We need to improve community mental health care services John Tingle
T
he good running of mental health services is vital to ensuring the health of the nation. This was very clearly recognised in the Mental Health Strategy for England (Department of Health (DH), 2011):
‘Good mental health and resilience are fundamental to our physical health, our relationships, our education, our training, our work and to achieving our potential.’
This report gives some important perspective from which to view the recently published CQC Community Mental Health Survey (2013).
The economic context The survey reveals that mental ill health represents up to 23% of the total burden of ill health in the UK—the largest single cause of disability. Nearly 11% of England’s annual secondary care health budget is spent on mental health. Estimates have suggested that the cost of treating mental health problems could double over the next 20 years. More than £2 billion is spent annually on social care for people with mental-health problems. The Mental Health Strategy for England provides some startling statistics. For instance: ■■ At least one in four people will experience a mental health problem at some point in their lives ■■ Almost half of all adults will experience at least one episode of depression during their lifetime ■■ One in ten children aged between 5 and 16 years has a mental health problem ■■Self-harming in young people is not uncommon: 10–13% of 15–16 year-olds have self-harmed ■■One in ten new mothers gets postnatal depression ■■About 60% of adults living in hostels have a personality disorder ■■About 90% of all prisoners are estimated to have a diagnosable mental health problem and/or a substance-misuse problem.
CQC Mental Health Survey (2013)
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
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The CQC survey involved 58 NHS trusts in England (including combined mental health and social care trusts, foundation trusts and community healthcare social enterprises that provide mental health services). Responses were received from more than 13 000 service users, a national response rate of 29%. Service users aged 18 and over were eligible for the survey if they were receiving specialist care or treatment for
a mental health condition and had been seen by the trust between 1 July and 30 September 2012. The results are primarily intended for use by NHS trusts to help them improve their performance. NHS England will use the results to understand service users’ experiences of NHS services and to drive improvements. The CQC has included data from this survey in its Quality and Risk Profiles to assess compliance with the essential standards of quality and safety. In the future, questions from the survey will be used in the new CQC surveillance model. Questions were asked regarding matters such as the care provided by outpatient clinics and local teams providing crisis home treatment; assertive outreach; early intervention for psychosis; and generic community mental health services. People generally responded positively to questions about staff (see ‘Key findings’ below). However, scope for improvement remained in most other areas, including information and involvement in: decisions about medication, care planning, care reviews, crisis care and support with dayto-day living.
Key findings Health and social care workers The majority of service users responded positively to questions about the health or social care worker that they had seen most recently (including their care coordinator or lead professional): ■■ 78% felt that they had ‘definitely’ been listened to carefully and 18% said that they had ‘to some extent’ ■■ 72% said that this person had ‘definitely’ taken their views into account and 23% said they had ‘to some extent’ ■■ 70% (down from 71% in 2012) said that they ‘definitely’ had trust and confidence in the person they had seen and 23% responded ‘to some extent’ (up from 22% in 2012) ■■ 86% said that they had ‘definitely’ been treated with respect and dignity and 11% said they had ‘to some extent’ ■■ 70% (down from 72% in 2012) said that they were ‘definitely’ given enough time to discuss their condition and treatment and 21% said that they were ‘to some extent’.
Medications The medications survey results showed no statistically significant improvements from the 2012 survey, suggesting that there is still scope for improving information provision and service-user involvement: ■■ Almost a third (32%) said that their views were only taken into account ‘to some extent’ when deciding which medication to take and almost one in eight (13%) said that their views were not ■■ Of those respondents who were prescribed new medication
© 2013 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission (CQC) report on community mental health care services.
British Journal of Nursing, 2013, Vol 22, No 19
British Journal of Nursing. Downloaded from magonlinelibrary.com by 139.080.123.050 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety by an NHS mental health worker in the last 12 months, 69% said that the purposes of the medication were ‘definitely’ explained to them. Less than half (43%) were ‘definitely’ told about the possible side-effects. Just over half (52%) were ‘definitely’ given information about the new medication in a way they could understand ■■ Almost a quarter (23%) of respondents who had been on prescribed medication for 12 months or longer said that their medication had not been reviewed. These findings on medications are both disappointing and worrying. They show low levels of healthcarer compliance with fundamental good practice standards and must be improved significantly in order to safeguard patients’ rights and interests.
