Mental health services

• Who runs mental health services?
• Care Quality Commission
• Changes in the NHS: Health and Social Care Act (2012)
• Foundation trusts
• Care Programme Approach
• Community mental health teams
• Crisis resolution teams (also called home treatment teams)
• Assertive outreach teams
• Early intervention in psychosis teams
• Outpatient clinics
• Psychiatric hospitals
• Acute day hospitals
• Forensic mental health services
• Children and young people
• National Institute for Health and Clinical Excellence
• Government policy

Who runs mental health services?

Most mental health services in England are run by specialist NHS mental health trusts. In addition, mental health services are run by charities, voluntary organisations and private organisations. Some mental health services are run jointly by an NHS organisation and a local authority social services department: they are called 'integrated' services. Some NHS organisations work with local authorities more formally through 'care trusts': these sort of organisations run both mental health services and social care services.

The majority of mental health services are based within the community (rather than in hospital) where specialist treatment and support is given by different teams of mental health professionals.

Specialist mental health services are ‘commissioned’ and ‘purchased’ by other NHS organisations that are responsible for planning and organising services for people living in different areas. Some mental health services are commissioned jointly by NHS organisations and local authority social services departments. The sort of mental health services available in each area is therefore determined by the way a commissioning organisation decides to spend its money.

This means some of the services and facilities described on this page may not be available in the area in which you live. Some of the treatments recommended by the National Institute for Health and Clinical Excellence (NICE) (see What you can expect from the NHS page) may not be available either.

In addition, many NHS organisations are currently re-organising and re-structuring their services. Some of those changes may be to do with 'efficiency savings' demanded by the NHS chief executive Sir David Nicholson. The 'Nicholson Challenge' expects NHS organisations to deliver 4 per cent 'efficiency savings' every year until 2014.

Ask your GP what mental health services are available locally and who organises them. You can also look on the website of your local NHS mental health trust. These are all listed on the NHS Choices website.

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Care Quality Commission

The Care Quality Commission is the independent regulator of health and social care in England. This organisation inspects and checks the quality of health and adult social care services that are provided by the NHS, local authorities, private companies and voluntary organisations. It is also charged with protecting the interests of peoples whose rights are restricted under the Mental Health Act. A Care Quality Commission survey of 17,000 people who used community mental health services in 2010 reported 59 per cent saying the care they had received from mental health services in the previous 12 months had been 'excellent' or 'very good'.

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Changes in the NHS: Health and Social Care Act (2012)

The Health and Social Care Act (2012) is going to change the way NHS services are commissioned in England.

Responsibility for commissioning all health services is to be given to new 'clinical commissioning groups' led by GPs and including other health professionals with different areas of expertise. From 2012, these clinical commissioning groups will decide what specialist health services the people living within a particular area need, and then pay NHS trusts, voluntary or private organisations to provide those services. The emphasis will be on 'joint commissioning' with local authorities to provide integrated services, offering both health and social care expertise.

Under the Act, new ‘health and well-being boards’ will be set up to help plan local health and social care services and influence spending decisions. These boards will bring together representatives from the clinical commissioning groups, local authorities and public health experts. They will also include representatives of 'Local HealthWatch', new groups that will include patients and members of the public. A 'parent' HealthWatch England will be set up by October 2012 and will be part of the Care Quality Commission. 

Under previous arrangements, primary care trusts were responsible for commissioning health services. (You might see primary care trusts described as 'PCTs', though ‘PCT’ is not in their title. They are normally called ‘NHS’ followed by the name of the specific area they cover – NHS Southwark, for example.)

The majority of the new GP-led clinical commissioning groups have now been set up and some are beginning to manage local NHS budgets. But PCTs remain as statutory organisations and will still be accountable for the NHS budget until they are abolished and officially hand over commissioning duties in 2013. In the meantime, they have been streamlined and are supporting the new clinical commissioning groups.

An NHS Commissioning Board will, from 2013, start to oversee the new clinical commissioning groups and allocate their budgets. This Board will also be responsible for commissioning some very specialist services that take referrals from all over the country. A 'shadow' NHS Commissioning Board Authority has already been set up. 

