10 High Impact

Changes
for Mental Health Services

June 2005UnJune 2006

Contents
Forewords 3
10 High Impact Changes 5
Introduction 6

High Impact Change 1 15

Treat home based care and support as the norm for
the delivery of mental health services

High Impact Change 2 18

Improve the flow of service users and carers across health and
social care by improving access to screening and assessment

High Impact Change 3 19

Manage variation in service user discharge processes

High Impact Change 4 22

Manage variation in access to all mental health services

High Impact Change 5 23

Avoid unnecessary contact and provide necessary contact in
the right care setting

High Impact Change 6 26

Increase the reliability of interventions by designing care based
on what is known to work and that service users inform and influence

High Impact Change 7 28

Apply a systematic approach to enable the recovery of people with
long term conditions

High Impact Change 8 30

Improve service user flow by removing queues

High Impact Change 9 32

Optimise service users and carers flow through the service using an
integrated care pathway approach

High Impact Change 10 38

Redesign and extend roles in line with efficient service user and carer
pathways to attract and retain an effective workforce

Conclusions and recommendations 41

Supporting implementation of High
Impact Changes in Mental Health Services 42
Literature and context review to the 10
High Impact Changes 44
Acknowledgements 52
The High Impact Change working group 53
References 54

2
Forewords
The 10 high impact changes were first launched in 2004. The changes aimed
to make sure that every single service user received the best possible care,
every single time. The original high impact changes demonstrated how staff
and organisations improve the quality of care service users received.
Now, building on the success of the original work, this guide sets 10 High Impact Changes for
use across mental health services. The scope is wider but our aim of improving quality and
efficiency of care for each and every service user remains the same and will continue to guide
our service improvement activity through 2006 and beyond.

The 10 high impact changes aim to improve quality of care but they are also about improving
the efficiency of services – making the best use of resources to benefit service users. In this
sense the drive to increase efficiency provides a more streamlined and effective service
tailored to individual service user needs.

I am grateful to all of those organisations who have worked to identify what the 10 High
Impact Changes can mean to mental health services and to capture their invaluable learning
and experience.

Building on the success of the original 10 High Impact Changes and the early work
undertaken by pioneering organisations, this resource is based on experience in the field.
But we also recognise that this is only the start of knowing more about what works and what
has the greatest impact. We will continue to increase that evidence base and improve our
working knowledge.

The 10 High Impact Changes for mental health services reflect the journeys that service users
and carers make through services and ways in which we can improve their experience. This
way of working will help us all deliver and demonstrate the system reforms outlined in the
White Paper ‘Our Health, Our Care, Our Say’.

Offering real choice and improving access require us to look at the whole picture and how
each component of the system impacts on others. Our challenge is to continue building on
the successes already achieved, sharing learning and securing benefits. The High Impact
Changes for mental health services confirm that making a real difference is possible.

Louis Appleby
National director for mental health
Department of Health

3
It is a particular pleasure to introduce the Care Services Improvement Partnership’s
guide to the 10 High Impact Changes for mental health services. The guide extends the
scope of the original work to include a ‘whole systems’ approach to incorporate all types
of services that support people with mental health problems whatever level of support
and care is required.
The 10 High Impact Change evidence included in this guide has been gathered from regional and local
initiatives, giving details of changes made to services, the results achieved, and the role of the staff and
service users in improving services.

The ‘impact measures’ demonstrate in real terms the improvement in service provision through
implementation of the 10 High Impact Changes, particularly in terms of service user experience and the
efficiency of care they receive.

This evidence is presented as case studies which set out in detail the changes made, who was involved in
those changes and – most importantly – how the benefits realised have been measured.

This guide includes examples of effective partnerships between staff, service users and carers and how
we can change practice in ways that will make a genuine difference to the lives and experience of people
with mental health problems, and to the working lives of staff. For example, implementation of the High
Impact Changes has resulted in service users spending shorter times in hospital, being discharged more
efficiently, receiving more appropriate or less contact with services and increased employment
opportunities.

In conclusion, the 10 High Impact Changes have made a real difference to service users’ experience of
mental health services. I hope that within CSIP we can build on the already substantial achievements of
staff and service users to extend this work more widely and look to enhance the growing evidence base
across the range of care groups within mental health care services.

Peter Horn
National mental health lead
Care Services Improvement Partnership

4
10 High Impact Changes
for Mental Health Services
1 Treat home based care and support as the norm for
delivery of mental health services.
2 Improve flow of service users and carers across
health and social care by improving access to
screening and assessment.
3 Manage variation in service user discharge
processes.
4 Manage variation in access to all mental health
services.
5 Avoid unnecessary contact for service users and
provide necessary contact in the right care setting.
6 Increase the reliability of interventions by designing
care based on what is known to work and that
service users and carers inform and influence.
7 Apply a systematic approach to enable the recovery
of people with long-term conditions.
8 Improve service user flow by removing queues.
9 Optimise service user and carer flow through an
integrated care pathway approach.
10 Redesign and extend roles in line with efficient
service user and carer pathways to attract and
retain an effective workforce.

This document refers to people that use services as 'service users' and the people that support
them as 'carers'. We have used this wording throughout for consistency and continuity.
We understand that our choice of words may not be everyone’s preferred phraseology.

5
Introduction
The Care Services Improvement Partnership
The main goal of the Care Services Improvement Partnership (CSIP) is to support
positive changes in services and in the wellbeing of:
• people with mental health problems
• people with learning disabilities
• people with physical disabilities
• older people with health and social care needs
• children and families with health and social care needs; and
• people with health and social care needs in the criminal justice system.

We aim to:
• provide high-quality support to help services improve
• help services to put national policies into practice and provide them with a link to government
• involve people who use services and their carers in all improvement work
• share positive practice and learning about what works and what doesn’t
• pass on research findings to organisations to help them improve services; and
• encourage organisations to work in partnership across all sectors.

The 10 High Impact Changes underpins the majority of the work of the Care
Services Improvement Partnership and reflects the principles adopted in its
service improvement activity.

How CSIP will support implementation of High Impact

Changes in mental health services
CSIP is committed to supporting service improvement in health and social care.
The ways of doing this are negotiated locally and in response to local need and
existing resources.
We have eight regional development centres (RDCs) spread across the country. All RDCs employ
staff with service improvement expertise to advise and support local implementation of new ways
of working, including the 10 High Impact Changes for mental health.

Contact details for all RDCs are at the end of this document.

6
National Institute for Mental Health in England
As a CSIP programme, the National Institute for Mental Health in England
(NIMHE) supports and improves services for people with mental health
problems and runs a range of programmes that support positive changes
in mental health services.
We support service improvement and help to deliver change in local health communities in a
variety of ways including:
• providing examples of positive practice
• sharing learning
• sharing skills; and
• sharing tools and techniques for service improvement.

Background to the 10 High Impact Changes for mental

health services
In 2004 the NHS Modernisation Agency published the 10 High Impact Changes
for service improvement and delivery: a guide for NHS leaders.
Based on evidence derived from work with clinical teams and services around the country, the
document identified areas of service improvement that have the biggest impact and can realise
maximum benefit for service users and carers and on clinical outcomes, service delivery and staff
and their organisations.

Essentially the document provided measurable evidence gained from work that involved
redesigning systems, processes and roles.

While some of the Modernisation Agency work included examples from mental health settings, it
was uncertain whether the 10 High Impact Changes (2004) could be applied across the full range
of mental health services.

In summer 2005 NIMHE released a discussion paper, The ten high impact changes: making them
relevant for mental health. The paper was designed to support evidence collection in order to find
out how the 10 high impact changes are relevant to service improvement throughout mental
health services.

During 2005 and early 2006, CSIP regional development centres (RDCs) began to identify
examples of service and process redesign within local health and social care communities
where demonstrable impact is evident and which supports one or more of the high impact
change areas.

7
How has the evidence been collated?
Case studies and data from the field that have been mapped against the NIMHE
10 High Impact Changes (Discussion Paper 2005) have been highlighted and
selected through CSIP Development Centres and pooled nationally.
Our case studies have been peer reviewed by a small project group made up of service
improvement leads and representatives from service providers and commissioners. All other
material has been reviewed in relation to the strength of qualitative and quantitative evidence of
impact of service or process redesign on the service user and carer experience, service delivery,
outcomes and organisations.

We have included case studies as well as supplementary impact measures taken from other
examples that indicate components of the high impact change.

This initial collection only reflects the evidence we have been able to capture to date as a result of
this exercise.

Details of the services and organisations that have provided case studies and supplementary
information and data are listed at the end of this document. Further details of case studies can be
found at: www.nimhe.csip.org.uk/10highimpactchanges.

An independent literature review has been mapped against each of the high impact change areas
to further validate experience from the field.

While not all of the literature reviewed directly supports the high impact change areas the rest of
the material does specifically relate.

We know there are gaps in this collective evidence base, not least in relation to individual high
impact changes. There are a variety of possible reasons for this:
• we have not captured much of the good practice and experience in the field yet
• the data collection exercise identified ‘work in progress’ that was not yet ready to demonstrate
impact and realisation of benefits’; and
• there has been some service improvement work which while representative of good practice
has not included a measurement system to demonstrate the level of impact.

