Community Mental Health Framework - making the vision a reality

The Community Mental Health Framework provides a constructive vision for the expansion of services but it needs to be properly resourced.

When I first started in psychiatry, Community Mental Health Teams were a relatively new thing. We had an inpatient/outpatient model, and our patients came under the consultant who was on-call when they were admitted.

It wasn’t until 1992, following the tragic death of Jonathan Zito by Christopher Clunis, that we saw a significant step change in how mental health services were delivered. It was at this time that the Care Programme Approach (CPA) was introduced, the cornerstone of which was individualised, needs-led care planning, coordinated by a keyworker. The CPA meant that there were now rules around how community mental health care was to be delivered:

• Care co-ordinators took responsibility for their patients until they were transferred to and accepted by another service;
• Patients were discharged only when they were ready to leave mental health care; and
• When discharged from hospital, patients were given the support and supervision they needed from the relevant responsible agencies.

How it started

After deinstitutionalisation, community provision was somewhat piecemeal until enhanced community care models were pioneered by the likes of Professors Kim Mueser, Mary Test and Leonard Stein.

Mary Test, who sadly passed away earlier this year, had described community mental health care in the USA in the 1970s and 1980s as being full of 'gaps and cracks'. Together with Leonard Stein she developed the Program of Assertive Community Treatment (PACT), designed to provide care in the community for patients with severe mental illness, who were not engaging with treatment, as an alternative to asylum-based mental health care.

Around that time, the NHS community offer for patients with severe mental illness was unsystematic; services were poorly developed, not evidence-based, and there was a lack of integration with other services. A more systematic approach was needed. Modelled on the successful PACT teams, Assertive Outreach was born.

Pioneers of UK community psychiatry – Professors Tom Burns, Sir Graham Thornicroft and Dinesh Bhugra – were developing innovative services that provided highly skilled, recovery-focused, person-centred care for people with severe mental illness (SMI), but in primary care; in day centres; in people’s homes and in the community. It was an exciting time, and the community teams were where the best staff wanted to work – developing and expanding these new models of care. Community psychiatry and Assertive Outreach, in particular, was novel and innovative.

The evidence for Assertive Outreach was (and remains), compelling. It has been shown to reduce frequency and duration of hospitalisation; improves engagement and compliance with treatment; improves quality of life (by supporting with social issues) and helps to improve patient autonomy. In the UK, the CPA became the rulebook which we used to practice.

Fast forward 30 years

There has been increasing sub-specialisation and fragmentation of mental health services. There are teams that only do assessment and brief treatment; teams that only do rehab; teams that only do psychosis; teams that only do mood disorders; teams that only do psychological input for those with no comorbidity and so on. Everyone else, who doesn’t fit the criteria for these supra-specialist teams goes to the generic community team, too many of which are no longer innovative and don’t always adhere to CPA rules. Instead, they provide monitoring and signposting but little in the way of intervention and treatment. In fact, evidence from when the CMHF was being developed showed that community mental health staff were spending up to 40% of their time turning down referrals. I’m sorry to say we are back to the days of 'gaps and cracks'.

Community psychiatry is the bedrock of mental health care, so we need it to work, yet it’s no longer invested in. It is not supported, and I don’t simply mean financially, I mean culturally. It just isn’t “sexy” anymore. Even when money was provided for community transformation, sometimes Trusts just added more of the same, rather than really sharing the resources so that there could be a meaningful and downstream shift in the delivery of services, such that people do not have to be in crisis to receive mental health care.

A readymade solution

The good news is that we already have an off-the-shelf 'sexy' model to help us deliver effective and relational care that will help people to get well, and stay well, in their local community - the Community Mental Health Framework (CMHF).

Unfortunately, the CMHF is yet to be consistently and properly implemented across England. Together with the recent resurgence of Assertive Outreach Teams (AOTs), the CMHF is an opportunity to revive our community mental health services and make them 'sexy' once again.

Those who criticised AOTs for being more expensive than standard community mental health teams are now realising that they did not take into account the reduction in hospital utilisation. When the costs of hospital admissions are factored in, AOTs more than pay for themselves, as well as providing much needed high quality, person-centred care for the most marginalised patients with SMI.

The CMHF supports the delivery of care to all those with SMI who do not need AOTs. The CMHF encourages us to utilise the community in which patients live, to support them to remain stable. People with SMI often face significant social disadvantage that we, as clinicians, can make little difference to - we are not housing providers, employment agencies or debt management agencies. It is often the stresses that occur in their daily lives that bring our patients to hospital. We patch them up and, as Michael Marmot says, send them straight back to the conditions that made them unwell in the first place.

The CMHF is a model which, when implemented properly (as they have done in Tees, Esk and Wear Valleys, Cambridgeshire and Peterborough and Somerset NHS Foundation Trusts), works to use the assets that exist in the community. These assets support people with mental illness with all the social difficulties that interfere with them being able to get on with their lives. Skilled specialist mental health staff work in partnership with primary care providers and the Voluntary, Community, Social Enterprise (VCSE) sector. They support patients with their social problems such as housing needs, which hopefully reduces some of the stresses that make them unwell in the first place.

If and when they do start to become unwell, specialist mental health professionals are there, co-located, to give advice and support early on, hopefully reducing the likelihood of a full-blown relapse and referral upstream to secondary mental health services. If a relapse does happen however, there is more time to devote to the smaller number of people being referred. If they need hospital admission as part of their treatment, this is simply that - part of their treatment, rather than a failure of care - and it is accessible in a timely fashion. And these services are exciting, and people want to work in them.

Where to from here?

So, there is light at the end of the tunnel, but an integral element holding back the implementation of the CMHF, and therefore the expansion of access to services, is the challenge of chronic under-resourcing and retention of the workforce.

Using NHS data, Colm Owens and colleagues have shown that there are approximately 1.3 million people with severe mental illness in England, but mental health services only have capacity to treat ~560,000 patients.

The latest edition of the biennial workforce census from RCPsych found that 15.9% of consultant psychiatrist and 20.4% of Specialty and Associate Specialist (SAS) posts were vacant across English NHS trusts. This was a ‘true vacancy’ rate of 29.1% and 31.6%, respectively, once locum posts were also factored in.

Earlier this week I provided evidence to the Commons Health and Social Care Select Committee as part of their inquiry into community mental health services, I was able to use this opportunity to set out the challenges facing community mental health teams and the solutions that must be implemented to ensure good care for all.

During this critical period for the NHS, the College will continue to call on the UK Government to effectively fund and resource community mental health services so that psychiatrists, mental health practitioners and patients can achieve the aspiration of the CMHF.

We will also campaign for the UK Government to look at the refresh of the Workforce Plan and the 10 Year Health Plan in tandem and set out how the two link to each other, to ensure that any reform is backed with adequate action on retention and recruitment.

Your views from our local capacity survey will help to strengthen our voice and provide much-needed evidence for us to influence at local level and among Government.

Light at the end of the tunnel – YES – but still much to be done.