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Community care 1 - The spectrum of mental health services
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Introduction
Inpatient care
Hospital care
Regional secure units
Special hospitals
Outpatient clinics and day hospitals
Community-based care
Community mental health teams
Team members
Community care services
Day care centres
Drop-in centres or social clubs
Befriending schemes
Welfare rights/advice centres
Employment/training projects
Laundry services, home helps and meals-on-wheels
Residential facilities
Hostels
Hospital hostels
Residential care homes
Therapeutic communities
Supported housing and group homes
Crisis services
Assertive outreach teams
Accident and emergency departments
Further reading
Useful contacts
Introduction
This factsheet describes what mental health services are available in England and Wales, in the hospital and in the community. It also explains the roles and responsibilities of those who work within these services. (For information about accessing mental health services, see Community care 2 -systems for delivering mental health services and Community care 3 - how to access community care services.)
Mental health services are provided by the statutory, voluntary and private sectors. The statutory sector includes the NHS and local authorities (local, city or regional councils), which provide care through their social services departments. Services are also sometimes arranged and jointly funded by the NHS and local social services departments. NHS services are free at the point of delivery. Users of community care provided by social services may be asked to contribute towards the cost.
The voluntary sector is made up of non-profit making organisations and charities, providing various community-based services. Voluntary sector service providers receive funding in different ways. They may receive donations from the public. Their services may also be commissioned by the local authority social services department - the voluntary organisation will provide a service in return for local authority funding. Users may be asked to pay towards the cost of a service, particularly if the local authority has funded it. Voluntary organisations are also commissioned by health authorities.
The private sector is profit making, and provides a range of hospital and community-based mental health services. People using these services must pay for their own care or receive funding from elsewhere. In certain circumstances, health and social services may provide funding for care by an independent provider.
There are wide variations in the standards and availability of care in different parts of the country. The Government's National Service Framework for Mental Health (introduced in England in 1999 and in Wales in 2002) aims to tackle variations in access, drive up quality and increase the effectiveness of care.
Inpatient care
Hospital care
Some psychiatric hospitals/units are managed by general NHS trusts and others by specialist mental health trusts. The emphasis is on treatment and most people stay in hospital only for as long as is considered necessary. Most hospitals rely heavily on medication for treatment, but some also provide talking treatments, such as counselling or group therapy and some form of occupational therapy.
Some people are admitted for treatment voluntarily, others are compulsorily placed in hospital care ('sectioned') under the Mental Health Act 1983. According to the Act, someone can only be compulsorily admitted to hospital if they are 'suffering from mental disorder' and detention is necessary:
- in the interests of his own health or
- in the interests of his own safety or
- for the protection of other people.
The different sections of the Act require additional specific criteria to be met.
(For more information on the Act, see Mind's booklet Mental Health Act 1983: an outline guide)
People can admit themselves to hospital voluntarily if a psychiatrist agrees that this is necessary. The psychiatrist may make this decision after seeing a person in the outpatient clinic (following a referral from a GP) or after visiting a person at home (following a request from his or her GP). Sometimes people are admitted after going to a hospital accident and emergency department.
Most psychiatric wards are not locked, although some may have seclusion rooms for people who are acutely disturbed. Seclusion rooms should never be used as a 'punishment', but only to hold people for a brief period of time and only for as long as necessary. Staff must hold records about the use of seclusion.
Occasionally, people are admitted to wards that are kept locked. This is to prevent people who have been detained under the Mental Health Act from leaving (however, not all patients held under this Act will be on a locked ward). Voluntary patients are able to leave the ward as and when they choose, however, doctors and some nurses may use their 'holding powers' under the Mental Health Act to prevent a person from leaving.
Regional secure units
People with mental health problems who are caught up in the criminal justice system may be admitted into a regional secure unit. They may be:
- admitted from the courts under an order of the Mental Health Act
- transferred from an ordinary hospital because it is thought they need to be in a more secure setting
- transferred from prison under the Mental Health Act or
- transferred from a special hospital because they no longer need to be under maximum security.
Special hospitals
People with a major mental disorder, who are detainable under mental health law and who are considered to pose a risk to others, may be admitted to a high security special hospital. In England and Wales these are Ashworth, Broadmoor and Rampton.