Care coordinators or lead professionals The survey shows that some respondents say they did not know who their care coordinator or lead professional was: ■■ For respondents on CPA (Care Programme Approach), 11% did not know and 5% were unsure ■■ For respondents not on CPA, 33% did not know and 10% were unsure. Although the majority of respondents who knew whom their care coordinator was were generally positive about them, results had declined from 2012: ■■ 72% said that they could ‘always’ contact their care coordinator (or lead professional) if they had a problem, down from 74% in 2012 ■■ 60% said that that their care coordinator (or lead professional) organised the care and services they need ‘very well’, down from 61% in 2012.
© 2013 MA Healthcare Ltd
Care plans The survey shows that some respondents say they either did not have an NHS care plan, or that they did not fully understand it: ■■ 14% of respondents on CPA said that they did not have an NHS care plan. Of the remainder, 46% ‘definitely’ understood their care plan (down from 48% in 2012), 32% did ‘to some extent’ and 9% said they did not ■■ 42% of respondents not on CPA said that they did not have an NHS care plan. Of the remainder, 26% said that they ‘definitely’ understood it, 23% did ‘to some extent’ and 9% said that they did not understand it. Of those respondents who did have an NHS care plan: ■■ Some respondents said they had not been given or offered a written or printed copy of their NHS care plan: 24% of those on CPA and 44% of those not on CPA responded this way ■■ Over half (54%) of respondents said that their views were ‘definitely’ taken into account when deciding what was in their NHS care plan. Once again, these figures on being given an NHS care plan and understanding it (or not) are not high and show considerable room for improvement.
Care review The survey shows that some respondents say they had not had a care review in the last 12 months to discuss their care:
British Journal of Nursing, 2013, Vol 22, No 19
■■ 26%
of respondents on CPA said that they had not had a care review meeting in the last 12 months, up from 24% in 2012 ■■ Almost half (47%) of respondents not on CPA said that they had not had a care review in the last 12 months. Those respondents who had had a care review in the last 12 months reported that: ■■ 79% were told they could bring a friend, relative or advocate to it ■■ 70% had the chance to talk to their care coordinator about what would happen before the care review meeting ■■ 69% were ‘definitely’ given the chance to express their views at the care review meeting ■■ 48% ‘definitely’ found the meeting helpful ■■ 58% ‘definitely’ discussed whether they needed to continue using NHS mental health services.
Crisis care Just over three-fifths of respondents (61%, up from 59% in 2012) said that they had the number of someone from their local NHS mental health service whom they could telephone during out-of-office hours. Of those who called the number, less than half (49%) said that they ‘definitely’ got the help that they wanted.
Day-to-day living The survey results suggest that some respondents would like more support in getting help with the aspects of day-to-day living asked about in the survey. ■■ Over a third (37%) of respondents with physical health needs said that they did not receive support from anyone in NHS mental health services in getting help with this, but that they would have liked it ■■ Almost two-fifths (39%) said that they did not receive support from anyone in NHS mental health services in getting help with care responsibilities, but that they would have liked it.
Conclusion When the survey results are examined closely, major failings are revealed in community mental health care service provision. There are numerous problems identified in the report. Clearly, too many who use community mental health services are simply not being involved in decisions about their own care. Having an NHS Care Plan, and understanding it, is also a key issue identified. Also, too few people have had a care review. These survey figures on medications are concerning and disappointing. They show low levels of healthcarer compliance with fundamental good practice standards. They must be improved significantly if we are to safeguard the BJN interests and basic human rights of patients. Department of Heath (DH) (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages. https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/213761/dh_124058.pdf (accessed 10 October 2013) Care Quality Commission (CQC) (2013) National Summary of the Results for the 2013 Community Mental Health Survey. http://www.cqc. org.uk/sites/default/files/media/documents/20130911_mh13_national_
1139
British Journal of Nursing. Downloaded from magonlinelibrary.com by 139.080.123.050 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
T
he good running of mental health services is vital to ensuring the health of the nation. This was very clearly recognised in the Mental Health Strategy for England (Department of Health (DH), 2011):
‘Good mental health and resilience are fundamental to our physical health, our relationships, our education, our training, our work and to achieving our potential.’