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Foundation trusts

Many NHS trusts are already 'foundation trusts'. This is a status that gives the NHS organisation a little more power over how it runs its services and how it spends its budget. Local people and local organisations can become members of foundation trusts to have a say in how they are managed.

The Health and Social Care Act says all NHS trusts than run services should work towards having foundation trust status (many are working towards achieving this status by 2014). Monitor is the independent organisation that processes NHS organisations' applications to become foundation trusts, and also regulates established NHS foundation trusts. You can find out more about foundation status means by visiting the Monitor website.

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Care Programme Approach

People with a high level of needs, or who receive care from more than one professional, may be offered a package of mental health services under the Care Programme Approach (CPA). This means the health and social needs of an individual are assessed and then a written ‘care plan’ is produced, detailing all the services that individual is to be offered. The care plan should also include information about what to do in a crisis.

Each person receiving support and care under the CPA should have a care coordinator, an individual mental health professional responsible for making sure he or she has access to all the services in the care plan. A care coordinator is normally a member of a community-based team of professionals – a member of a community mental health team, for example. Each care plan should be regularly reviewed – at least once a year – to make sure the services it includes are still appropriate. The person who is unwell should be given a copy of the care plan. Family members can only see the care plan with the permission of the individual they support.

However, a Care Quality Commission survey of 17,000 people who used community-based mental health services between July and September 2010 showed that 12 per cent of people on CPA did not know who their care coordinator was, and five per cent were unsure of the care coordinator's identity. 16 per cent said they did not have a care plan, and 27 per cent who did have a care plan said they had not been given or offered a copy. 26 per cent of people on CPA said they had not had a review of their care plan within the previous year.  (Of the 17,000 people in the survey, 42 per cent were on CPA).

People with less complex needs or who are seeing just one mental health professional may not be treated under the CPA. They should still be given clear information about the care they are offered, including advice on how to seek care in a crisis, or if their needs change.

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Community mental health teams

These are teams of mental health professionals who work with people with mental health problems and support them in their homes. You may see community mental health teams referred to as CMHTs.

The professionals working for these teams include psychiatrists, mental health social workers, community psychiatric nurses, psychologists and occupational therapists – all the main professions involved in mental health care. Some teams include a vocational specialist or advisor who can help people prepare or look for work. Community mental health teams have been around for a long time and have become the mainstay of community-based (as opposed to hospital-based) mental health care.

Community mental health teams operate differently in different parts of the country, depending on the policies of the local NHS mental health trust. Sometimes they are divided into teams of staff who each focus on specific areas such as ‘recovery’, or on specific conditions such as psychosis or mood disorders, or they may have separate 'assessment' and 'treatment' teams. Other community mental health teams are ‘generic’, offering services for a wide range of problems.

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Crisis resolution teams (also called home treatment teams)

These are teams of mental health professionals who treat people with serious mental illness when they are very unwell – when they are experiencing an episode of psychosis, or have tried to take their own life, for example. In the past, people who are in crisis would usually have been admitted to a hospital for treatment. Crisis resolution teams aim to avoid admission to a psychiatric ward by offering people intensive, community-based support, either at home or somewhere near their home – at a day centre or at a dedicated crisis hostel, for example.

After the crisis has passed, crisis resolution team members are responsible for planning what happens next in terms of the ongoing care and support offered to an individual. This often involves referral to a community mental health team.

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Assertive outreach teams

The mental health professionals who are part of an assertive outreach team aim to stay in touch and help people who have a history of serious mental health problems but who find it difficult to keep in contact with mental health services, even though they may still need treatment.

Assertive outreach teams (or AOTs) will visit people at home, at flexible times, or at a location of an individual's choice, and encourage them to accept support and treatment from mental health services again. 

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Early intervention in psychosis teams

These specialist teams of mental health professionals work with people aged between 18 to 35 who have experienced their first episode of psychosis, or who are having experiences that may lead to a first episode, or who have been unwell for less than three years. Research has shown that the earlier people get treatment and support, the better. Early intervention teams offer a wide variety of support packages to people who are referred to them (see Early intervention services page) and work with people's families and friends.

