeutic optimism isneither idealistic nor misplaced.A prospective cohort study carried outin Ireland that compared service usersin receipt of mental health rehabilitationservices with those receiving care fromgeneral adult mental health services whohad similar levels of complex needs andwere wait listed for rehabilitation services,found that those receiving treatmentand support from rehabilitation serviceswere eight times more likely to achieveand sustain successful community livingeighteen months later10.A five year programme of research,funded by the National Institute for HealthResearch and led by a team at the MentalHealth Sciences Unit, University CollegeLondon, is currently investigating theclinical and cost-effectiveness of mentalhealth rehabilitation services in England(the “REAL” study - RehabilitationEffectiveness for Activities for Life).This includes a national survey of inpatientrehabilitation services which found thatthe quality of services was positivelyassociated with service users’ experiencesof care and autonomy2. Later phases willreport in 2014 on longitudinal outcomesincluding social functioning and successfulcommunity living. (www.ucl.ac.uk/REAL-Study).HOW DO MENTAL HEALTHREHABILITATION SERVICES WORKWITH OTHER AGENCIES?Rehabilitation services operate as a wholesystem that includes a range of otheragencies and organisations. Collaborativeand partnership working is key to this. Ithelps ensure the provision of a holisticand comprehensive care pathway that cansupport service users to make incrementalimprovements in their everyday and socialfunctioning, and to successfully takeon increasing levels of responsibility inmanaging as many aspects of their ownlife as possible.Rehabilitation services and the wider networkof services with which they work developstrong links with local community resources tofacilitate service users’ social inclusion.Similarly, productive partnerships with usersand carers are needed to ensure that localprovision is adequate to enable recoveryand to support informal support networks.Integrated health and social carecommissioning is therefore required toensure that the local rehabilitation carepathway is appropriate for the localpopulation, that there are functionaland productive partnerships betweenproviders to inform this provision, and itis appropriately used to enable people tomove on smoothly between services. Commissioners and providers also needto take account of the personalisationapproach within social care. A full descriptionis beyond the scope of this document, butin short, personalisation aims to ensurethat social care services are tailored tothe needs of every individual, rather thandelivered in a one-size-fits-all fashion. It is– to paraphrase the Department of Health- an approach where “every person whoreceives support…will have choice andcontrol over the shape of that support inall care settings”. (For further informationon personalisation in social care, pleasesee: www.scie.org.uk/topic/keyissues/personalisation).Guidance for commissioners of rehabilitation services for people with complex mental health needs 9
Why are mental health rehabilitation servicesimportant to commissioners?People with especially complexmental health needs cannot beadequately managed by generaladult mental health servicessince their particular needsrequire specialist assessment andtreatment (see p.14-15).This group often require lengthyadmissions and ongoing intensive supportfrom rehabilitation and other mentalhealth services to live in the communitysuccessfully after discharge. Despite being arelatively small group, they absorb around25% of the total mental health budget27.As described earlier, a recent study inIreland found that people with complexmental health needs were eight times morelikely to achieve and/or sustain successfulcommunity living if they were supportedby mental health rehabilitation services ascompared to general adult mental healthservices10.Investment in local rehabilitation servicescan reduce ‘out-of-area’ treatment costs.• Disinvestment in NHS rehabilitationservices after the publication of theNational Service Framework for MentalHealth28led to a rapid and uncontrolledrise in provision of ‘out-of-areaplacements’ in hospital, nursing andresidential care homes in the independentsector for people with longer term andcomplex mental health problems whocould not be discharged from acuteadmission wards12,28.• This phenomenon has been referredto as the ‘virtual asylum’ since, untilrecently, there was little attention paid tothe ongoing review of these individuals’needs and their potential for recovery andprogress to more independent living29.• Out of area placements displace serviceusers from their communities and families.Furthermore, criticisms of the quality ofcare and lack of rehabilitative ethos insome have been made30.• Out of area treatments are expensive,costing, on average around 65% morethan similar local services11. In 2008-9,out-of-area placements cost the NHSand social services around £330 million8.Historically, most placements werecommissioned by Primary Care Trusts,and – as clinical commissioning groupsmay discover – there are often inadequatesystems for monitoring the quality of careand the ongoing need for the level ofsupport provided31.• Service users placed in out-of-areafacilities have similar profiles in mostrespects to those placed locally32.Rehabilitation psychiatrists and otherexperienced rehabilitation cliniciansshould be involved in assessing theappropriateness of making individual outof area placements and reviewing theneeds of people placed in them in orderto clarify whether local services couldprovide a better alternative.• General adult mental health services areunlikely to have the appropriate skills toassess and review people placed out ofarea with a view to repatriation. “Outof area reviewing officers”, supportedby rehabilitation psychiatrists and otherclinicians are required for this role.Without them, many individuals become“stuck” in placements unnecessarily withno clear care pathway back to their localarea.• Lack of clarity about commissioning andhousing responsibility when individualswish to settle in an “out of area” localityfurther complicates the situation. Ithighlights the importance of integratingcommissioning between health and localcouncil social care and housing resourcesfor this group.• In times of increasing constraints onresources it is imperative for local mentalhealth economies that this money isspent effectively. ‘Repatriating’ peopleto local services and helping them liveas independently as possible is likely tobenefit the individual as well as savingmoney which could be used in moreuseful ways.