Outpatient clinics and day hospitals
The GP will arrange an initial appointment with a psychiatrist at the outpatient clinic. The psychiatrist may prescribe medication or refer the patient on to other forms of treatment such as psychotherapy. They may also refer the patient to the community mental health team (see below) or admit him or her to hospital.
Psychiatrists usually see people who have been admitted to a psychiatric unit or referred to the outpatient department by a GP. However, if the situation is urgent enough, the GP can ask the psychiatrist to visit and assess a person at home.
Mental health day care is provided in many hospitals, usually in a separate 'day hospital' attached to the hospital psychiatric unit. Day hospital care is similar to the programme offered to inpatients and can include therapeutic activities, such as occupational therapy and group therapy. Day hospitals are still part of mental health services, although the trend is for day care to be arranged outside hospitals by social services departments or voluntary organisations.
Patients may be referred to the day hospital after being discharged from a psychiatric unit. Sometimes people are referred by the psychiatrist at the outpatient clinic or can be referred from other specialist services, such as the community mental health team.
Community-based care
Community mental health teams (CMHTs)
Community mental health teams are made up of different mental health professionals, including social workers, community psychiatric nurses, occupational therapists, psychiatrists and psychologists. (For more information on these roles, see A brief guide to who's who in mental health.) Members of the team are employed by different agencies, but mostly by either the NHS or social services.
As well as having different professional roles and responsibilities, members also have a general team responsibility to ensure that service users' health and social care needs are met in the community. They must follow certain processes for ensuring this - the Care Programme Approach and Care Management. (For more information see Community care 2 - systems for delivering mental health services.)
People can be referred to the team by their GP. Social workers, psychiatric nurses and psychiatrists can also refer people to the team. CHMTs generally (although not exclusively) support people with more serious forms of mental health problems, such as bipolar disorder (manic depression) and schizophrenia.
Team members
The community mental health team will appoint a care coordinator (formerly known as a keyworker) for each individual service user. The care coordinator's role is to keep in regular contact with the service user (who might be living in his or her own home, supported accommodation or residential care). The care coordinator should ensure that the service user's care plan is being carried out and should report any problems or issues back to the team. The role of care coordinator is taken on by any member of the team and is not a separate profession in its own right.
The care manager is responsible for assessing a person's social care needs and arranging the delivery of community care services within available resources. Care managers are often Approved Social Workers or other social workers with a range of therapeutic skills. They are not usually involved in the direct delivery of services to the person for whom they have designed a community care package.
Community care services
Services are organised in the community by both social services and voluntary agencies. Depending on the area, these may include community centres for users and carers, welfare rights advice, employment schemes, laundry services, home helps and/or meals-on-wheels. Users may have to contribute towards some of the cost of community care services provided by the local authority, depending on their income.
Day care centres
The aim of day care is to provide recreation, therapy and rehabilitation. The company and support offered can ease the loneliness and isolation that often accompanies mental distress. Day care is usually provided in centres run by social services or voluntary agencies, such as Mind. Many day centres run by voluntary organisations accept self-referrals.
Drop-in centres or social clubs
Many areas have informal drop-in centres or social clubs where people can meet others who are in a similar situation and enjoy each other's company. This can be a way of keeping in touch with other people when more formal therapeutic activities are not needed, not suitable or unavailable. Most drop-in centres and/or social clubs accept self-referrals.
Befriending schemes
Befriending schemes help by putting people in touch will volunteer befrienders who are given training. Befrienders offer support and friendship on a one-to-one basis. Schemes are usually run by voluntary organisations.
Welfare rights/advice centres
Welfare rights and advice centres offer advice and support on a range of issues, including mental health, legal rights, employment and housing. Citizens advice bureaux, welfare rights centres (sometimes based in hospitals and social work departments) and voluntary organisations, such as some local Mind groups, can provide information and/or advice. Some telephone helplines, such as NHS Direct and MindinfoLine, can also offer advice on rights (see Useful contacts below).
Employment/training projects
Employment and training projects provide opportunities for people with mental health problems to work and/or receive training, in environments that are both responsive to individual needs and concerned with rehabilitation. The aim is for people to gain skills and training, whilst receiving support for their mental health problems. Many projects are run by voluntary organisations, although some are arranged through social services departments. (For more information see the Seeking Employment factsheet.) People can sometimes refer themselves to these projects, but some projects will require a referral from a specialist mental health service.