The ongoing high impact changes programme will continue to identify and collate case-study
examples of service improvement so the evidence base will continue to grow.

How will we build on this evidence base?

In the longer term, and in response to feedback from local health and social care
communities the high impact change programme will target areas where the
evidence base needs strengthening.
Practice based evidence will continue to be identified and supported through the RDCs and from
localities who wish to highlight and share service improvements.

If you would like to contribute to this evidence base please go to

www.nimhe.csip.org.uk/10highimpactchanges to download the case study template.

8
Future focus areas
In the context of the implementation of White Paper 'Our Health, Our Care, Our
Say', both the literature review and the evidence collection suggest we need to
pay particular attention to:
• service user and carer involvement
• integrated health and social care settings
• progress of service improvement initiatives to improve the experiences of people with
dual diagnosis
• children and adolescent mental health services (CAMHS)
• older people services
• specialist mental health services undergoing redesign and at early stage of development such
as early intervention psychosis
• health and social care criminal justice
• complementing the National Framework to Support Local Workforce Strategy Development
(2005). Subject to the review of central returns (ROCR) approval collate evidence of the impact
of new roles like the support time and recovery workers, graduate workers and in relation to the
other High Impact Changes
• supporting the continued work of the BME focused implementation sites that will in time provide
more material about their impact
• the impact of work to improve the physical health of people with mental health problems; and
• increasing knowledge on the High Impact Changes that lead to greater efficiency and
resource savings.

The launch of this High Impact Changes programme is just beginning. We have produced this
resource specifically so it can be updated on the web and accessed in a bespoke way that will
be most helpful to NHS and social care organisations.

9
Using the 10 High Impact Changes for
mental health services
What is the scope of this work?
The 10 high impact changes for mental health services are relevant across the
range of health and social care statutory and non-statutory mental health
organisations and settings from children's' services to older peoples mental
health services to specialist services within the criminal justice system. Often the
principles and application of service improvement are transferable and learning
can be usefully shared across different areas of the health and social care
community.
The 10 High Impact Changes for mental health services will be most helpful if used in the wider
context of service improvement. The Integrated Service Improvement Programme (ISIP) stepped
guide to service improvement 'Delivering quality and value: the ISIP guide to strategy and
benefits' (2005), provides a framework for delivering integrated service improvement.
ISIP is based on the principles that achievement of benefits of service improvement can be
enhanced by aligning process redesign, workforce and technology reform.
Key principles of benefits management are outlined below:
• a benefit can be defined as an advantage to a person or a group of people i.e. a stakeholder or
group of stakeholders
• a benefit is only a benefit when the recipient says it is
• benefits are often retrospective i.e. they come to light afterwards rather than having been
planned for
• we often rely on perceived benefits rather than articulating what benefits we expect to see
before the change and identifying measures to show us that they have been realised
• benefits must at the very least be observable and should be measured; and
• realising benefits usually means: doing something new, doing things better or stop
doing something.

Benefits management
Using a 'balanced scorecard' approach to identify the potential benefits and
their measures can be helpful in ensuring a cross-section of measures are
incorporated including quantitative and qualitative measures.
Measures of the impact of the change are what inform us that the benefits have been realised and
sustained, ensure resource efficiency, avoid duplication, reduce waste and streamlines processes.

10
How can the high impact changes programme support
local health and social care communities?
The 10 high impact changes programme presents just a small sample of service
improvement work from around the RDCs areas from which we will develop an
ongoing programme of work.
Case study evidence will be updated and accessible through the website
(www.nimhe.csip.org.uk/10highimpactchanges).

Through the RDC service improvement role

• the work programme will support local health and social care communities to implement the
White Paper 'Our Health, Our Care, Our Say' (2006). It will underpin and support the system
transformation and process redesign components of the White Paper. In particular: service
redesign that will support the shift to providing treatment in the community, integration of health
and social care services, choice, support for service user-focused services, service user and
carer involvement and support for self-care; and
• it will provide a framework for service improvement alongside Connecting for Health and
workforce reform (ISIP)

Integrated Service Improvement Programme (ISIP)

The work programme will also support local health communities within the
context and framework outlined through ISIP. The focus on care which provides
both quality and value is central to the delivery of a patient-led NHS.
ISIP sets out how local health and social care communities can align their efforts to maximize the
benefits of workforce reform (new roles and new ways of working, pay modernisation), process
(high impact changes) and technology (Connecting for Health) by integrating these three key
enablers of change within service improvement.

ISIP provides tools, techniques and support to assist the delivery of transformational change by
encouraging local health communities to focus on planning and delivering benefits from their
service improvement activities.

The identification of common goals and working in an integrated way are essential to deliver the
quality and efficiency improvements required to achieve financial health.

By promoting collaboration across local health communities, ISIP provides an integrated

approach to transformational change, reconciling local imperatives with national priorities and
focusing improvements to deliver an efficient, patient led NHS. (ISIP 2005)

11
Local health and social care communities can use the 10 high impact changes
for mental health services in relation to the following CSIP resources:

What works?
The 10 high impact changes for mental health services can inform what service improvements
work based on practical experience from the field. A baseline assessment tool can be
downloaded on www.nimhe.csip.org.uk/10highimpactchanges to help in initial mapping against
the 10 high impact change areas.

What skills are required?

The competencies required to undertake service improvement activity are included on the NIMHE
and Skills for Health websites. (www.nimhe.csip.org.uk/serviceimprovement &
www.skillsforhealth.org.uk)

What are the tools and techniques?

Building on the NHS Modernisation Agency Improvement Leaders Guides (2005), the CSIP Directory
of Service Improvement includes practical methods that will support implementation of the 10 high
impact changes (www.csip.org.uk/serviceimprovementdirectory). The directory is further supported by
the ISIP website (www.isip.nhs.uk) which provides a resource linked to tools and techniques that aid
the delivery of effective change.

Directory of Service
Improvement

10 High Impact Changes

CSIP Regional
Development Centre Service Improvement
Competencies

12
The High Impact Change service improvement award
NIMHE Positive Practice Awards scheme will include an award to be made to an outstanding
example of a high impact changes service improvement initiative where compelling and robust
impact has been evidentially demonstrated using the ‘balanced scorecard’ approach. Further
details will be made available on the website www.nimhe.csip.org.uk/10highimpactchanges

Achieving a balance of benefits through a variety of measures

The improvement dividend framework or ‘balanced scorecard’ approach outlines some examples of
potential benefits from process or service redesign in mental health services. From every benefit
identified in any service improvement or change process the questions to ask are:
• How will we know that we have achieved the benefit we identified?
• How can the benefit be measured and demonstrated?

Achieving benefits and demonstrating High Impact Change requires robust baseline assessment
and ongoing measurement of the service improvement.

13
A balanced scorecard of benefits

IMPACT ON SERVICE DELIVERY IMPACT ON SERVICE USERS & CARERS

• improved process flow across service boundaries • less duplication
• co-ordinated and integrated care packages e.g. • absence of ‘ping-pong’ effect
through single assessment process (SAP) or care
• access to services closer to home
programme approach (CPA)
• improved choice
• unnecessary admissions avoided
• better co-ordination of care
• re-admissions reduced
• carer recognition
• shorter length of stay
• reduced delay in discharge
• early and co-ordinated discharge planning
• fewer delays shorter waiting times
• fewer cancellations and Did Not Attend (DNA)
appointments • less anxiety and greater satisfaction
• more effective use of existing resources: cost • clearer decision-making
savings and redistribution
• greater control of self-care
• reduction of out of area treatments.
• information on where to get help
• better quality of life.

IMPACT ON OUTCOMES IMPACT ON STAFF

• speedier access to effective treatment • less turnover
• implementation of National Institute for Clinical • improved sickness and absence rates
Excellence ( NICE) guidelines
• improved recruitment
• DUP (duration of untreated psychosis) reduced
• complimentary skill mix
• better crisis management and relapse prevention
• better demand management
• improved recovery rates
• improve staff satisfaction and morale
• improved clinical care for people with long term
• reduce ‘firefighting’
conditions
• professional and career development
• improved physical health
• role development e.g. supplementary prescribing
• increase in up-take of Direct Payments
• gaining dual qualifications
• increase in service users accessing employment
• opportunities to work across professional
• effective utilisation of advanced directives.
boundaries.