• Recent guidance for commissionerson out of area placements has beenproduced by the National Mental HealthDevelopment Unit. (www.rcpsych.ac.uk/pdf/insightandinmind.pdf) This stressesthe importance of provision of local carepathways for people with complex mentalhealth needs to minimise the use ofout of area placements to the particularcircumstances where clinical complexity issuch that local provision would be clearlyunfeasible12.Since there is geographical variation insociodemographic characteristics andpsychiatric morbidity, the exact componentsof the rehabilitation care pathway thatwill be required in different areas are likelyto vary.More details on which components ofthe rehabilitation care pathway should beprovided locally, and which are more likelyto be required at a regional level are givenon pp.12-17.Commissioning of a local rehabilitationcare pathway will be informed by thelocal Joint Strategic Needs Assessment formental health which should include data onindividuals currently residing in out of areaplacements due to their complex mentalhealth needs.Successful joint strategic commissioningof health and housing for this groupwill require good co-operation betweencommissioners, enhanced and supportedby Health and Wellbeing Boards, andthe alignment of resources from clinicalcommissioning groups and local authoritiesto enable people to achieve their maximumlevel of independence33.10 Practical Mental Health Commissioning
Guidance for commissioners of rehabilitation services for people with complex mental health needs 11What do we know about currentmental health rehabilitation services?While the Royal Collegeof Psychiatrists’ Faculty ofRehabilitation and SocialPsychiatry has produced atemplate for rehabilitationservices (upon which thiscommissioning guidance isbased)34, there is no nationallyagreed service specificationwithin the UK for mentalhealth rehabilitation.Nevertheless, almost all NHSTrusts have at least one highdependency inpatient orcommunity based rehabilitationunit per Local Authority areawith an average 14 beds.Over a half of Trusts have acommunity rehabilitation team2.Around 25% of the total mental healthbudget is absorbed by rehabilitationservices and supported accommodationfor people with longer term and complexmental health needs. This proportionexpands to around 50% if the wider familyof services that provide for this groupare included (including standard generaladult services). Much of this spendingon rehabilitation falls within mainstreamhealth and social care services8.The importance of providing a localrehabilitation care pathway to minimisethe use of out of area placements hasbeen emphasised in a number of policydocuments including:• guidance produced by the NationalMental Health Development Unit for theDepartment of Health12• Mental Health and the EconomicDownturn; national priorities andNHS solutions35The implementation guide to the MentalHealth Strategy; No Health WithoutMental Health also supports investmentin rehabilitation services13.Similarly, the supporting document to theMental Health Strategy, “The economiccase for improving efficiency and qualityin mental health services” also emphasisesthe need for local investment in arehabilitation care pathway to reducethe need for out of area placements36.
What would a good mental healthrehabilitation service look like?An effective rehabilitationservice requires a managedfunctional network of servicesacross a wide spectrum of care,and the exact components ofthe care pathway providedshould be determined by localneed. These comprise:• inpatient and community basedrehabilitation units• community rehabilitation teams• supported accommodation services• services that support service users’occupation and work• advocacy services• peer support services.Some of the components of therehabilitation care pathway may beprovided by independent and third sectororganisations. Pathways through theseservices should be as seamless as possible,which will be dependent on good workingrelationships between the components.Commissioners play a key role infacilitating these relationships.INPATIENT REHABILITATION SERVICESAn inpatient service is a unit with‘hospital beds’ that provides 24-hournursing care. It is able to care for patientsdetained under the Mental HealthAct, with a consultant psychiatrist orother professional acting as responsibleclinician. This does not mean that allor even a majority of patients will bedetained involuntarily. All units shouldhave access to the full range of skillsof a multi-professional team. As mostrehabilitation service users will requirelengthy inpatient treatment, rehabilitationunits should provide a safe and homelyspace that fosters stability and security,avoids institutionalisation and provides theexperience for service users of non-abusiverelationships.Inpatient rehabilitation services require arange of different facilities that work aspart of an interdependent system, ratherthan stand-alone units. Only the largestNHS Trusts will provide a full spectrumof inpatient rehabilitation services. Mostwill work with other providers in theindependent sector or NHS to provide acomprehensive inpatient care pathway.Very specialist services, for example unitsfor people with co-morbid conditions suchas mental health problems and brain injuryor Autism Spectrum Disorders, can only beprovided supra-regionally whereas thoseoffering rehabilitation in high dependencyand/or community rehabilitation unitsshould be available locally. Around onethird of Trusts provide a local low securerehabilitation unit. Other Trusts accesslow secure services through out of areaplacement or through regional forensicservices.A full range of inpatient services should beprovided across the dimensions and typesdescribed below.Typology of inpatient rehabilitation unitsLow secure rehabilitation units• Client group and focus: this group hasdiverse needs but have all have beeninvolved in offending or challengingbehaviour. They will all be detainedunder the Mental Health Act 1983 andthe majority under Part 3 of the Act.Levels of security will be determined byMinistry of Justice requirements and akey task will be the accurate assessmentand management of risk. Clients willhave varying levels of functional skillsand are likely to require therapeuticprogrammes tailored to their offendingbehaviour in addition to their mentaldisorders.• Recovery goal: to move on to ahigh dependency or communityrehabilitation unit.• Site: stand alone unit or within ahospital campus.• Length of admission: 2 years plus;variable, depending on the nature ofthe offending or challenging behaviourand psychopathology.• Functional ability: domestic servicesprovided by the unit rather thanits residents, although participationin domestic activities with supportencouraged as part of therapeuticprogramme.• Risk management: higher-staffed unitsable to manage behavioural disturbancewith full range of physical, proceduraland relational security and specialist riskassessment and management skills.• Degree of specialisation: one unit isneeded for a population over 1 million.High dependency inpatientrehabilitation units• Client group and focus: people whoneed this kind of facility will be highlysymptomatic, with multiple or severeco-morbid conditions, significant riskhistories and challenging behaviours.Most will be detained under the MentalHealth Act. Around 20% will havehad forensic admissions. The focusis on thorough ongoing assessment,maximising benefits from medication,engagement, reducing challengingbehaviours and re-engaging withfamilies and communities. These unitshave a major role in repatriating patientsfrom secure services and out-of-areaplacements to local services and,ultimately, to local community living.• Recovery goal: to move on tocommunity rehabilitation unit or tosupported community living.12 Practical Mental Health Commissioning