Laundry services, home helps and meals-on-wheels
Local authorities can arrange laundry services, home helps and meals-on-wheels to enable people to stay in their own homes or other community settings.
Residential facilities
The following are examples of the types of accommodation available for people with mental health problems. These may be managed by statutory, voluntary or independent providers. (For more information, see the Supported housing and residential care factsheet.)
Hostels
These often accommodate 20 or more people and are managed either by local authority social services departments or voluntary agencies. They are regarded as short-term housing facilities, with the aim of promoting the residents' independence and supporting them with their mental health problems. Staff employed in hostels may include nurses, mental health support workers and residential social workers. In some cases, 24-hour support is provided. In others, an on-call system operates when staff have gone home.
People will generally require social services funding to enable them to pay for their place in a hostel. This usually applies whether the hostel is run by social services or by a voluntary organisation.
Hospital hostels
These accommodate 10-20 people and are designed to meet the needs of people with more severe mental health problems. Nursing care is provided on a 24-hour basis and links with hospital services are maintained.
Residential care homes
Residential care for people with mental health problems can be provided by local authority social services departments or voluntary organisations. These homes are staffed round-the-clock by residential social workers, nurses and mental health support workers. They offer a very high level of support for people with severe mental health problems who cannot manage in their own homes despite receiving community care services.
The funding for residential care comes from social services. This applies whether the home is managed by social services or by a voluntary or private agency.
Therapeutic communities
Therapeutic communities provide a supportive environment for rehabilitation. Accommodation is often shared and there are regular house meetings with the resident therapist. Different types of therapy, including counselling, may be provided. Stay is often limited to an agreed time period.
The funding for a place in a therapeutic community usually comes from social services departments or the NHS (although services are often arranged by other organisations, such as the Richmond Fellowship).
Supported housing and group homes
Supported housing schemes provide furnished accommodation for people who are able to live independently but appreciate the support of a mental health support worker. Group homes are similar, but involve a number of service users living together with additional support from a worker. Both types of project vary in relation to the level and amount of support they offer. Projects can be run by social services or voluntary organisations.
Crisis services
Some areas have developed crisis intervention teams as part of their community mental health care service. These teams provide services either in the person's home or in another community setting (such as a staffed house). (For more information, see the Crisis services factsheet.)
Crisis houses may have a small number of beds, often for a group with specific needs, for example, women, people from Black and minority ethnic communities or young people. The aim is to provide community support in order to prevent hospital admission. Some services are open 24 hours, whilst others provide out-of-hours cover, but have specific closing times. Many crisis services have 24-hour telephone lines where a person can contact the service quickly.
Some crisis services will only offer support to people already known to them, whilst others are happy to accept self-referrals. Despite evidence of their value, there is a shortage of places in 24-hour staffed and supported accommodation in many parts of the country.
Assertive outreach teams
Assertive outreach teams have developed in response to recent Government mental health policy. Their aim is to keep in contact with people who are 'difficult to engage with'. They are particularly concerned with those people who have severe mental health problems but who fail to take up aftercare once they have been discharged from hospital.
Assertive outreach teams will generally deal with people who have been in contact with specialist mental health services, either because they have been admitted to hospital or are experiencing mental health problems in the community. Specialist mental health services may refer someone to the assertive outreach team if he or she fails to take up the services on offer.
Accident and emergency departments
People in mental health crisis may go to accident and emergency departments, although these are often not best equipped to deal with psychiatric emergencies. The environment tends to be busy and unsettling, and there may be a long wait to see a doctor. However, in some instances, the accident and emergency department may be the only place to go for help. There should be a psychiatrist on call who will attend and sometimes 'psychiatric liaison' staff who can link people into mental health services.
Some health and local authorities, particularly in areas where there are lots of people with mental health needs, provide 24-hour walk-in clinics, staffed by psychiatrists, nurses and social workers, and supported by the community mental health team in the daytime.
Further reading
The following leaflets, factsheets and guides are produced by Mind publications (tel: 0844 448 4448, email publications@mind.org.uk or visit the Mind shop.