14
High Impact Change 1 Impact on service delivery

Treat home based care and • a comprehensive 24 hour crisis service is now
provided 365 days a year
support as the norm for the • referrals increased from 210 in 2003 to 412 in 2004
delivery of mental health • admissions reduced significantly from 175 in 2002,
services to128 in 2003 and to 92 in 2004; and
• projections for 2005 predict a 70% reduction against
Hospital admission can be used efficiently and 2002 statistics, compared with the national norm of
effectively when it is the most appropriate 30% following the introduction of a crisis service.
intervention required but can be avoided
when alternatives are in place.
Impact on service user experience
This means that inpatient services should be seen
• 97% of service users found CRHT easy or very
as a specialist and intensive intervention; and that
easy to access or contact
there should be provision of a range of self-help
and home treatment and care options, including • 100% found the appointment/response system
appropriate community based support that can good or very good
realise multiple benefits. • 92% were aware of the out of hour's procedure
• 95% were informed of the care co-ordination procedure
• 97% were involved in the planning and evaluation
Case study 1 Demonstrating the of care; and
impact of a crisis resolution and • 100% were satisfied or very satisfied with the care
home treatment team (CRHT) they received

Easington CRHT, Tees, Esk and Wear

Valleys NHS Trust (formally Tees and Impact on staff and organisation
North East Yorkshire NHS Trust) • staff sickness rates were 2.86% compared with the
trust average of 3.97%
The Easington area had links to two specialist
• worker testimony indicates increased confidence
mental health trusts (now reconfigured) which had
and reduction in stress as a result of shared
led to a variation in service provision for people in
decision making
the community.
• the implementation of the European Working Time
In the north of Easington there was no community Directive for medical staff was supported; and
based crisis service provision outside of 9-5 Monday
• the delivery of the trust's capital programme was
- Friday. In the south there was a home treatment
achieved by reducing inpatient bed use from 40
team that provided a 9-5, seven day per week
inpatient beds to 28.
service to people already within secondary care.
Between June 2003 and May 2004 Easington PCT
The intention was to improve care so that an purchased 2,234 inpatient bed days. Between June
equitable service based on social inclusion, recovery 2004 and May 2005, Easington PCT purchased
and home based treatment could be delivered and 1,585 bed days. The reduction in bed days achieved
provide a genuine alternative to hospital in-patient was 649 and at a cost of £220 per bed day, the total
admission. The project included involvement from the saving was £142,780.
two provider trusts previously known as Tees and
North East Yorkshire NHS Trust and South of Tyne
and Wearside Mental Health NHS Trust (now part of
Northumberland, Tyne and Wear NHS Trust), Case study 2
together with Easington PCT and Durham County
Social Services. Crisis resolution home treatment teams
and crisis house, South Warwickshire
PCT and Rethink
• 2 CRHT teams set up and Crisis House run by
RETHINK

15
• care is provided to people who would have been This review also coincided with the introduction of
previously admitted to acute inpatient wards and crisis resolution and home treatment teams within the
who are now offered Home Treatment as an Trust. Senior medical staff concluded that a number
alternative; and of admissions to acute inpatient wards could be
avoided by changing the existing model of service to
• Crisis House is also available as a crisis resolution
incorporate the role of the new crisis teams and the
service.
development of an assessment facility, prior to
admission onto the wards.
Impact on service delivery
The Trust opened its new eight-bed assessment unit
• reduction in bed occupancy, average 85% over last during early 2005 and aimed to integrate this service
year on acute wards with the newly formed crisis resolution and home
treatment teams. The role was to review and assess all
• reduced length of stay
referrals (not those under the Mental Health Act 1983)
• increase in range of services offered. The CMHT and to develop alternatives to admission.
offer a wider range of interventions including
housing and occupation; and This approach helped to avoid any breaches to the
four hour A & E target. This new service model
• comprehensive service offered 365 days a year,
enables sufficient time for the crisis teams to assess
24-hours per day.
each referral in a safe, calm environment and to
determine and arrange for intensive support in the
Impact on service user experience community, where appropriate. The operational policy
for the new assessment unit is based on a maximum
• choice of treatments and places to be treated stay of 72 hours.
• more recovery focused, flexible and individually
tailored care As part of this change process, senior medical staff
across the Trust increased the number of ward
rounds to ensure that admissions and transfers to
Impact on outcomes acute wards were appropriate.

• targeted treatments Where necessary they engaged the crisis resolution

and home treatment teams to accelerate discharge
arrangements.
Impact on staff and organisations
• staff focused in area of work The Trust believes the success of this initiative is due
to a close review and identification of the factors
• more effective working with Social Services, and influencing admission, particularly by junior doctors
RETHINK (Crisis House providers); and and the need to provide a safe environment to enable
• rotation of staff from acute ward to CRHT improves sufficient time for an appropriate community response.
range of services offered by PCT

Impact on service delivery

• within four weeks of implementation of the new
Case study 3 model there were no new out of area placements

South Essex Partnership NHS Trust • dramatic reduction in the level of bed occupancy
across the adult service and release of adult acute
The Trust has focused on reducing the number of bed capacity
admissions to adult inpatient wards. Prior to this • the Trust has now taken the opportunity to close
there was a bed occupancy rate of 115% with one adult ward (23 beds) and is confident that this
pressure on acute beds resulting in a total of 42 out excellent record of avoiding out of area placements
of area placements at any one time. can be maintained in the medium to long term
As part of the Trust's work in examining admissions and • the Assessment Unit has an average length of stay
discharges a series of meetings took place with senior of 17 hours
medical staff within the Trust. Analysis of admissions • the new service provides appropriate support away
revealed that a significant percentage of admissions from the A & E Department for service users, their
occurred as a result of out of hours assessments. families and carers; and

16
• provision of an effective gateway for all potential Case study 4 Demonstrating the
admissions.
impact of an adult mental health
Other impact measures identified day service as an alternative to
from the field:
hospital admission
CRHT adult mental health Acute Day Hospital Banbury,
• 50% of available beds closed within 4 months of Oxfordshire & Buckinghamshire Mental
CRHT being in operation Health Partnership Trust
• admissions into acute inpatient services of people
The introduction of this acute day hospital as part of
from the area were reduced by 33%
an integrated community service in Banbury followed
• average bed occupancy reduced from 109% to 85% the relocation of acute inpatient beds to Oxford.
• mean length of stay in inpatient services reduced
The day hospital has been set up as a multi-
by 33%
disciplinary assessment and treatment service for
• estimate of 2,750 to 3,000 in-patient days made people who are acutely unwell and at risk of
available due to avoiding admission and facilitating admission to hospital.
early discharge over an 11-month period; and
Medical cover is provided by the locality CMHT
• average wait time for initial assessment reduced to
consultants. The service is available 9 - 5pm 7 days
4 days and 2 hours for urgent referrals.
per week. Around 45% of clients are referred from the
• over 60% of all trust service users aware of how to crisis resolution team or are worked with jointly by the
contact services in a crisis. (Mori poll) Day Hospital and CRHT. The service works primarily
• audit demonstrates a 98% satisfaction rate over a with people on enhanced CPA. The service also works
number of issues related to CRHT input; and with people on discharge or during extended leave.

• reduction in sickness absence to an average of 2%

from a service average of around 6%.
Reason for Referal

CRHT older people Alternative to

Admission 60
• reduced utilisation of in-patient beds Early Discharge 3
• after 6 months 14% increase in available bed days Post Discharge 1
for two in-patient assessment units. After 18 Relapse 20
months bed reductions in same two units (20 to 12
in dementia unit and 24 to 20 in mental health unit)
have been sustained with typical occupancy rates
below 100%; and 71% of all admissions provide alternative to acute
• increased capacity for home based care inpatient admission, 23% are to prevent relapse of
illness and 6% support potential discharge from the
Before
acute units.
1) 52% hospital contact
2) 48% community contact 63% of service users reported success in recovery
After after receiving treatment at the Day Hospital.
1) 34% hospital contact
2) 66% community contact
Other benefits repeatedly identified in
• 2% overall increase in capacity for contacts.
the field:
• reduced inpatient days
• service user stay reduced
• delayed discharges decreased
• greater service user and staff satisfaction with
home based care services; and
• alternatives to admission improves range of options
to service users and carers.

17
High Impact Change 2 Impact on service delivery

Improve the flow of service • the average response time was almost halved from
21 days to 11 days
users and carers across • the referrers report more confidence in the
health and social care by Postnatal Depression protocol illustrated by a 50%
reduction in unnecessary referrals for assessment
improving access to • a redistribution of resources has allowed the clinical
screening and assessment team to redirect some of their time to work with
existing service users; and
This change makes it easier for service • regular audit of activity data allows planning in
users and carers to access screening and response to any changes in demand for
assessment services throughout their assessment e.g. during school holidays.
journey. It includes:
• improving access to expert screening and Impact on service user experience
assessment in primary care e.g. talking therapies • Service users, when surveyed, indicated they are
• improving access within and to secondary services very satisfied with the response times

• implementing referral guidelines and protocols

• improving efficiency of referral process by reducing Impact on outcomes
inappropriate referrals • introduction of a three day response time for urgent
• provision of pre-referral consultation for primary assessments; and
care teams • an audit of the referral data demonstrates that the
• demonstrating the impact of integrated mental response time improvements have been sustained
health services. over a 12-month period.

Impact on staff
Case study 1 Demonstrating the • More effective management of assessment activity
impact of improving access and has increased capacity in the team for clinical
response times interventions allowing for more effective time
management.
Newcastle and North Tyneside Perinatal
Service, Northumberland, Tyne and
Wear NHS Trust (formerly Newcastle, Other impact measures identified
North Tyneside and Northumberland from the field:
Mental Health NHS Trust)
Primary Care Mental Health Team
From February 2003 to February 2004 the service • all service users are seen within a ten week time
received 381 referrals from primary care and frame and approx 80% are seen within 6/52. Once
secondary care services. 138 (36%) were women assessment has been done therapy begins, people
who received a psychiatric assessment but required are NOT assessed to go on a waiting list
no further involvement.
• waits reduced from nine months to 6 weeks
The waiting time for a psychiatric assessment ranged • 91% of service users report an improvement in
from 1 day to 49 days with the average length of their ability to manage anxiety symptoms
waiting time being 21 days. 'Full booking' (DoH
• 89% reported satisfaction with treatment provided; and
2004) was introduced utilizing process mapping and
demand and capacity methodologies. • reduction in referrals to secondary services by 33%
and to psychology services by 25%.