Guidance for commissioners of rehabilitation services for people with complex mental health needs 13• Site: ward usually based in the localmental health unit to benefit fromsupport from other wards and outof hours cover.• Length of admission: 1 to 3 years.• Functional ability: domestic servicesprovided by the unit, althoughparticipation in domestic activitieswith support encouraged as part oftherapeutic programme.• Risk management: higher-staffed (oftenlocked/lockable) units able to managebehavioural disturbance.• Degree of specialisation: should beavailable in all Trusts. One unit is neededfor a population of 600 000 to 1 million.Community rehabilitation units• Client group and focus: peoplewith complex mental health needswho cannot be discharged directlyfrom hospital to an independent orsupported community placement dueto their ongoing high levels of need.The focus is on facilitating furtherrecovery, optimising medicationregimes, engagement in psychosocialinterventions and gaining skills for moreindependent living.• Recovery goal: to achieve a successfulreturn to community living. Most peoplewill move on to a supported tenancy.• Site: local, community based unitproviding a domestic environment thatfacilitates service users’ confidenceand abilities in managing activitiesof daily living (self-care, shopping,cooking, budgeting etc) and promotesengagement in community basedactivities/vocational rehabilitation.• Length of admission: 1-2 years.• Functional ability: domesticenvironments that facilitate serviceusers to acquire everyday living skillsin preparation for more independentcommunity living.• Risk management: “open” units, staffed24 hours by nurses and support workerswith regular input from other membersof the multidisciplinary team. Specialistrisk management skills are essential.• Degree of specialisation: should beavailable in all Trusts. One unit is neededfor a population of around 300 000.Longer term complex care units• Client group and focus: patients willusually have high levels of disabilityfrom complex co-morbid conditions,with limited potential for gaining skillsrequired for supported communityliving, and have associated, significantrisks to their own health and/or safetyand/or to others. Co-morbid seriousphysical health problems are commonand will require ongoing monitoringand treatment.• Recovery goal: other rehabilitationoptions will usually have been triedunsuccessfully; disability and risk issuesremain but a more domestic setting thatoffers a high level of support is practical.The emphasis is on promoting personalrecovery and improving social andinterpersonal functioning over the longerterm.• Site: usually community-based,sometimes on a hospital campus.• Length of admission: 5-10 years.• Functional ability: domestic servicesprovided by the unit rather thanits residents, although participationin domestic activities with supportencouraged as part of therapeuticprogramme.• Risk management: higher staffed unitsbut with emphasis on unqualifiedsupport staff; risk management basedon relational skills and environmentalmanagement.• Degree of specialisation: should beavailable in all Trusts. One unit is neededfor a population of around 600 000.Highly specialist unitsThese units provide specialist treatmentprogrammes for people with veryparticular and complex mental healthneeds and co-morbidities (e.g. acquiredbrain damage, severe personalitydisorder, autism spectrum disorder).They are provided at a super-regionalor national level and are therefore likelyto be commissioned by the NationalCommissioning Board.COMMUNITY REHABILITATIONSERVICESA substantial proportion of people withsevere mental illness continue to havesignificant problems with social andpersonal functioning many years afterdiagnosis, despite optimum treatment.Around 10% of service users presentingfor the first time with a psychotic illness,will go on to require rehabilitation servicesdue to the severity of their functionalimpairment and symptoms1.Most are not so disabled or behaviourallydisturbed that they require long-termhospital care, nor so difficult to engageor so high-risk as to require assertiveoutreach, but their problems place them atrisk of social isolation, self-neglect, relapseinto acute illness, inability to cope andexploitation in community settings.At present, 51% of NHS trusts have acommunity rehabilitation team2. Theskills of these teams provide a key role inkeeping the whole system of supportedaccommodation moving, by supportingclients and supported accommodationproviders to enable through-put.Referrals to community rehabilitationservices are received from earlyintervention services, from assertiveoutreach teams for clients who arenow well engaged but have ongoing
14 Practical Mental Health CommissioningWhat would a good rehabilitation service look like? (continued)problems with everyday living skills, fromcommunity mental health teams forclients whose functional needs are toosevere to be managed by general adultservices and from inpatient (general adult,rehabilitation, low and medium secureservices), nursing and residential carehomes (both local and out of area) forclients who are ready to move to a lesssupported, community based setting.The main functions of communityrehabilitation services are to:• care co-ordinate – around 15% ofcommunity rehabilitation teams providefull CPA care co-ordination21, or thisfunction is provided by thelocal community mental health team(the care co-ordinator providescontinuity of care, will often haveknown the client for many years, andwill remain in contact if the client isadmitted to hospital and are involvedin making referrals to appropriatelysupported accommodation prior todischarge, facilitating the person’s accessto appropriate welfare benefits, adultprotection procedures, other legal issuesincluding use of the Mental HealthAct and Mental Capacity Act wherenecessary, and in all aspects of careplanning required on discharge to thecommunity)• provide support to clients as theymove from hospital to supportedaccommodation and from higher toless supported accommodation• enable clients to gain confidencein their everyday living skills, theirself-management of their illness andmedication, and their day to day life• widen clients’ social networks• support clients to build “meaningfuloccupation” into their daily routine• hold therapeutic optimism for clientsand plan for a potential move