Factsheets
Community care 2 - systems for delivering mental health services
Community care 3 - how to access community care services
Community care 4 - commissioning services
Community care 5 - charging for community care services
Crisis services
Emergency housing
Employment
How to access services - information for carers
List of crisis services open to self-referrals
Supported housing and residential care
Booklets
Getting the best from your Approved Social Worker
How to assert yourself
How to cope as a carer
How to help someone who is suicidal
How to look after yourself
Making sense of antidepressants
Making sense of cognitive behaviour therapy
Making sense of ECT
Making sense of minor tranquillisers
Making sense of sleeping pills
The Mental Health Act 1983: an outline guide
Mind guide to advocacy
Understanding mental illness
Mind's rights guides
1. Civil admission to hospital
2. Mental health and the police
3. Consent to treatment
4. Discharge from hospital
5. Mental health and the courts
These legal advice booklets are designed to help users of mental health services, their relatives and professionals understand the Mental Health Act 1983 and related law. They should be read in conjunction with the Code of Practice.
Books
Baldwin, S. (ed). 1998, Needs assessment and community care - clinical practice and policy making, Butterworth-Heinemann.
Bornat, J., Johnson, J., Pereira, C., Pilgrim, D., & Williams, F. (eds). 1997, Community care: a reader (second edition), Oxford University Press.
Carpenter, J. & Sharaini, S. 1997, Choice, information and dignity - involving users and carers in care management and mental health, The Policy Press.
Crepaz-Keay, D., Binns, C. & Wilson E. 1997, Dancing with angels, CCETSW.
Jones, R. 2001, Mental Health Act manual (seventh edition), Sweet and Maxwell.
Mandestam, M. 1998, An A-Z of community care law, Jessica Kingsley Publishers.
Mandelstam, M. 1998, Community care practice and the law, Jessica Kingsley Publishers.
Mind. 2000, Legal rights and mental health: the Mind manual.
Orme, J. 2001, Gender and community care, Palgrave.
Pedler, M. 1999, Mind the law: Mind's evidence to the Government's Mental Health Act Review Team, Mind.
Spears, F. E. (ed). 1999, Housing and social exclusion, Jessica Kingsley Publishers.
The Stationary Office. 1999, Mental Health Act 1983 code of practice.
Stein, L. I. & Santos, A. B. 1998, Assertive community treatment of persons with severe mental illness, W W Norton.
Tyrer, P., Harrison-Read, P. & van Horn, E. 1997, Drug treatment in psychiatry: a guide for the community mental health worker, Butterworth-Heinemann.
Villeneau, L. 1992, Housing with care and support, Mind.
Useful contacts
Carers UK
20-25 Glasshouse Yard
London EC1A 4JT
carers line: 0808 808 7777 (Wed and Thurs 10am-12pm, 2-4pm)
tel: 020 7490 8818
fax: 020 7490 8818
email: info@carersuk.org
website: www.carersuk.org.uk
Provides information and support for carers. Branches throughout the UK. Information on subjects such as benefits, residential care, respite care and the Carers Act.
Citizens Advice Bureaux
Head Office
Myddleton House
115-123 Pentonville Road
London N1 9LZ
tel: 020 7833 2181
websites: www.citizensadvice.org.uk, www.adviceguide.org.uk
Citizens advice bureaux offer advice and information to the public, on welfare rights, legal issues, benefits and housing. To find your nearest branch, contact the head office, see the website, ask in your library or look in your local telephone directory.
Mind's Legal Unit
tel: 020 8519 2122 (Monday, Wednesday and Friday 2-4.30pm)
Legal advice on mental health law and related areas
NHS Direct
tel: 0845 4647
website: www.nhsdirect.nhs.uk
24-hour helpline, providing healthcare advice and information to the public. Enables callers to speak directly to experienced nurses.
UK Advocacy Network (UKAN)
14-18 West Bar Green
Sheffield S1 2DA
tel: 0114 272 8171
email: office@u-kan.co.uk
website: www.u-kan.co.uk
Supports, advises and represents a network of user-run advocacy groups.
Originally written by Jackie Golding. Updated in June 2002 by Carole Reid-Galloway, and by Sarah Jane Gillam in February 2005.
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