18
Early intervention team High Impact Change 3
• Trained 75% of secondary care, mental health and
voluntary sector colleagues in use of screening tool
Manage variation in service
which is also the team referral form. user discharge processes
Other benefits identified from the field: This change looks for a timely and
consistent discharge regardless of the day
• improved data quality of week or clinician availability. Discharge
• clarity of roles in teams from all services should be integral to care
planning and in collaboration with service
• improved information available for service users,
carers and families
users and carers.
• pathway re-design involving process mapping
• designing team based protocols and guidelines
• implementation of partial or full booking as per
Case study 1 Demonstrating the
Choose & Book impact of service redesign on
• provision of a single point of access
variation in discharge
• improved staff morale due to the reduction in DNA rates Southwark Adult Mental Health
• inpatient and CRHT staff able to interchange roles Services, South London and Maudsley
and responsibilities NHS Trust
• appointment of a single consultant to manage both
Southwark has seen extreme pressure on beds
the Inpatient Ward and Crisis Resolution Home
leading to acute overspill into the private sector.
Treatment Service; and
• simple, clear, consistent and defined process of In 2000/01 36% of admissions went to the private
admission and discharge overseen by same sector. Service redesign to reduce admissions and
consultant with immediate input from CRHT and provide alternative home treatment now means
inpatient team. private sector beds are not required. Delays are
now routinely monitored from the time of the
decision to admit.

Reducing the variation in discharges has been

addressed without incurring additional costs. An
initial assess-ment of the causes of variation in
patient discharge and the causes of delayed
discharge was achieved by a comprehensive clinical
audit of wards activity.

This identified significant differences in length of stay

between inpatient units and differences in clinical
practice and leadership. The following targeted
interventions were introduced:

1) the introduction of a weekly bed management

meeting involving inpatient and community teams,
designed to free beds, to problem solve issues
relating to delays and to manage within existing
capacity

2) use of Statistical Process Control charts to clarify

daily bed capacity required

3) home Treatment/Crisis Resolution Teams screen all

admissions and treat at home where possible.

19
4) a new bed management database that does not
rely on central IT systems is accessible to all
Impact on outcomes
clinical team leaders, medical staff, and managers.
This is now the primary system for managing • fewer re-admissions leading to improved mental
admissions and discharges and for obtaining health stability and social inclusion: Readmission
information required for performance management. rate is 4% compared to the national rate of 10.7%
• HoNoS (Health of the Nation Outcome Scales) are
5) the introduction of a Daily Bed Management
now routinely used by staff to evidence the
Handover Report. This is circulated by bed
improvements in health outcomes: Preliminary
managers to senior Directorate managers who are
HoNoS results suggest a high level of acuity is
now able to monitor bed activity on a daily basis
being managed at home
6) a bed management seminar was convened
involving key stakeholders. The purpose was to
Impact on staff and organisations
feedback systems analysis information, discuss
audit findings and identify methods to overcome • reduced pressure on bed managers
the primary causes of bed pressures. The seminar
• no private sector acute bed placements
was designed to gain staff consensus and
ownership regarding the next steps for service • financial savings: reduction in bed numbers
improvements enabled provision of single sex wards, better
staffing levels and more space to manage higher
7) interventions to prevent the admission of service levels of activity and over 60% of service users who
users known to the service are being planned. are detained; and
These will include improvements in the application
• reduction in stress for community staff: there is
of the CPA process and the introduction of a more
now less stress associated with delays in admitting
systematic approach to relapse prevention and
people who are acutely unwell.
crisis planning by CMHT staff; and

8) statistical Process Control technology is gradually

spreading throughout the Directorate so that
clinicians and managers can measure the impact
Case study 2 Demonstrating the
of service changes as they are introduced and impact of a discharge facilitator
monitor progress over time.
Adult Mental Health Care Group,
Sheffield Care Trust
Impact on service delivery
• less unnecessary admissions: The admission rate is • during 2003/ 04 bed occupancy was on average
below that predicted for population and morbidity. 119% (on 4 Wards with 106 beds in total) and on
average 20 beds were occupied by service users
• reduction in length of stay: The Home Treatment who were ready for discharge
Crisis Resolution Teams help to achieve early
discharge • referrals for Out of Town Admissions within
Sheffield occurred for 52 service users (out of a
• fewer delayed discharges total 968 admissions)
• easier access to beds • some of the delayed discharges were due to waits
• beds are now available when required without to access rehabilitation units and generally around
excessive numbers of service users 'sleeping out' half would include waiting for supported
accommodation: basic tenancy, benefits and grant
• reduction in bed numbers by 15 to ensure that no applications to support furnishing new homes or
ward has more than 18 beds secure funding arrangements
• bed managers report that the pressure on beds • review highlighted difficulties in co-coordinating the
has reduced. interface between the full range of services involved
often due to the shift pattern systems within wards
which meant key staff were often not available
Impact on service user experience during normal working hours to liaise with
Greater service user satisfaction due to less delay on Community Teams, Housing Offices, and
admission, a shorter length of stay, fewer delayed Supported Accommodation providers; and
discharges and the choice of Home Treatment as an
alternative to admission.

20
• also it was considered to be a time consuming and Impact on service user experience
in-effective process for staff who had a range of
• of 182 service users identified as at risk of losing
other day to day; and responsibilities e.g.
their home or needing a change in
supporting service users to visit several
accommodation, during 2004/ 05, 67% did not
accommodation options could take a couple
experience any delays in being discharged
of weeks.
• periods of delay have reduced by 50%, from on
The discharge facilitator initiative aimed to create well
overage 11 weeks to 5 weeks
co-coordinated and timely discharge for people who
experience difficulties with benefits or • 20% service users accessed the support
accommodation during their period of inpatient care.
• 60 individuals benefited from assistance in
obtaining new accommodation; and
This was to be delivered through two dedicated
posts, each working into two of the wards focused • service user feedback indicates a positive response
on people identified as being vulnerable to to the proactive work of the Discharge Facilitators:
protracted lengths of stay. The client group focus on service user choice, practical support
included people who; provided including being accompanied during a
'move' and whilst 'settling in'.
• were at risk of becoming homeless or who had
financial difficulties e.g. through rent arrears
Impact on outcomes
• were homeless upon admission, or became
homeless during their inpatient care Re-admission rates for the 182 service users during
2004/05 were 2% at 1 month and 8.8% at 3
• housing requirements had changed due to their
months.
care needs

The main focus of the initiative was to:

Impact on staff and organisations
• prevent people from becoming homeless by
• the reduction in Out of Town Admissions has
resolving identified issues
significantly resulted in savings for the
• address the needs of homeless people before commissioners
discharge and prevent unnecessary delays
• closer links and networks with the voluntary sector,
• reduce delays as far as possible. housing providers and organizations for the
homeless
Impact on service delivery
• removal of a range of administrative tasks from
• 2004/ 05 – The acute inpatient service had 892
nursing duties enables more time for direct care
admissions, of which 182 were supported by the
delivery; and
discharge facilitators
• feedback from CMHT indicates improved
• bed occupancy is down from 119% (2003/04) to
communication and interface working.
108% (2005/06)
• out of town referrals have reduced from 52
(2003/04) to 13 (2005/06) (26 pro rata); and
• permanent funding from November 2004.