to a moreindependent setting (no service user isassumed to be in a placement likely tosuit their needs forever)• build and maintain partnershipswith local providers of supportedaccommodation, education andvocational rehabilitation services andother community resources• work closely with commissionersto scope and review the ongoingsupported accommodation needs ofthe local population• have expert knowledge of theavailability, referral and fundingprocesses required to access supportedaccommodation• keep clear discharge criteria to ensureongoing access for new clients• review clients placed out of area.The specific interventions provided bycommunity rehabilitation services include:• holistic multidisciplinary assessmentand formulation of individualised,collaborative care plans that enablerecovery and social inclusion• clinical interventions to minimisesymptoms (e.g. psychologicalinterventions and support withmedication management)• practical support to enable clients tomaintain their placement/tenancy (e.g.access to appropriate welfare benefits,help with budgeting, paying bills,assistance with activities of daily livingsuch as shopping, cooking and cleaning)• supporting clients to:– access appropriate physical anddental health care including attendingprimary and secondary medical careappointments– access social, cultural and leisureactivities, education and vocationalresources– re/engage with family and friends– access personal budgets asappropriate to support theirindividualised recovery goals• providing support to: – clients’ families and informal carers– staff in supported accommodation toincrease their confidence in managingpeople with complex mental healthproblems• managing safeguarding assessments.Out of area placement reviewThis can be effected through a dedicatedteam, or individuals within a communityrehabilitation service, depending on thenumber of clients placed out of area.The aims of the review are to:• ensure that the placement continues tomeet the person’s needs• identify an appropriately supported,(ideally more independent) placementfor the client to move-on to in thefuture, ideally in their area of origin(where desired and clinically indicated)• identify with the client and the staffof the out of area placement, cleargoals for progression through thepathway being identified (e.g. managingmedication more independently,self-catering, budgeting)• facilitate assessment by the potentialmove-on accommodation provider at anappropriate time• liaise with all parties, including familymembers, and support the client andfamily practically and emotionallythrough the assessment and move-onprocess, including visits, transitionalleave and final move• continue to review the new placementif out of area, or hand over case to localcommunity mental health/rehabilitationservice after an appropriate settling period.
TREATMENTS AND INTERVENTIONSDELIVERED BY INPATIENT ANDCOMMUNITY MENTAL HEALTHREHABILITATION SERVICESMental health rehabilitation inpatientand community services are staffed bymultidisciplinary teams with the expertise toaddress the complex and diverse treatmentneeds of their clients. Ideally, some staffprovide continuity of care by workingacross inpatient and community settings.All staff deliver their specialist interventionswithin the collaborative framework of therecovery approach. Given the complexityof the client group, the team should haveaccess to regular group and individualsupervision to share concerns andproblem solve. Wherever possible, specificinterventions are delivered in accordancewith NICE guidance37,38.MedicationMany people are referred for rehabilitationbecause they have not respondedadequately to medications, often includingthose prescribed for ‘treatment resistance’.The ability to find the best medicationregime to minimise symptoms withoutproducing distressing or physically harmfulside-effects is a key skill for rehabilitationpsychiatrists. Special expertise in the useof clozapine, other atypical antipsychoticmedications and mood stabilisers and theuse of combination of therapies is a keycompetence. Their expertise in managingtreatment resistant conditions means thatrehabilitation psychiatrists are also calledon to review patients in other parts ofthe service and to advise colleagues ontreatment. They also identify when referralto a tertiary service for very specialistadvice and treatment is required (such asthe National Psychosis Unit).Psychological interventionsPsychological therapies (such as cognitivebehaviour therapy for psychosis and familyinterventions) promote communication andunderstanding of an individual’s mentalhealth problems and identify strategiesthat can be helpful in reducing distress andunhelpful interaction patterns. Individualisedproblem solving and goal setting are alsocrucial parts of the rehabilitation programme.Clinical psychologists also offer consultationto the staff team to develop psychologicalformulations of the clients’ difficulties, whichsupport positive relationships betweenstaff and clients, therapeutic optimism andcreative interventions. Whenever possible,staff work with clients to help them developself-management strategies. Clinicalpsychologists may also provide trainingand supervision to other staff to provide“low intensity” psychological interventions,such as behavioural activation, anxietymanagement and relaxation techniques,relapse prevention, and motivationalinterviewing for co-morbid substancemisuse.Arts TherapiesArts Therapies (art, drama, music,dance) are delivered in around one thirdof inpatient rehabilitation units acrossEngland21. Arts therapies combine art andpsychotherapeutic techniques to enableservice users’ communication, expressionand understanding in the context of aninterpersonal therapeutic relationshipas part of the recovery process. ArtsTherapies for the treatment of negativesymptoms of schizophrenia are supportedby NICE Guidelines38.Healthy livingGuidance and support to improveunhealthy lifestyles (such as exercise,smoking cessation and dietary advice)and monitoring of physical health are anessential component of a high qualityrehabilitation service. All members ofthe team may be involved in promotinghealthy living, but medical team memberslead on physical health assessment andappropriate referral and treatment forco-morbid physical health problems.This is especially relevant in relation toregular screening for known side effectsof medication. As individuals progresstowards community living, liaison withgeneral practitioners becomes increasinglyrelevant to ensure adequate monitoringand treatment of physical healthproblems continues outside the inpatientenvironment.Self-care, everyday living skills andmeaningful occupationNurses, support workers and occupationaltherapists are key to helping service usersgain/regain the confidence and routineinvolved in managing their medicationand activities of daily living (self-care,keeping their living space clean, laundry,shopping, budgeting, cooking). Theyalso support service users to access andengage with community leisure activities(e.g. cinema, sport) and vocationalrehabilitation activities (e.g. education,training and employment). Occupationaltherapists can identify specific functionalproblems that the service user may haveand contribute to care plans to addressthese. They will often organise andfacilitate individual and group activities oninpatient and community rehabilitationunits and develop links with localresources to facilitate community basedactivities. Techniques such as motivationalinterviewing and behavioural programs,supervised by clinical psychologists, canbe particularly helpful in assisting staffto engage clients with severe negativesymptoms who struggle with motivation.Guidance for commissioners of primary mental health care services 15