This report gives some important perspective from which to view the recently published CQC Community Mental Health Survey (2013).
The economic context The survey reveals that mental ill health represents up to 23% of the total burden of ill health in the UK—the largest single cause of disability. Nearly 11% of England’s annual secondary care health budget is spent on mental health. Estimates have suggested that the cost of treating mental health problems could double over the next 20 years. More than £2 billion is spent annually on social care for people with mental-health problems. The Mental Health Strategy for England provides some startling statistics. For instance: ■■ At least one in four people will experience a mental health problem at some point in their lives ■■ Almost half of all adults will experience at least one episode of depression during their lifetime ■■ One in ten children aged between 5 and 16 years has a mental health problem ■■Self-harming in young people is not uncommon: 10–13% of 15–16 year-olds have self-harmed ■■One in ten new mothers gets postnatal depression ■■About 60% of adults living in hostels have a personality disorder ■■About 90% of all prisoners are estimated to have a diagnosable mental health problem and/or a substance-misuse problem.
CQC Mental Health Survey (2013)
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
1138
The CQC survey involved 58 NHS trusts in England (including combined mental health and social care trusts, foundation trusts and community healthcare social enterprises that provide mental health services). Responses were received from more than 13 000 service users, a national response rate of 29%. Service users aged 18 and over were eligible for the survey if they were receiving specialist care or treatment for
a mental health condition and had been seen by the trust between 1 July and 30 September 2012. The results are primarily intended for use by NHS trusts to help them improve their performance. NHS England will use the results to understand service users’ experiences of NHS services and to drive improvements. The CQC has included data from this survey in its Quality and Risk Profiles to assess compliance with the essential standards of quality and safety. In the future, questions from the survey will be used in the new CQC surveillance model. Questions were asked regarding matters such as the care provided by outpatient clinics and local teams providing crisis home treatment; assertive outreach; early intervention for psychosis; and generic community mental health services. People generally responded positively to questions about staff (see ‘Key findings’ below). However, scope for improvement remained in most other areas, including information and involvement in: decisions about medication, care planning, care reviews, crisis care and support with dayto-day living.
Key findings Health and social care workers The majority of service users responded positively to questions about the health or social care worker that they had seen most recently (including their care coordinator or lead professional): ■■ 78% felt that they had ‘definitely’ been listened to carefully and 18% said that they had ‘to some extent’ ■■ 72% said that this person had ‘definitely’ taken their views into account and 23% said they had ‘to some extent’ ■■ 70% (down from 71% in 2012) said that they ‘definitely’ had trust and confidence in the person they had seen and 23% responded ‘to some extent’ (up from 22% in 2012) ■■ 86% said that they had ‘definitely’ been treated with respect and dignity and 11% said they had ‘to some extent’ ■■ 70% (down from 72% in 2012) said that they were ‘definitely’ given enough time to discuss their condition and treatment and 21% said that they were ‘to some extent’.
Medications The medications survey results showed no statistically significant improvements from the 2012 survey, suggesting that there is still scope for improving information provision and service-user involvement: ■■ Almost a third (32%) said that their views were only taken into account ‘to some extent’ when deciding which medication to take and almost one in eight (13%) said that their views were not ■■ Of those respondents who were prescribed new medication
© 2013 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission (CQC) report on community mental health care services.
British Journal of Nursing, 2013, Vol 22, No 19
British Journal of Nursing. Downloaded from magonlinelibrary.com by 139.080.123.050 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
patient safety by an NHS mental health worker in the last 12 months, 69% said that the purposes of the medication were ‘definitely’ explained to them. Less than half (43%) were ‘definitely’ told about the possible side-effects. Just over half (52%) were ‘definitely’ given information about the new medication in a way they could understand ■■ Almost a quarter (23%) of respondents who had been on prescribed medication for 12 months or longer said that their medication had not been reviewed. These findings on medications are both disappointing and worrying. They show low levels of healthcarer compliance with fundamental good practice standards and must be improved significantly in order to safeguard patients’ rights and interests.