21
High Impact Change 4 • in older peoples services, clinicians now make the
initial contact by telephone to arrange assessment
Manage variation in access
to all mental health services
Feedback from service users
This change is about having in place effective has been positive:
and consistent processes that ensure
responsive access to services regardless of “blimey, that was quick”
day of week or clinician availability through a (one of the comments from an adult
co-ordinated approach. This includes: service user.)
• service user choice
• single point of access where appropriate CAMHs service users said:
• consistent booking systems
• primary care liaison “Really good, felt in control of
• secondary care and the flow between specialist
booking appointment and not
services such as A&E to mental health services, just told when to come. I felt
CAMHS to adult mental health services and adult more inclined to attend this
mental health service to older peoples mental
health service
appointment because it was
• proactively manage the interfaces between mental
convenient for us.”
health services; and Mother
• flow between health and criminal justice services
and mainstream services.
“Good idea, my calendar was
checked at the same time as the
Case study 1 Demonstrating phone call. I could then feel
the impact of a choose and confident in confirming our
book system attendance.”
Mother
East Cambrigeshire and Fenland
locality, Cambridgeshire and
Peterborough Mental Health Trust “No problems – works fine every
Following a choose and book launch event, one time I’ve needed an appointment.”
clinician and one administration worker formed a Father
locality steering group to take implementation
forward. As a result:

• adult services chose to set up weekly Impact on service delivery

assessment clinics
• CAMH and older people’s teams opted to identify • CAMHs rolled out the new system in September
regular assessment slots spread over the course of 2005 and have since reported a steady decline in
the working week DNA's: October 2005 – January 2006, of the 67
referrals received, 6 were reported as DNA's.
• four of the six teams have developed the use of
Outlook calendars and transferred assessment • Older People's Services have a zero DNA rate for
slots onto the calendars to make appointment 96 referrals received over the same period of time.
booking easier
• adult and CAMH services make the initial contact
with service users by letter, giving them a reference
number to quote to confirm identity when they
telephone in

22
High Impact Change 5 Impact on staff and organisation

Avoid unnecessary contact • culture and practice change within team regarding
caseload management.
and provide necessary
contact in the right care
Case study 2 Demonstrating the
setting impact of an assessment pathway
Follow up appointments should only
Newcastle Adult Inpatient Services,
occur when needed or requested by the
Northumberland, Tyne and Wear NHS
service user.
Trust (formerly Newcastle, North Tyneside
This change requires planned and negotiated care and Northumberland NHS Trust)
including effective interface arrangements.
The process of developing the pathway was multi
Follow up contact is determined by clinical need dimensional and incorporated the following elements:
or service user led request. Unnecessary contact
is avoided through effective caseload management, • a multi disciplinary group: with representation from
which reduces waste and ensures efficient use the inpatient service; CMHTs; crisis assessment
of resources. team; occupational therapists, senior nurses;
medical consultants; nurse consultants; senior
This supports social inclusion of users in active managers; and clinical nurse leaders. The group met
rehabilitation and recovery. monthly to review and develop the pathway
• user and carer involvement
• cross pathway approach
Case study 1 Demonstrating the
impact of effective caseload • process mapping and analysis: patient journey
methods were utilised to develop the pathway,
management which was refined following wider dissemination
and discussion with stakeholders. Service redesign
Tooting and Furzedown CMHT, South methodology allowed staff to identify steps in the
West London and St Georges Mental process that were of no value to the service user or
Health NHS Trust the service provider.
• integrated notes: senior nurses mapped the desired
Analysis of variation from performance reports service user pathway against the multi-disciplinary
demonstrated that Tooting and Furzedown CMHT was integrated notes to reduce duplication; refine the
an outlier in terms of bed use and caseload. A review documentation and develop an ideal set of notes
of team caseload management was undertaken to together with an information guide to support the
identify people without an allocated care coordinator, use of the pathway and integrated notes; and
to review the out-patient clinic population and the
rationale for follow up and to analyse and review the • training and dissemination: senior nurses utilised a
need for continuing care and the care setting. cascade approach to training respective teams on
the use of the assessment pathway and this was
also supported by in-patient consultants with their
Impact on service delivery medical colleagues.
• baseline caseload 420 with 100 unallocated cases. The pathway comprises the following elements:
The team caseload reduced at one year to 294
• pre admission – 7 items
• there are now no unallocated cases with exception
of new referrals awaiting allocation; and • safety – 6 items
• 10-15 patients were identified living out of area and • medical and nursing assessment – 20 items
transferred. • investigations – 14 items
• specialist assessment – five items; and
Impact on service user experience • formulation for 1st Case review – nine items.
• no unnecessary out patient follow up by junior
doctor on rotation

23
 The assessment pathway has helped to develop • satisfaction with adult acute admission and care
consistent standards across the adult acute in- review processes.
patient service:
Service user surveys are being repeated on a regular
basis and the findings will further influence the
• staff have been involved in the approach
implementation of the pathway process.
throughout
• the auditing process has brought tangible results in
that teams are able to identify areas of strength and Impact on outcomes
development across the pathway; and
Evaluation reports that there is greater consistency
• it provides a benchmark for all wards and staff across the pathway and these relate to the following:
teams within the service to review practice and
promote cross pathway learning. • performance tool identifying strengths and areas for
development in pathway components
• enhanced problem and need analysis and timing
100 of interventions
80
60 • more focused interventions and specialist assessments.
40
20
0
Impact on staff and organisations
Pre Admission

Saftey and
Security
Planning

Nursing and
Medical

Investigations

Specialist
Assesment

Formulation at
First Case

• clear and focused approach to collaborating with

service users during admission to hospital
• strengthened links with community mental health
and crisis resolution teams
• improved multi-disciplinary care
Impact on service delivery • more effective and efficient use of staff resources
• reduced variation in the assessment process • improved cross pathway care-co-ordination
across the division
• provides benchmark with other wards
• development of performance monitoring framework
• improved quality assurance for pathway
to improve service delivery
components; and
• identification of areas for improving practice
• a redistribution of resources has allowed the clinical
development across the pathway; and
team to focus intervention and spend more time in
• benchmarking of services across the division. service user engagement.

Impact on service user experience

An audit of service user experience identified the
Case study 3 Demonstrating the
following benefits of the pathway on their experience: impact of providing necessary
contact with Pharmacy Services
• reduced delays in interventions
• involvement in a range of therapeutic activity Pharmacy Services, Mersey Care
NHS Trust
• reduction of multiple assessment processes
• needs clearly identified to aid treatment planning: Service users were accessing medication from the
service user views incorporated in care decisions trust Pharmacy on a repeat basis because of
problems in accessing supplies from GPs or
• clearer engagement strategy during admission to community pharmacies.
hospital: Purpose of admission clearly outlined,
early engagement during first two days of Many service users had been receiving medication in
admission, including orientation and meeting key this way for several years. Some service users may
professionals involved in care; and also have been receiving medication from a GP. This
meant that the same or a similar medication could be
supplied from two different sources.

24
Service users were either visiting day hospitals to Impact on service delivery
pick up their medication or community nurses were
• reduction in drugs expenditure; and
delivering it to them.
• reduced risk: cases have been identified where
A 'seamless care' model involving a pharmacy co-prescribing was taking place e.g. service users
technician role was developed. An MTO 3 (Medical receiving one type of antidepressant via the trust
Technical Officer) pharmacy technician was employed and another via their GP.
to lead a seamless medicines management approach
to the supply of medications following discharge. As
part of the process service users are able to choose Impact on service user experience
where they want to pick up their medication.
Service users are now able to access all of their
medications via their GP/community pharmacy services
Long-standing repeat prescriptions were
identified as below:
total repeat prescriptions = 55 Impact on outcomes
one location accounted for 56% of these Each case is reviewed
repeat prescriptions.

Impact on staff and organisations

Work undertaken
• freeing up of time for CPNs and day hospitals
The 31 service users at this specific location were
• improved dialogue between the Trust, community
identified as the first group that would be
pharmacies and general practitioners; and
approached regarding their medication. Following the
intervention of the seamless care technician these • pharmacy technician leads a seamless medicines
changes have been made: management approach to the supply of
medications following discharge.
• 8 service users receive their medication on a repeat
basis from community pharmacies
• service users receive their medication via a
trust depot clinic
• 5 service users had their medication reviewed
and stopped
• 4 service users stated a preference that they
continued to receive medication via the trust
pharmacy service
• in four cases appropriate access is still being
sought; and
• two service users have since been re-admitted to
inpatient wards.

Cost impact
The monthly average expenditure for the locality
community prescription prior to the interventions
was £7,116.33. The current monthly expenditure
is £6,136.34.

Therefore an average saving of £979.99 per month

is being made.

25
High Impact Change 6
Increase the reliability Impact on service delivery
• reduction in use of Mental Health Act Section 136's
of interventions by by 87% per annum
designing care based on • acute inpatient admissions down by 85% per
what is known to work annum; and
• reduction in use of A&E services by 60% per
and that service users annum.
inform and influence
This change aims are to increase the Impact on service user experience:
reliability of therapeutic interventions by
enabling service users and carers to be at
the centre of decision-making and “'Since I've been using The
establishing systems that support Haven, I haven't been admitted
meaningful service user and carer once to the acute hospital and
involvement and participation.
that to me is a big break through
and I'm sure they're relieved too”
Service user Haven project.
Case study 1 Demonstrating the
impact of service user involvement
in service delivery “I like the open notes policy. That
The Haven Project: Core partnerships – helps me, that's about trust,
North Essex Mental Health Partnership knowing what's written about you.
NHS Trust, local service user groups, I also really like the fact that it's
local and commissioning PCTs, local client-led, service-user led. I mean
voluntary agencies inc. Mind, A&E Dept, it's one of its kind and I think it's
Essex Police, Colchester Borough setting a lead I think mental health
Council. Extended Partnerships: -
Psychology Dept, North Essex Mental
services are going to be following
Health Partnership NHS Trust because I think, no I seriously do, I
think this is the way forward.”
The Haven Project is a voluntary sector agency Service user Haven project.
dedicated to the support and treatment of people
with a personality disorder in the Colchester, Tendring
peninsula and Halstead areas in Essex.
“For me personally having
The project combines a full day services programme somebody, anybody, and it was
with crisis services that are available 24 hours 7 days
per week. It opened in June 2004 and has 110 The Haven for me, believe in me
registered service users and on average provides as a person and my potential,
1600 contacts per month. actually enabled me to have the
Service users play a central role in the shaping and confidence and courage to go out
running of the service. The Haven Community and get a job and was my first
Advisory Group consists of members drawn from step to recovery. Just somebody
registered Haven service users and its function is to
advise staff, management, The Haven Partnership having faith in me brought out the
Steering Group, and Board of Directors. fact that I had faith in myself.
There are two members of staff and one volunteer
Somebody believed in me and
that have used mental health services and 5 that came from The Haven.”
members (50%) of Board of Directors have used Service user Haven project.
mental health services.