What would a good rehabilitation service look like? (continued)SUPPORTED ACCOMMODATIONSERVICESPeople with mental health problems needgood quality housing and appropriatesupport to facilitate their recovery andability to manage independent living inthe future. People with mental healthconditions are twice as likely as thosewithout to be unhappy with their housingand mental ill health is frequently citedas a reason for tenancy breakdown39.Housing problems often contributeto the stresses that lead to relapse ofmental health problems and admissionto hospital, and lack of availability ofsuitably supported accommodation oftencontributes to delayed discharges. Theprovision of supported housing is thereforean important factor in enabling the socialinclusion of this group39.In England, a considerable proportion ofworking age adults with severe mentalhealth problems reside in supportedaccommodation provided by health andsocial services, voluntary organisations,housing associations and otherindependent providers. These includenursing and residential care homes, grouphomes, hostels, blocks of individual orshared tenancies with staff on site, andindependent tenancies with “floating”or outreach support from visiting staff.Around half of all clients with disabilitiesaccessing housing support through the“Supporting People” programme in2008/09 defined themselves as having amental health problem and half of thesewere subject to the Care ProgrammeApproach (CPA), indicating high mentalhealth needs40.Although, historically, nursing carehas been considered an NHS financialresponsibility and other forms of supportedaccommodation were considered theresponsibility of Local Authorities, themixed economy of provision and greaterintegration of mental health and socialcare services in general, has led to ablurring of this distinction. Many serviceusers require care packages that includehealth and social care inputs and localmental health services provide careco-ordination and additional supportto the residents and staff of supportedaccommodation projects through theCare Programme Approach. It is thereforenot meaningful to separate “health” and“social care” investment in mental healthsupported accommodation services.Despite the economic cost of supportedaccommodation, there has been verylittle research to investigate the types ofsupport delivered and their effectiveness.The only survey of mental healthsupported accommodation to be carriedout in England sampled 250 servicesand over 400 service users from 12geographically representative regions41.They found few differences in service usercharacteristics between those residing innursing/residential care homes, supported(staffed) housing and floating outreachprojects: the majority were male, 80%had a diagnosis of a psychotic disorderand 48% also had a substance misusehistory. Around 40% of those in supportedhousing or receiving floating outreachwere participating in some form ofcommunity activity (compared to 25% ofthose in residential care) but only 3% werein open employment. Although residentialcare settings had a higher proportion oftrained mental health staff than the otherservices, almost all service users in all typesof setting were prescribed medication andall services provided support with personalcare and activities of daily living. Between18 and 25% of residents moved on fromeach service annually. This study calledfor further research into the effectivenessof different models of supportedaccommodation since they appear to havedeveloped without an evidence base.Most supported accommodation pathwaysare designed for service users to moveto more independent settings as theirskills improve. This allows for graduated“testing” but many users dislike repeatedmoves. Recently, there has been increasedinvestment in supported flats rather thangroup settings since many services usersprefer their own independent living space,though some service users and familymembers have reported that independenttenancies are socially isolating.Evaluations of American models of mentalhealth supported housing have shownsome benefits in reducing other welfareand health system costs, through loweringthe frequency of unplanned psychiatricadmissions, reducing homelessnessand contacts with the criminal justicesystem42,43,44.In the absence of a clear evidence base,most localities provide a spectrum ofsupported housing designed to meet localneeds. These need to be developed inpartnership with health, local authorities,independent and third sector providers andin reference to the Joint Strategic NeedsAssessment and will include:• nursing and residential care homes• supported housing; group, shared orindividual tenancies with staff on-site• floating outreach services that providevisiting (off-site) support to individualsin independent tenancies.16 Practical Mental Health Commissioning
SERVICES THAT SUPPORTOCCUPATION AND WORKSupporting people with mental healthproblems to access meaningful occupationand work is important in helping tomaximise their recovery since occupationforms an important part of everybody’spersonal and social identity. Althoughoccupation is often equated with work,employment rates for people with severemental health problems are very low.This is due to many reasons including thefunctional impairments associated with theillness, discrimination by employers, andthe “benefits trap” that can make part-time and graduated working financiallyunviable. A major focus of rehabilitationservices is the facilitation of service users’meaningful occupation, including hobbies,leisure activities and social engagements,through to educational and vocationalcourses, voluntary, supported and paidemployment. Occupational therapists playa key role here in making links with localcommunity resources (e.g. cinemas, gyms,colleges and employment organisations)and, along with nursing staff, supportworkers and activity workers, in supportingservice users to access and engage withthese. It is vital that occupational careplans are developed with service users toreflect their interests and goals and thatthere is a recognition that not all serviceusers are able, or wish, to work.There are two main types of vocationalrehabilitation service - prevocationaltraining and supported employment. TheNational Institute of Clinical Excellencerecommend that supported employmentprogrammes should be provided for peoplewith schizophrenia who wish to returnto work or gain employment. However,they should not be the only work-relatedactivity offered when individuals areunable to work or are unsuccessful in theirattempts to find employment38.