National Public Health Service for Wales / Community mental health teams: Supplementary guidance to support the implementation of Raising the Standard.

Community mental health teams
Supplementary guidance to support the implementation of Raising the Standard, the revised adult mental health national service framework and action plan for Wales
Author: Julie Caffel - Public Health Practitioner
Date: 04/07/07 / Version: 2.7
Status: Final
Classification: Secure (Vulnerable Adults Team)
Purpose and Summary of Document:
The document has been produced for Welsh Assembly Government as the basis upon which they can offer guidance to service commissioners and providers on the establishment of Community Mental Health Teams
Publication/Distribution:
To be sent to Welsh Assembly Government for comment

© 2007 National Public Health Service for Wales

Material contained in this document may be reproduced without prior permission provided it is done so accurately and not in a misleading context. Acknowledgement to the National Public Health Service for Wales to be stated.

CONTENTS / Page
List of abbreviations / 4
1 / Introduction / 5
2 / Purpose of the document / 6
3 / Guiding service principles / 6
3.1 / Equitable / 6
3.2 / Empowering / 6
3.3 / Effective / 7
3.4 / Efficient / 7
4 Efficiency / Policy framework / 7
5 / Tiered approach to mental health service delivery / 8
6 / The community mental health team within the mental health whole system / 9
7 / Role and core Community mental health teams functions / 11
7.1 / Service user group / 13
7.2 / Child and adolescent mental health / 14
7.3 / Older people / 14
7.4 / Learning disability / 14
7.5 / Substance misuse / 14
8 / Community mental health team workforce / 15
9 / Standards for Community mental health teams / 15
References / 16
Appendix 1 / Definition of severe mental illness / 18
Appendix 2 / Standards for Community mental health teams
Standard one. Referral to service / 20
Standard two. Assessment / 22
Standard three. Care planning / 26
Standard four. Intervention / 30
Standard five. Liaison with other components of mental health whole system / 36
Standard six. Discharge and transfer / 40
Standard seven. Performance monitoring / 42
Appendix 3 / Key actions within the Revised adult mental health national service framework / 43
Appendix 4 / Community mental health teams care pathways
Care pathway one: Primary care referral route / 45
Care pathway two: Specialist assessment / 46
Care pathway three: Secondary care interventions / 47
Care pathway four: Review and discharge arrangements / 48


List of abbreviations

ACT / Assertive community treatment
AWMSG / All Wales Medicines Strategy Group
CAMHS / Child and adolescent mental health services
CMHTs / Community mental health teams
CPA / Care programme approach
CRHT / Crisis resolution home treatment
EIP / Early intervention in psychosis
GPs / General practitioners
LHB / Local health board
MDT / Multi disciplinary team
NSF / National service framework
PHCTs / Primary health care teams
SCIE / Social care institute for excellence
UACM / Unified assessment and care management framework

1  Introduction

Community mental health teams (CMHTs) are specialist multi disciplinary, multi agency teams providing expert mental health assessments and interventions. Their central function is to provide assessment and management of those individuals who have severe or enduring mental illness that significantly impacts on their functioning or ability to manage daily living. (See Appendix 1)

CMHTs represent the cornerstone of community mental health services within Wales. Although this central role is crucial and emphasised in policy guidance since 19891,2,3 the development of new evidence based service models for community mental health provision has suggested that the detailed functions of CMHTs needs to be clarified and updated.

The key roles of the CMHT are:

•  The delivery of specialist packages of mental health care through the multidisciplinary team (MDT)

•  The delivery of care co-ordination within the care programme approach (CPA)4

The Mental health national service framework emphasised the importance of early intervention, recovery and health promotion.3 CMHTs are expected to incorporate these policy initiatives into their core functions in order to ensure that they offer a service focused upon empowering service users to live a fulfilled life as independently as possible.

The introduction of new service models and initiatives such as primary care counselling and crisis resolution home treatment (CRHT), have additionally identified more specific roles for the CMHT

2  Purpose of the document

This document has been produced as supplementary guidance to the Revised national service framework (NSF).3 It is intended to support the development of CMHTs for adults across Wales by:

a) describing the core functions of secondary community services delivered by the CMHT or teams closely aligned to the CMHT, and

b) by listing service standards for CMHTs as detailed in Appendix 2.

Specific reference is also made to core functions that have seen the development of dedicated teams or resources primarily for:

•  Early intervention in psychosis

•  Crisis resolution and home treatment

•  Assertive outreach

•  Rehabilitation (separate policy guidance is under development)

•  Primary care support such as first access teams and gateway workers

The guidance has been developed using the four underpinning principles set out in the Adult mental health strategy services for Wales.2 It incorporates and expands on key actions relevant to the development and functioning of CMHTs within the revised NSF.3

The guidance is intended to assist both commissioners and service providers to realise the strategic intent for community mental health services across Wales and builds on the current requirements and recommendations set for CMHTs.

3  Guiding service principles

As CMHTs form the cornerstone of community mental health services it is important that the key principles underpinning the delivery of these services are reinforced.

CMHTs should therefore provide services that are:

3.1  Equitable

·  Based on an individuals assessed level of need

·  Easily accessible

·  Provided within a holistic model of care that identifies and addresses the biological, psychological and social needs of the individual.