26
Case study 2 Demonstrating the The SUN achieves this by creating a new approach
to services. It works to a new model using coping
impact of service user involvement process theory, following a user led agenda, new
staff roles have been designed to maximise service
use involvement and empowerment including a new
service user role to work alongside the staff team.
The Service User Network (SUN),
funded by the Department of Health's As part of the core service, the SUN provides a liaison
function to help members access existing services as
National Pilot Programme for
well as the SUN. This aims to simplify pathways with
Personality Disorders, and hosted by the Trust and voluntary sector services.
South West London and St George's
Mental Health Trust.
Impact on service delivery
The SUN reflects the national agenda that personality
disorder should no longer be a "diagnosis of The SUN conducts quarterly review and evaluation
exclusion" and follows a user led approach where by service users about the effect of the service.
service users significantly influence and contribute to Service users said they were:
service development.
• feeling more supported: 100% either agreed or
strongly agreed
National strategy is implemented in a local context
and has helped shape personality disorder services • feeling more included: 91% either agreed or
in South West London. strongly agreed
• feeling more empowered: 83% either agreed or
The SUN's target group is adults with personality
strongly agreed
disorder (with or without a formal diagnosis) who
cannot access existing services or who may feel that • learning more coping strategies: 82% either agreed
existing services cannot meet their needs. or strongly agreed
• experiencing fewer crises that become
An example of this would be a client group who may
emergencies: 67% either agreed or strongly agreed
not meet the criteria for their CMHT and has no other
support, or who has been discharged because they • finding difficulties easier to manage: 66% either
are well and who can then only access emergency agreed or strongly agreed
services when in crisis (which may be precipitated by
• satisfied with the SUN: 75% either agreed or
the lack of other support).
strongly agreed
The overriding aim of the SUN is service user
• finding groups are easy to understand: 83% either
inclusion, empowerment and averting or better
agreed or strongly agreed; and
management of crises thereby preventing unplanned
emergencies. The SUN aims to: • more able to express themselves: 83% either
agreed or strongly agreed.
• support, train and empower key service users to
be an integral part of the SUN project, including As part of the quarterly review the SUN asks service
service development users what they find most/least useful about the
service. Service users then ascribe it a rank of most of
• provide sustained and consistent support from
least important (5 being the highest and 1 the lowest).
dedicated mental health care professionals to allow
this to happen
• enable individuals who do not access existing
services improve and manage the difficulties with The comments below come from the most
having personality disorder; and recent review of service users views:
• have an inclusive client group to help diverse
needs, specifically including black and minority
ethnic groups and people who experience other “That there is actually a service for
problems in addition to their personality disorder.
people with personality disorders.”
Ranked 5

27
 “Self-empowerment through High Impact Change 7
support from other members, Apply a systematic
accessing accessing the right approach to enable the
help (The) group know what to
do in an emergency to access recovery of people with long
help (and the) group is very term conditions
beneficial in situations of crisis. This change aims to provide an approach
The service makes sure people that supports and empowers people with
don't get left out in the cold. The long term conditions to better manage their
group is proactive e.g. we can mental health. It also aims to demonstrate
the benefits of mental health interventions
ring our CPN or consultant, with people with long-term conditions.
otherwise we might just leave
it/self advocacy – it gives use
more confidence Case study 1 Demonstrating the
to say things” impact of supported employment
Ranked 5.
Café On the Hill, West London Mental
Health NHS Trust
“Having your own crisis and
The Café was established as a work unit where service
support plan/self referral is quick users gain genuine work experience and qualifications
and simple. ( It is very) positive within a support structure that provides a pathway to
that people with mental health education, employment and meaningful activity.
problems are able to work within The Café operates as a small business with a
and for the SUN. and the trust.” requirement that it covers all costs including
Ranked 4 and development but excluding current staffing.

On average there are 13 Team Workers (service

“A sense of being involved, a users) working in the Café. 8 of whom have
feeling of empowerment, it feels completed the NVQ in Food Preparation and of those
like you are being listened to and 4 went on to further study – 3 to the next level of
catering training and 1 to a Health and Social Care
that your views actually count for access course. From the opening in January to May
something/organising and taking the number of customers using the Café has risen
part in SUN events” from 200 to 600 per week.

Ranked 4.
Impact on service user experience
Impact on staff & organisations
• experience being treated as competent and
• introduction of a new role including a service user capable adults, and
role which works as part of the SUN team.
• increased social contact with a mixed group and
• a training package is offered to the service user the opportunity for mutual peer support and team
post holder and links with the Trusts User work: development of social and work skills.
Employment Programme.

Impact on outcomes
• educational success of the service users.

28
Impact on staff and organisation alternative employment
• culture and attitude shift from service users • to offer supported employment to those eligible for
providing a service for staff (as well as others): Supported Permitted work (working less than 16
essential participants rather than recipients hours per week for as long as necessary) or for
those wanting to work longer hours
• provision of a social space and facility for people
living and working on site away from wards and • to help people who have been out of work or
offices; and education for up to 2 years to return to work or
education; and
• won a quality award for improving working lives
and has inspired other services to develop new • to support anyone who wants to access voluntary
partnerships i.e. with the local college. work, training and education.

Examples of the support provided: Job Profiling, job

search, education retention, medical retirement,
Case study 2 Demonstrating the accessing education and training, signposting to
impact of employment and other agencies and organisations and obtaining in-
house support from employer, college or other
education opportunities support services.
Employment and Education service,
North Yorkshire Social Services Impact on service delivery

This service is provided by an Employment and • out of 55 referrals, over 500 hours per week of
Education Opportunity Officer (EEOO) based in paid work is being done and several service users
Hambleton and Richmondshire. This service is have returned to full-time (30+ hours) work
available to people: • 20 service users are involved in voluntary work
• with severe and /or enduring mental health problems • 21 service users were involved in education or
• with drug and alcohol problems; and training to progress to full-time work; and

• aged 18 to 65, although occasionally supports • 10 service users have been helped to retain their
people of other ages. existing work.

The EEOO role is very diverse and the interventions can

be very long term. People are visited in their own homes Impact on service user experience
or in local venues where appropriate, so the service
is easily accessible by service users. The EEOO works Asked about in impact on independence and
with the community mental health teams, the community inclusion service users report:
support officers and service development officer. • 87% feel they have increased their independence

The main ethos of the service is to enable service • they have been enabled to access other services
users to return to or obtain full-time work and/or within their local community e.g. Learn Direct,
access appropriate educational or training courses Disability Employment Advisor, Outreach Services,
and individual programmes are service user led. Advice and Guidance.

Service users are encouraged to access meaningful 100% of service users feel that their confidence and
occupation by doing voluntary, paid or unpaid work, self esteem have increased
training or education with a long term aim for them to
obtain full time employment appropriate to their 100% agreed that they had been enabled to work at
abilities and needs. their own pace and without pressure and they had
been given the correct amount of support to meet
Support to do this can be over several years, until the their needs; and
person has recovered sufficiently to return to full time
work. This service therefore reflects the need for social 100% of service users were satisfied with the service.
inclusion and encourages service users to improve their
self esteem, and become confident and independent.
Impact on staff and organisations
The priority aims of this service are: Positive feedback from care co-ordinators indicates a
• to help people retain their employment or positive difference to the employment prospects of
education status when they become ill, either by people with mental health problems and substance
retaining current employment or by seeking misuse needs, satisfaction with the referrals

29
guidelines and a sense that there is appropriate High Impact Change 8
support to them as well as service users.
Improve service user flow by
removing queues
Case study 3 The aim is to reduce the time service users
wait at any point in the health and social
Community Support Service, North care process e.g. between referral and the
Yorkshire Social Services first appointment and any referrals to
internal services.
The main ethos of the service is to ensure service
users, and their immediate families, have adequate
and suitable accommodation and that their income is
maximised. Case study 1 Demonstrating the
The take up of Welfare Benefit 2004 was over impact of removing queues in an
£401,000.61 improving the financial situation for adult mental health service
service users and in some cases housing conditions.
Mersey Care NHS Trust Mental Health
There were 74 successful outcomes relating to Directorate
housing issues. Of the cases closed in 2004,
21 people were helped who were homeless and a Mersey Care's NHS Trust adult mental health
further 8 who were threatened with homelessness to directorate undertook a project in January 2005 to
remain housed, as well as support with housing improve how people access local mental health
benefits, home improvements, fuel costs, etc. services in the Southport and Formby locality. The
key reasons for this project were:
There were 33 successful outcomes for employment
issues including support and signposting for cases • regular criticism from referrers, service users and
such as unfair dismissal, supporting people who had carers about the difficulties and delays they
not received statutory sick pay from their employer experience when accessing services
and help with employment tax credits
• the development of new teams (e.g.) crisis resolution
There were 49 successful outcomes for other issues, home treatment teams covering 24 hours a day,
such as fuel costs, debt and tax rebates. potentially adds more complexity to local provision
• high rates of DNA's, cancelled clinics, and low
rates of discharges back to primary care

Another example identified from the field: • future changes to waiting time targets
• the relatively high number of "crisis / emergency"
Care Programme Approach (CPA) system, South referrals
Warwickshire PCT
• caseload sizes and "blocked" outpatient clinics
The CPA system is recorded using a format that was • national policy encouraging better gateway
devised to enable scanning onto the electronic processes and more choice. With primary care being
system in a way that ensures all workers can access able to electronically book appointments direct
the correct service user information and input what
care is needed. • advances in information technology and changes in
consumer expectations means services need to
have prompt responses; and
• national policy introducing payment by results and
practice based commissioning means services
need more effective information and data
processes.
The gateway worker started in April 2005. An audit
was completed for a six month period.