• Individual Placement and Support (IPS)aims to get people with mental healthproblems into competitive employmentthrough training and support on thejob. Some IPS services also help clientsdevelop their CVs, conduct mockinterviews (including ‘how to’ disclosea mental health problem), and providelonger term support such as mentoringand coaching, whereas in other areasthese supportive functions are carried outby other specialist employment servicesfor people with mental health problems.• prevocational training programmesprovide preparatory work training in asheltered environment to help serviceusers become re-accustomed to workingand to develop the skills necessary forlater competitive employment. Someservices (particularly the “Clubhouse”model) offer transitional employmentschemes which provide time limitedwork experience in a mainstreamemployment setting.• welfare benefits advice services shouldbe available to provide independentand free benefits advice to addressservice users’ concerns about theimpact on their benefits of entering intoemployment, and to ensure they areclaiming all the benefits they are eligiblefor. Access to debt advice can also bebeneficial for some service users.• volunteering services can also assistpeople in getting back into employmentthrough part-time, flexible poststhat help them learn new skills, gainconfidence and reduce social isolation.ADVOCACY SERVICESThese provide independent advice andsupport to people with mental healthproblems to get their voice heard andhave their rights protected. Advocacycan be paid for or provided voluntarily.It can be provided on an individual, oneto one basis, or through self-advocacy,group or peer advocacy. Some people whoare subject to either the Mental HealthCapacity Act or Mental Health Act areentitled to access formal advice from anIndependent Mental Capacity Advocate(IMCA) or Independent Mental HealthAdvocate (IMHA).PEER SUPPORT SERVICESThis involves the use of people withexperience of mental health problemsto provide individualised support andexpertise about treatment and care topeople with mental health problems.This is an evolving field which isrecognised within policy as having thepotential to transform the outcomes ofpeople with mental health problems, andwhere a number of services are alreadyreporting positive experiences45. Theevidence base for peer support reflectsthe fact that this is an initiative in itsearly stages in the UK, with some studiesconcluding that peer support may leadto a reduction in admissions and healthimprovements46.Guidance for commissioners of primary mental health care services 17
18 Practical Mental Health CommissioningWhat would a good rehabilitation service look like? (continued)ASSESSING THE EFFECTIVENESSAND QUALITY OF MENTAL HEALTHREHABILITATION SERVICESMetrics that can be used to assess thedemand for mental health rehabilitationservices and the quality of response toreferrals, include the number of referrals,time from referral to assessment and timefrom acceptance to transfer to a mentalhealth rehabilitation facility.Length of stay in each component of theinpatient rehabilitation care pathway andsupported accommodation will help assesswhether the whole system is workingeffectively.Similarly, readmissions and placementbreakdowns will identify where dischargeplans have not provided adequate support.In addition to the Health of the NationOutcome Scale (HoNOS), and serviceuser satisfaction scales used across allmental health services, two staff-ratedstandardised outcome measures havebeen recommended by the Royal Collegeof Psychiatrists for the clinical assessmentof mental health service users that can beused at the individual and group level47.Both are free to use:A the Social Functioning Questionnaire(SFQ). This measure was developedoriginally by Paul Clifford and IsobelMorris for the assessment of mentalhealth rehabilitation service users. It hasonly recently undergone psychometricassessment but appears to have goodreliability and validity, is quick tocomplete and provides a useful graphicalpresentation of the results.B the Camberwell Assessment of NeedsShort Appraisal Schedule (CANSAS).This is a widely used, brief and easilycompleted measure which has goodpsychometric properties. It reportson met, unmet and total needs in22 domains and may be especiallyimportant for rehabilitation servicesto evidence the degree to which theyare addressing service users’ complexproblems (i.e. by increasing theproportion of met to unmet needs) evenwhen total needs don’t change (as isoften the case for people with complexneeds).SERVICE QUALITYThe Royal College of Psychiatrists’’ Centrefor Quality Improvement has recentlyestablished an accreditation programmefor inpatient mental health rehabilitationunits, along the same lines as its other“AIMS” (Assessment of InpatientMental Health Services) Programmes.The AIMS-Rehab programme providesa comprehensive quality assessmentof units registered with them, thatincludes assessment of quality standardsagreed by an expert reference groupthrough review of policies, processes andprotocols, interviews and assessmentswith staff, service users and carersand a visit by a peer assessment team(rehabilitation practitioners from anotherorganisation). It is possible that the CareQuality Commission will increasinglyuse AIMS accreditation as a key part ofthe evidence for registering inpatientunits. (www.rcpsych.ac.uk/quality/qualityandaccreditation/psychiatricwards/aims/whygetaccredited/aims-rehab.aspx)The Quality Indicator for RehabilitativeCare (QuIRC) is a web based self-assessment tool for mental healthrehabilitation wards and community basedrehabilitation facilities that provide 24hour support to people with longer termmental health problems. It is completed bythe manager of the facility and has beenvalidated against service user experiencesof care. It has excellent psychometricproperties is free to use and takes around60 minutes to complete. It provides anaccessible report of the unit’s performanceshowing its percentage scores, and thoseof similar units across England, on sevendomains of care (Living Environment;Therapeutic Environment; Treatmentsand Interventions; Self-managementand Autonomy; Human Rights; SocialInclusion; Recovery Based Practice). TheQuIRC has been incorporated into theAIMS-Rehab programme and the REALstudy. Thus, national quality benchmarkingdata are now available for inpatient mentalhealth rehabilitation units across England.Later phases of the REAL study will help toidentify the aspects of care that are mostclinically and cost-effective48,49.