·  Delivering comprehensive secondary community services offering effective recovery focused interventions and alternatives to inpatient admission

·  Accessible to members of black and minority ethnic communities with services tailored to meet the needs of locally diverse cultures

·  Delivered in line with current policy and guidance

3.2  Empowering

·  Using person centred care planning

·  Delivering agreed outcome focused services

·  Using a strengths based model that promotes recovery

·  Using a social model of disability for people with long term consequences of their mental health problem

·  Providing services that promote service users dignity, respect

·  and choice

·  Provide service users with up to date and accurate information

·  Provide services that are socially inclusive and culturally sensitive

·  Ensure that carer/families rights and involvement are acknowledged

·  Provide services determined by individual service user need via agreements contained in local protocols.

·  Enable positive risk taking

3.3  Effective

·  The CMHT operates within a mental health whole system

·  Provides interventions that reflect current best practice and evidence base.

·  Delivers health promotion

·  Has a workforce fit for purpose

·  Delivered in such a way that balances individual need and public safety

·  Ensures staff supervision and training through the knowledge and skills framework and local authority equivalent

3.4  Efficient

·  Providing multidisciplinary outcome focused care, treatment and support

·  Integrated management of health and social care

·  Ensures appropriate partnership between agencies, professional groups and services users and carers

·  Delivering the right service at the right time in the right place

·  Have appropriate quality assurance and clinical governance systems in place

4  Policy framework

The Adult mental health services for Wales strategy set out the strategic intent for mental health services and within this identified the role of CMHTs.2

The strategy was followed by the publication of the Adult mental health national service framework 5 which has since been updated and revised in 2005.3 The Revised NSF for adult mental health services reinforces the need for services to work collaboratively and emphasises the importance of a twin tracked approach of health promotion / prevention and service quality improvement.

Many of the key actions within the NSF impact on all aspects of service provision e.g. implementation of the CPA4 however a number are specific to the development of CMHTs (see Appendix 3 for further detail) these require that CMHTs:

·  Are based around primary care geographical groupings.

·  Are full multi disciplinary working teams from a common base.

·  Establish liaison posts ensuring close integration with mental health specialist services.

·  Identify primary care liaison (gateway) workers.

·  Have explicit joint management arrangements between health and social care.

·  Develop protocols through the LHB to ensure appropriate liaison between primary and secondary care.

·  Have medicine management systems in place in partnership with primary care.

The strategy and national service frameworks have been supplemented with additional policy guidance issued by the Welsh Assembly, including:

·  Mental health policy guidance. The care programme approach for mental health service users.4

·  The development of crisis resolution and home treatment (CRHT) services in Wales. Policy implementation guidance.6

·  Adult mental health services in primary healthcare settings in Wales. Policy implementation guidance.7

·  Stronger in partnership. Involving service users and carers in the design, planning, delivery and evaluation of mental health services in Wales. Policy implementation guidance 8

·  Creating a unified and fair system for assessing and managing care.9

·  Assertive outreach in mental health services. A guidance to support delivery of SaFF target 21 2007/08.10

·  Rehabilitation and recovery. Supplementary guidance to support the implementation of Raising the standard.11

·  Mental health inpatient services for adults. Supplementary guidance to support the implementation of Raising the standard. 12

The supplementary guidance on CMHTs should therefore be read in conjunction with these other Policy Implementation documents.

5  Tiered approach to mental health service delivery

Central to the effective delivery of mental health care is the development and delivery of a whole system model. The strategy and NSF set the requirement for the development of a seamless service which can conceptually be described through a tiered approach.

Figure 1 provides an illustration of the various service components that make up the whole system. Primary health care teams (PHCTs) provide both assessment and treatment and act as the gateway to services in all tiers. All four tiers may be delivered by a range of providers - the differentiation in the tiers is the nature of the service provided and not who provides it.

Health promotion should be an integral part of provision at all layers. Service providers should have locally agreed operational and referral criteria and service users will move through the tiers dependant on individual need, or may have services from different providers and different tiers.

Figure 1

Source: National Public Health Service for Wales 2006

6  The CMHT within the mental health whole system

A mental health whole system requires close working and service integration between and across statutory and non statutory health, social care and housing services. This needs to include primary care, general and specialist mental health services.

As already identified the CMHT remains the cornerstone of mental health services in Wales. As such it acts as the centre for secondary care mental health services by directly delivering some components of specialist mental health care and by providing access to other specialist services.

CMHTs act as the core around which the other components of community mental health services, both statutory and non-statutory, are developed and provided. It is essential therefore that all composite parts of the service work together effectively. This requires:

·  Effective communication at an operational level

·  Locally agreed protocols on referral and transfer between and across the system

·  Commissioning structures to be in place so that effective and efficient use of available resources is made within a whole systems model.

In some areas of Wales CMHTs will deliver the functions of early intervention in psychosis (EIP), assertive community treatment (ACT), crisis resolution and home treatment (CRHT) and psychological therapy services. In others dedicated teams delivering these functions have been developed. Where dedicated teams have been developed unambiguous pathways should be established to set out the process by which patients flow seamlessly between service components or are provided with shared care between services.

Figure 2

Source: National Public Health Service for Wales 2006.


In many cases the CMHT cannot deliver all aspects of a holistic care plan. In many circumstances therefore it will act as the access point to other statutory and non statutory mental health and mainstream services as required.

7  Role and core CMHT functions

The role and remit of CMHTs team clearly needs to be understood by all local agencies and stakeholders. CMHTs are specialist multi disciplinary, multi agency teams which provide expert mental health assessments and interventions. They deliver health, social care and psychological interventions together with medical treatment to those experiencing severe and or enduring mental illness. The CMHT is a secondary care service with the majority of referrals coming via general practitioners (GPs). Most mental health problems are managed in the primary care setting with less than a fifth of those identified being referred on to secondary care for assessment and or treatment.13