30
Activity Baseline Figure After Gateway Impact on service user experience
April ’04 – figures April –
• more prompt response – decisions made in 24 hours
March ‘05 Dec 2005
• better customer care – telephone calls rather than
Average Out- letters; and
patient Waits 7 weeks 4 week
• current routine referral waiting time is 4 week,
emergency same day, urgent one week.
Outpatient
DNA’s 26.6% 13.8%
Impact on outcomes
Referral
Received 364 per annum 884 in a six • achieving CRHT targets; and
month audit period
• improved rate of discharges in outpatient clinics.
Discharges
form service 157 258 in 9
Impact on staff and organization
month period
(344 estimate • freed up staff time in outpatients and other teams
for the year)
• enabled decisions about referrals to be made and
communicated to service users in 24 hours
CRHT targets N/A CRHT team achiev-
ing LDP targets for • enabled the Crisis Resolution / Home Treatment
home treatment (CRHT) team and other teams to focus on
supporting people with serious mental illness; and
• improved the relationship with primary care by providing
Impact on service delivery
dedicated time to develop a partnership approach.
• 884 referrals were received in the audit period, an
average of 34 referrals per week
• 59% of referrals were received from primary care
Case study 2
• 22% of referrals were not seen in secondary care.
They were given advice, support and sign posted Greenwich CAMHS, Oxleas NHS Trust
on to other services
• anxiety and/ or depression were the main reasons The information department provided monthly reports
for referral in 43% of the referrals received from about numbers of people seen to be breaching the
primary care waiting time targets for discussion and action by a
group of senior staff: 2 consultant psychologists, the
• the gateway worker completed 81 face to face mental locality team manager, the borough administration
health assessments (9% of total number of referrals). manager, the business manager for the service, the
An additional 26 service users were seen face to face information manager and the trust service
by the gateway worker for advice / support improvement lead.
• 17% of referrals received an outpatient
appointment, 17% of referrals we sent on to Key results include:
counseling / psychology, 7% received a crisis • administrative procedures for intake have been clarified
resolution home treatment assessment, 4%
received a CMHT assessment • referrals with inadequate information are being
returned to the referrer and so no longer affect
• enabled CRHT and other teams to focus on waiting times
serious mental illnesss
• the guidelines also clarify procedures for dealing with
• enabled service to comply with Choose and a referral for a further episode of care for a known
Book initiatives service user. A new referral needs to be opened
• improved relationship with primary care; and rather than re-opening the original referral; and

• reduced DNA rate for new referrals by 16%: • information gaps have been identified and
from 26.6% in 2004 to 13.8% in 2005, for working groups set up to devise the content of
outpatient referrals. additional leaflets.
Having piloted the analysis and intervention in one
locality team, there is potential to roll this out across
the service and borough. Better systematic

31
administrative procedures and clarity about clinical High Impact Change 9
roles and responsibilities results in better prediction of
the number of people accessing services. Optimise service users and
carers flow through the
Impact on service delivery service using an integrated
• reduction in average waiting time care pathway approach
• reduction in longest waiting time from 28 weeks in
September 04 to 17 weeks in September 05
This change increases efficiency and
outcomes through a whole service evidence
• care pathways clarified for different subgroups of based systematic approach to delivering a
service users. care package. It may involve the use of
service improvement tools to identify the
causes of blocks and delays and implement
Impact on staff & organisation sustainable solutions.
• clarity of roles and responsibilities, especially for the
team manager and team administration in relation
to data quality, but also for all staff in relation to
assessment as a proportion of their workload Case study 1 Demonstrating the
• created clinic slots within which most of the impact of an Older People's
assessment work is carried out Memory Clinic
• more reliable internal information about caseloads
and activity Centre for the Health of the Elderly,
Northumberland, Tyne and Wear NHS
• staff roles support a breadth of skills; and
Trust (formerly Newcastle, North Tyneside
• more integrated service planning and delivery and Northumberland NHS Trust)
evidenced by wider range of referral sources.
Development of Memory Clinics are advocated as
part of National Guidance (e.g. National Service
Other impact measures from the field Framework for Older People; 2001 NICE Guidance
on anti-dementia drugs) and provide an important
Adult CMHT
route for early diagnosis, as advocated by users and
Single point of access and use of full booking. carers (e.g. Alzheimer's Society).
Subsequent reduction of DNA's and reduced wait for
initial appointment from 6-8 weeks to 1-2 weeks. Calculated incidence rates for dementia show an
expected 450 new cases each year in the local area.
The Newcastle Memory Clinic receives 120 new
Primary Care Mental Health Team referrals each year for assessment and diagnosis of
early dementia and mild cognitive impairment.
Waits reduced from nine months to 6 weeks.
This group has previously not been well served by
existing resources and services. Several service users
below the age of 65 would have been seen by general
psychiatry or neurology services. Many service users,
both older and younger, would not have been seen for
specialist assessment at all. For example, outcomes
from a published audit indicate that the clinic sees
service users, on average, 2 years earlier than
traditional services (Luce A, McKeith I, Swann A, Daniel
S, O'Brien J (2001): How do memory clinics compare
with traditional old age psychiatry services?
International Journal of Geriatric Psychiatry 16:837-45).

32
The service aimed to: Impact on outcomes
• develop clear referral procedures and care • annual follow-up procedures in place for those with
pathways and standardised assessment mild cognitive impairment
procedures for outpatient assessment and
• guidance on anti dementia drugs confirmed by
diagnosis of early cognitive problems
clinical audit first 12 cases prescribed medication
• establish a memory remediation group run jointly by through clinic. Standards assessed;
nursing/psychology to inform and empower users
• specialist diagnosis AD (100% compliance)
and carers about their mild memory problems and
to provide practical advice, aids and strategies to • MMSE>12 at baseline (100% compliance)
optimize memory function in a supportive
• regular review (100% compliance); and
environment. This is a seven week course.
• continue only while MMSE>12 (92% compliance)
• develop, in conjunction with the Alzheimer's
society, new patient information leaflets and advice Each memory remediation group is fully evaluated by
on practical issues (i.e. driving) commonly participants with good feedback and evidence of
encountered by those with mild cognitive continued benefit at follow-up.
impairment and early dementia
The Group was awarded the Queens Nursing
• provide a clear framework for regular monitoring of Institute Award for excellence and innovation in
those with suspected early dementia, including dementia care nursing (2003)
provision of antidementia drugs in accordance with
current NICE guidance; and
• assess patients under 65 who may have early Impact on staff and organisations
onset dementia and work closely with the Lewis Audit of referrers found over 90% extremely satisfied
Team ( multi disciplinary team for the under 65's). with waiting time, information provided and the
service the clinic provided.
Impact on service user experience Memory Clinic and Memory Remediation Group are
Two consumer surveys/audits demonstrated high now fully integrated into the care pathway for Newcastle
levels of service user satisfaction with the service Older People's Mental Health services. Regular
received, which also led to service change. audits and reviews will continue to be carried out.

Service users were asked if they:

• received appointments in sufficient time (95% yes) Case study 2 Demonstrating the
• received adequate information before appointment
impact of redesign across a whole
(100% yes) system of older people's services
• adequate parking (75% yes)
Nabcroft Older Peoples Service,
• staff courteous and helpful (100% yes) Kirklees, South West Yorkshire Mental
• diagnosis was clearly explained (85% yes) Health NHS Trust
• understand investigations (95% yes) This service re-design initiative aimed to focus the
• understand future management plan (100% yes); and community intervention offered by a range of teams 7
days per week. This included:
• overall experience 65% excellent, 35% good
• prolonged and intensive community support for
A new carers group was set up for those caring for people with severe and enduring needs
people with early (mild) dementia run jointly with staff
from the local Alzheimers Society and clinic CPN. • brief interventions in support of other professionals
with less severe or enduring difficulties; and
New information packs were developed for people
diagnosed with early dementia that are given to all • a reduction in Day Hospital places and the formation
service users at the time of diagnosis. of an Assertive Outreach Team that could offer
alternatives to in-patient admission whilst in-reaching
• Assessment packs containing detailed to wards in order to facilitate earlier discharge.
information about what is required is made
available when relevant

33
Services included: Before service change
Primary intervention and liaison • 52% hospital contact
• memory assessment service • 48% community contact
• care homes liaison team
After service change
• acute hospital liaison team
• 34% hospital contact
Secondary services • 66% community contact
• multi-agency/interdisciplinary CMHTs Some 63% of people attending the Day Hospital
indicated they would be satisfied attending on a
• assertive outreach team/day services; and
sessional basis as opposed to full day.
• in-patient assessment.