Supporting the delivery of the mental health strategyThe Joint Commissioning Panelfor Mental Health believes thatcommissioning which leads toeffective rehabilitation serviceprovision will support thedelivery of the Mental HealthStrategy by contributing to thefollowing shared objectives.Shared objective 1:More people will havegood mental health.A coordinated system that can provideappropriate rehabilitation for people withthe most severe mental health problemsresults in gradual recovery and successfulcommunity living.Shared objective 2:More people who developmental health problems willhave a good quality of life– greater ability to managetheir own lives, stronger socialrelationships, a greater senseof purpose, the skills theyneed for living and working,improved chances in education,better employment rates, and asuitable and stable place to live.Commissioning high quality rehabilitationservices will make a significant impact onachieving this objective as it encapsulatesthe core business of mental healthrehabilitation.Shared objective 3:Fewer people with mentalhealth problems will dieprematurely, and more peoplewill physical ill health will havebetter mental health.Commissioning high quality rehabilitationservices will help achieve this objectivesince more people with complex mentalhealth needs will be properly cared for insettings which are appropriate.Shared objective 4:Care and support, whereverit takes places, should offeraccess to timely, evidence-basedinterventions and approachesthat give people the greatestchoice and control over theirown lives, in the least restrictiveenvironment, and should ensurethat people’s human rights areprotected.Commissioning high quality rehabilitationservices will help achieve this objective aspeople will receive recovery-oriented carein settings which are appropriate for theirlevel of need.Shared objective 5:People receiving care andsupport should have confidencethat the services they use areof the highest quality and atleast as safe as any other publicservice.Commissioning high quality rehabilitationservices will help achieve this objective asit requires systems to be in place whichcontinually monitor the appropriateness ofcare settings and treatments.Shared objective 6:Public understanding of mentalhealth will improve and, as aresult, negative attitudes andbehaviours to people withmental health problems willdecrease.Commissioning high quality rehabilitationservices will help achieve this objective asit will help to end the stigmatising ‘out ofsight, out of mind’ approach to the care ofpeople with complex mental health needs.Guidance for commissioners of rehabilitation services for people with complex mental health needs 19
RehabilitationMental HealthServices ExpertReference GroupMembersAcknowledgementsThis guide was collectively writtenby Helen Killaspy, Richard Meier,Shawn Mitchell, Charlotte Harrison,Sridevi Kalidindi, Tom Edwards, ChrisFitch, David Jago (Royal College ofPsychiatrists), Mel Bunyan (BritishPsychological Society), Julie Kerry(Associate Director, Mental Health& Learning Disability, NHS South ofEngland), and Vicki Nash (Mind).Input from representatives of thefollowing organisations is gratefullyacknowledged:College of Occupational Therapists;Forum for Mental Health in PrimaryCare.We would like to thank the service userand carer representatives of the Facultyof Rehabilitation and Social Psychiatry,Royal College of Psychiatrists for theirhelpful comments on this document.Development processThis guide has been written by a groupof rehabilitation mental health serviceexperts, in consultation with patientsand carers. Each member of the JointCommissioning Panel for Mental Healthreceived drafts of the guide for reviewand revision, and advice was soughtfrom external partner organisationsand individual experts. Final revisionsto the guide were made by the Chairof the Expert Reference Group incollaboration with the JCP’s EditorialBoard (comprised of the two co-chairsof the JCP-MH, one user representative,one carer representative, and technicaland project management support staff).References1 Craig, T., Garety, P., Power, P., et al(2004) The Lambeth Early Onset (LEO)Team: randomised controlled trial of theeffectiveness of specialised care for earlypsychosis. BMJ, 329, 1067–1071.2 Killaspy, H., Marston, L., Omar, Ret al (2012) Service Quality and ClinicalOutcomes: an Example from MentalHealth Rehabilitation Services in England.British Journal of Psychiatry. In Press.3 Green, M.F. (1996) What are thefunctional consequences of neurocognitivedeficits in schizophrenia? American Journalof Psychiatry, 153, 321–3304 Wykes, T. & Dunn, G. (1992) Cognitivedeficit and the prediction of rehabilitationsuccess in a chronic psychiatric group.Psychological Medicine, 22, 389–398.5 Wykes, T., Katz, R., Sturt, E., et al (1992)Abnormalities of response processing ina chronic psychiatric group. A possiblepredictor of failure in rehabilitationprogrammes? British Journal of Psychiatry,160, 244–252.6 Holloway, F. (2005) The ForgottenNeed for Rehabilitation in ContemporaryMental Health Services: A PositionStatement from the Executive Committeeof the Faculty of Rehabilitation and SocialPsychiatry. Royal College of Psychiatristswww.rcpsych.ac.uk/pdf/frankholloway_oct05.pdf7 Killaspy, H., Rambarran, D. & Bledin,K. (2008) Mental health needs of clientsof rehabilitation