Care coordinators or lead professionals The survey shows that some respondents say they did not know who their care coordinator or lead professional was: ■■ For respondents on CPA (Care Programme Approach), 11% did not know and 5% were unsure ■■ For respondents not on CPA, 33% did not know and 10% were unsure. Although the majority of respondents who knew whom their care coordinator was were generally positive about them, results had declined from 2012: ■■ 72% said that they could ‘always’ contact their care coordinator (or lead professional) if they had a problem, down from 74% in 2012 ■■ 60% said that that their care coordinator (or lead professional) organised the care and services they need ‘very well’, down from 61% in 2012.
© 2013 MA Healthcare Ltd
Care plans The survey shows that some respondents say they either did not have an NHS care plan, or that they did not fully understand it: ■■ 14% of respondents on CPA said that they did not have an NHS care plan. Of the remainder, 46% ‘definitely’ understood their care plan (down from 48% in 2012), 32% did ‘to some extent’ and 9% said they did not ■■ 42% of respondents not on CPA said that they did not have an NHS care plan. Of the remainder, 26% said that they ‘definitely’ understood it, 23% did ‘to some extent’ and 9% said that they did not understand it. Of those respondents who did have an NHS care plan: ■■ Some respondents said they had not been given or offered a written or printed copy of their NHS care plan: 24% of those on CPA and 44% of those not on CPA responded this way ■■ Over half (54%) of respondents said that their views were ‘definitely’ taken into account when deciding what was in their NHS care plan. Once again, these figures on being given an NHS care plan and understanding it (or not) are not high and show considerable room for improvement.
Care review The survey shows that some respondents say they had not had a care review in the last 12 months to discuss their care:
British Journal of Nursing, 2013, Vol 22, No 19
■■ 26%
of respondents on CPA said that they had not had a care review meeting in the last 12 months, up from 24% in 2012 ■■ Almost half (47%) of respondents not on CPA said that they had not had a care review in the last 12 months. Those respondents who had had a care review in the last 12 months reported that: ■■ 79% were told they could bring a friend, relative or advocate to it ■■ 70% had the chance to talk to their care coordinator about what would happen before the care review meeting ■■ 69% were ‘definitely’ given the chance to express their views at the care review meeting ■■ 48% ‘definitely’ found the meeting helpful ■■ 58% ‘definitely’ discussed whether they needed to continue using NHS mental health services.
Crisis care Just over three-fifths of respondents (61%, up from 59% in 2012) said that they had the number of someone from their local NHS mental health service whom they could telephone during out-of-office hours. Of those who called the number, less than half (49%) said that they ‘definitely’ got the help that they wanted.
Day-to-day living The survey results suggest that some respondents would like more support in getting help with the aspects of day-to-day living asked about in the survey. ■■ Over a third (37%) of respondents with physical health needs said that they did not receive support from anyone in NHS mental health services in getting help with this, but that they would have liked it ■■ Almost two-fifths (39%) said that they did not receive support from anyone in NHS mental health services in getting help with care responsibilities, but that they would have liked it.
Conclusion When the survey results are examined closely, major failings are revealed in community mental health care service provision. There are numerous problems identified in the report. Clearly, too many who use community mental health services are simply not being involved in decisions about their own care. Having an NHS Care Plan, and understanding it, is also a key issue identified. Also, too few people have had a care review. These survey figures on medications are concerning and disappointing. They show low levels of healthcarer compliance with fundamental good practice standards. They must be improved significantly if we are to safeguard the BJN interests and basic human rights of patients. Department of Heath (DH) (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages. https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/213761/dh_124058.pdf (accessed 10 October 2013) Care Quality Commission (CQC) (2013) National Summary of the Results for the 2013 Community Mental Health Survey. http://www.cqc. org.uk/sites/default/files/media/documents/20130911_mh13_national_
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 139.080.123.050 on November 24, 2015. For personal use only. No other uses without permission. . All rights reserved.