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Outpatient clinics

People with mental health problems may be treated at specialist outpatient clinics run by NHS mental health trusts, sometimes based at hospitals, sometimes based within buildings in the community.

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Psychiatric hospitals

Someone with a mental health problem can voluntarily admit himself/herself to hospital if their psychiatrist agrees this would be the best option for them at that time. People can also be compulsorily detained in a hospital under the Mental Health Act, if it is in the interests of their health, their safety, or the safety of other people (see Psychiatric wards and Mental Health Act pages).

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Acute day hospitals

Acute psychiatric day hospitals offer diagnosis and treatment to people who are very unwell who would otherwise be admitted to a traditional psychiatric hospital ward. They are not suitable for people who are detained under the Mental Health Act.

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Forensic mental health services

Forensic mental health services are specialist services for people with mental health problems who have been arrested, who are on remand or who have been to court and found guilty of a crime.

These services are an alternative to prison for people who have mental health problems and offer specialist treatment and care. They are ‘secure’ units, which means that people who are referred there are not free to come and go. Most people are detained in secure forensic services under mental health legislation.

People with mental health problems can be transferred to forensic health services at the time of arrest, during court proceedings, or when they are in prison. They may be referred while they are on remand and waiting trial. A referral is usually made following an assessment of an individual’s needs, or a psychiatric report.

There are three levels of security within forensic units: low, medium and high. Some areas also offer community-based forensic services.

(see Forensic mental health services page).

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Children and young people

Mental health services for children and young people aged up to 18 in England are provided by Child and Adolescent Mental Health Services, known as CAMHS.

Professionals working in CAMHS are employed by a range of organisations, including NHS trusts and local authority-run social services and education departments. All professionals working in CAMHS specialise in working with children and young people, and include psychiatrists, psychologists, social workers, psychiatric nurses, psychotherapists, occupational therapists and family therapists. The way CAMHS are organised varies across the country. However, there are generally four 'tiers' of services.

Tier 1 services are provided by professionals who are not necessarily mental health specialists: GPs, for example, health visitors, school nurses, teachers, social workers, youth justice workers and voluntary agencies. They can refer children and young to more specialist services.

Tier 2 services are provided by mental health specialists who work in community-based venues like GP practices, paediatric clinics or schools.

Tier 3 services are specialist services for children and young people with more serious mental health problems, often provided by teams of different mental health professionals.

Tier 4 services are for children and young people with the most serious mental health problems. They may be provided in day units, highly specialised outpatient clinics or in-patient units.

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National Institute for Health and Clinical Excellence

The National Institute for Health and Clinical Excellence (NICE) is responsible for producing ‘clinical guidelines’ for health professionals that state how people with specific illnesses and conditions should be cared for in England and Wales. NICE also produces ‘technology appraisal’ guidance, which advises on when and how drugs and other treatments and procedures should be used in the NHS (see What you can expect from the NHS page). The government's Health and Social Care Bill proposes in future to rename NICE as the National Institute for Health and Care Excellence so it can make recommendations about social care as well as health 

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Government policy

The government published a new mental health strategy in February 2011. No health without mental health: a cross-government mental health outcomes strategy for people of all ages stresses that mental health is as important as physical health. It aims to improve people’s mental health and well-being through high quality services and focuses on early intervention and prevention, recovery and challenging stigma and discrimination. Several other documents were published at the same time to explain more about how the government plans to implement its new strategy. You can access them all, including a leaflet about the new strategy, at the Department of Health website. 

New Horizons: a shared vision for mental health was published in 2009 and had outlined the previous government’s plans to develop mental health services in England and Wales over the next 10 years.

The development of NHS mental health services in England and Wales over the previous decade had been governed by a policy document called the Mental Health National Service Framework (NSF), published in 1999. This report included plans for early intervention services and increased access to talking therapies, as well as the development of crisis resolution teams as an alternative to hospitalisation. These proposals were all implemented.