services: a survey inone trust. Journal of Mental Health, 17,207–2188 Mental Health Strategies (2010) The2009/10 National Survey of Investmentin Mental Health Services. London:Department of HealthResourcesQuality Indicator for RehabilitativeCare (QuIRC) www.quirc.euNational Mental Health DevelopmentUnit – toolkit to reduce the use ofout of area mental health serviceswww.rcpsych.ac.uk/PDF/insightandinmind.pdfSocial Care Institute for Excellence– personalisation resourceswww.scie.org.uk/topic/keyissues/personalisationRoyal College of Psychiatrists –Accreditation for Inpatient MentalHealth Services: rehabilitationwww.rcpsych.ac.uk/quality/qualityandaccreditation/psychiatricwards/aims/whygetaccredited/aims-rehab.aspxSocial Functioning Questionnairewww.rcpsych.ac.uk/docs/Social_Functioning_Questionnaire.docx20 Practical Mental Health Commissioning
9 Killaspy, H.and Zis, P. (2012) Predictorsof outcomes of mental health rehabilitationservices: a 5-year retrospective cohortstudy in inner London, UK. SocialPsychiatry and Psychiatric Epidemiology.In Press.10 Lavelle, E., Ijaz, A., Killaspy, H.et al(2011) Mental Health Rehabilitationand Recovery Services in Ireland: amulticentre study of current serviceprovision, characteristics of service usersand outcomes for those with and withoutaccess to these services. Final Reportfor the Mental Health Commission ofIreland, 201111 Killaspy, H & Meier, R.A (2010) FairDeal for Mental Health RehabilitationServices. The Psychiatrist, 34, 265-267.12 National Mental Health DevelopmentUnit (2011) In sight and in mind: Atoolkit to reduce the use of out of areamental health services. Royal College ofPsychiatrists. www.rcpsych.ac.uk/PDF/insightandinmind.pdf13 Department of Health (2011a) NoHealth Without Mental Health; a crossgovernment mental health outcomesstrategy for people of all ages. www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf14 Bennett, A., Appleton, S., Jackson,C. (eds) (2011) Practical mental healthcommissioning. London: JCP-MH.www.jcpmh.info15 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof primary mental health services. London:JCP-MH.16 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof dementia services. London: JCP-MH.17 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof liaison mental health services to acutehospitals. London: JCP-MH.18 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof mental health services for youngpeople making the transition from childand adolescent to adult services. London:JCP-MH.19 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof perinatal mental health services.London: JCP-MH.20 Joint Commissioning Panel for MentalHealth (2012) Guidance for commissionersof public mental health services. London:JCP-MH.21 Killaspy, H., Harden, C., Holloway,F., et al (2005) What do mental healthrehabilitation services do and what arethey for? A national survey in England.Journal of Mental Health, 14, 157–165.22 Mountain, D., Killaspy, H. Holloway,F. (2009) Mental Health RehabilitationServices in the UK in 2007. PsychiatricBulletin, 33, 215-218.23 Meltzer, H. (1997) Treatment-resistantschizophrenia: the role of clozapine.Current Medical Resident Opinion, 14,1–20.24 Harding, C., Brooks, G. , Asolaga, T.,et al (1987) The Vermont longitudinalstudy of persons with severe mentalillness. 1: Methodological study sampleand overall status 32 years later. AmericanJournal of Psychiatry, 144, 718–726.25 Harrison, G., Hopper, K., Craig, T.,et al (2001) Recovery from psychoticillness: a 15- and 25-year internationalfollow-up study. British Journal ofPsychiatry, 178, 506–517.Guidance for commissioners of rehabilitation services for people with complex mental health needs 2126 Trieman, N. & Leff, J. (2002) Long-term outcome of long-stay psychiatricin-patients considered unsuitable to live inthe community: TAPS Project 44. BritishJournal of Psychiatry, 181, 428–432.27 Department of Health (1999) NationalService Framework for Mental Health.TSO (The Stationery Office).28 Davies, S., Mitchell, S., Mountain, D.,et al (2005) Out of Area Treatments forWorking Age Adults with Complex andSevere Psychiatric Disorders: Review ofCurrent Situation and Recommendationsfor Good Practice (Faculty ofRehabilitation and Social PsychiatryWorking Group Report). Royal Collegeof Psychiatrists. www.rcpsych.ac.uk/pdf/fr_rs_02.pdf29 Poole, R., Ryan, T. & Pearsall, A. (2002)The NHS, the private sector, and thevirtual asylum. BMJ, 325, 349–350.30 Ryan, T., Pearsall, A., Hatfield, B., et al(2004) Long term care for serious mentalillness outside the NHS: a study of outof area placements. Journal of MentalHealth, 13, 425–429.31 Ryan, T., Hatfield, B., Sharma, I., etal (2007) A census study of independentmental health sector usage across sevenstrategic health authorities. Journal ofMental Health, 16, 243–253.32 Killaspy, H., Rambarran, D., Harden,C., et al (2009) A comparison of serviceusers placed out of their local area andlocal rehabilitation service users. Journal ofMental Health, 18,111–120.33 NHS Confederation (2011) Housingand mental health. NHS ConfederationMental Health Network.
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Guidance for commissioners of rehabilitation services for people with complex mental health needs 25A large print version of this document is available fromwww.jcpmh.infoPublished February 2013Produced by Raffertys