Impact on outcomes
Impact on service delivery
Service users now choosing intensive support at
• fewer in-patient beds needed home rather than hospital admission.
• 8 months after service redesign, 5% increase of
service users with recent history of hospital
Impact on staff & organisation
admission on CMHT caseload corresponded with a
14% increase in available bed days for two in- There was no increase in resignations or
patient assessment units sickness/absence despitesignificant service change.
There was an increased number of staff trained in
• 18 months after service change, bed reductions in
psychosocial interventions
same two units (20 to 12 in Dementia Unit & 24 to
20 in Mental Health Unit) have been sustained with
Prior to service change
typical occupancy rates below 100%
• 0 staff qualified/training in relevant Post-
• caseload audit indicates 72% of CMHT caseload in
Registration Dip/Degree
severe and enduring needs target group after
service change; and
After service change
• day service meeting needs of population with more
• 6 staff qualified/training in relevant Post-
severe and enduring difficulties reduction in day
Registration Dip/Degree
hospital places (from 300 per week to 100 per
week) resulted in freed staff time being used to
form assertive outreach team.
Case study 3 Demonstrating the
Prior to service change impact of a whole system approach
• 89% attending for anxiety/depression of these; to early intervention
• 80% no or mild symptoms on HADS; and
Gloucestershire Recovery in Psychosis
• 74% no or mild symptoms on GDS. service (GRIP), Gloucestershire
Partnership NHS Trust and Cheltenham
After service change Community Projects
• 53% attending with psychotic condition
The GRIP approach emphasises the development of
• 33% attending for anxiety/depression coherent links between a number of inter agency
• Of the 33%; and organisations, both statutory and non statutory. The
service is based in the community and shared with a
• 80% score in severe range on HADS/GDS. youth agency, Cheltenham Community Projects
(CCP). This encourages a symbiotic relationship and
sharing of expertise to support a potential shared
Impact on service user experience young client group.
Increased capacity for home based care

34
Extensive and meticulous planning was undertaken Impact on service user experience
prior to setting up GRIP. This involved consultation
Comparing treatment as usual (TAU) services with
with primary and specialist health agencies and the
the GRIP service:
voluntary sector, particularly youth agencies.
• TAU offered behavioural family intervention (BFI) to
A formal research project incorporated a combination 17% of first episode psychosis users and their
of questionnaires and interviews designed to elicit the families. With GRIP 93% of users and their families
views of GPs, service users and carers. A local now access BFI
stakeholders steering group was set up, its remit
• TAU services offered 10% of carer's formal carers
informed by the consultation and site visits to
assessment. GRIP now ensures that 100% of
national/international centres of excellence.
carers receive this assessment
The steering group drew up a service specification • TAU services only ensured that 17% of users
was drawn up by the steering group with the key before knew what the care programme approach
strategic aim to reduce Duration of Untreated (CPA) was. GRIP has aimed for and achieved a
Psychosis (DUP), which led to series of operational 100% success rate in ensuring that users know
service deliverables which include: what CPA is
• both users and carers are more satisfied with the
• widen access to allow direct access for potential
community and home treatment based style of
users and concerned family members
delivery; and
• offer a lower threshold for GPs to refer on suspicion
• they are also pleased with the range of individual
rather than certainty; supplemented by
and group based activities (including social and
communicating rapid feedback of assessments
sports groups) together with a holistic emphasis
and treatment proposals
upon recovery aiming for social integration and
• offer a programme of awareness raising: meaningful occupation / employment.
conducted across the community including formal
presentations to GP's, statutory and secondary
teams and also to the non statutory sector. Impact on outcomes
Supporting information and leaflets were distributed
• DUP has reduced within Gloucestershire from 13
and a number of helpful suggested initial
months (achieved by TAU services) to 3 months by
assessment questions; and
the GRIP Team from April 2003 to March 2006; and
• a screening tool developed by GRIP was
• fewer mental health act assessments.
distributed to potential referrers.
At April 2006 GRIP has lost no service users to follow up.
The clear majority of service users are visited and
This compares with an expected loss of around 50% in
assessed at home but can choose to be assessed at
TAU services at 12 months (McGovern et al 1994).
the GRIP offices. The community based nature of the
GRIP services places an emphasis on recovery which
At the same time there have been no incidents of
supports clinical improvement and reintegration with
suicide despite this client group expecting a 70 times
social networks. Service users also have the chance
higher risk of suicide. 0% suicide reflects the
to explore opportunities to work in vocational, unpaid
potential that EI services such as GRIP have to
or paid employment.
recognise and attend to suicide risk factors such as
social isolation, unemployment, and depression.
A number of clear operational targets have been
defined within the Mental Health Service Response to • For example two undergraduate service users
First Episode Psychosis in Gloucestershire Research recently resumed their studies, and GRIP
document (Davis and Morgan 2004 see successfully liaised with local early intervention (EI)
www.gripinitiative.org.uk). services close to the respective universities to
ensure they continued to receive appropriate support.
Suicide is the single largest cause of premature
Impact on service delivery
death: 10% of people with psychosis will ultimately
There was reduced bed occupancy. kill themselves, two-thirds within the first 5 years
(Wiersma et al 1998). Around the time of emerging
psychosis young females have a 150 times higher
and young males a 300-fold higher risk for suicide
than the general population.(Mortensen 1995). The

35
most vulnerable time follows the first episode, often • care coordinators from the NEIT offer education to
some months later, when the young person may GPs on the importance of early detection and
have experienced their first relapse or disengaged referral of possible cases of psychosis to the service
from services (linking with the benefits of GRIP's
• enhanced family work (family interventions):
assertive approach to follow-up).
working proactively with families to acknowledge
and help them deal with their own needs, and to
help them be more effective in their caring role.
Impact on staff and organisations
The following vignette displays how care pathways
Opportunity to achieve better outcomes and were used to decide who to target and what
trajectories for service users means that staff can see information to give them. This illustrates what can
tangible benefits of this way of working. There was be achieved if people are referred earlier and the
high interest from staff to join early intervention in service is prepared and able to work with families
psychosis services thereby supporting recruitment as co-therapists.
and retention of staff
Following an educational session a GP approached
To date the impressive reduction in DUP and use of a care coordinator to ask for advice. A mother,
the Mental Health Act and reduction in suicide rates had asked them to see her son, who was behaving
together with increased user and carer satisfaction oddly, however he had refused to see the GP. The
levels and employment / occupation rates for service Care Coordinator's subsequent attempts to see the
users together with 0% of users lost to follow up young man were met with refusal but, through the
demonstrates value for money. policy of encouraging family work, an alternative
approach could be offered. The use of legal
To sustain the improvement the following is critical. detention was discussed, but the family felt this
An audit cycle has been set in place to listen to and should be a last resort. Thus having defined some
learn from GPs and users and carers of the service. clear boundaries around risk it was agreed that the
Any unmet needs or more effective ways of helping young man be offered a formulation based
to deliver early intervention would be expected to psychosocial intervention approach, conducted by
help further improve the service. the mother and supervised by the Care Coordinator.
Improvement slowly followed and over many months
It is hoped to expand the service approach across he was able to re-engage some old friends,
Gloucestershire. eventually returning to work.

Case study 4
Northumberland Early Interventions
Team (NEIT), Northumberland Care Trust
NEIT focuses on improving engagement of service
users with first episode of psychosis. Typically,
service users are engaged after long delays and
frequent failed attempts by families to access help.

This often results in a crisis which usually requires

hospital admission often under the mental health act.
NEIT particularly works with families and service
users to promote hope and prevent social exclusion,
by encouraging service users to reintegrate with their
social and occupational networks.

Research suggests that by reducing DUP people will

have less traumatic entry into services, and an
admission at presentation can be avoided. The NEIT
developed two practical local measures:

36
Impact on service delivery

PACE NEIT 2004 NEIT 2005

Total First Admission Days 3146 708 1248

Total number of patients in data 71 33 69

Total Actually Admitted 48 13 23

Percentage Admitted 67.6% 43.3% 33.3%

Average length of first admission 65.5 54.5 55.8

Average length of admissions by total clients 44.3 21.5 18.1

Total relapse days - 40 41

Relapse days per month of care 2.01 0.054 0.320

NEIT 2004 NEIT 2005 PACE

96% 97% 49% after 2 years retain contact with mental health services

Impact on outcomes

Employment in service users has

increased from 20% to 36% NEIT 2005

Unemployed 36

Full time employed 15

Full time education 6

Part time employment 12

Impact on staff and organization

Cost Savings NEIT 2004 NEIT 2005

Reduction in first admission/length of stay 752.4 1807.8

Reduction in relapse days 1407.9 2162.8

Unit cost of health and social care 2001 (mental health acute) £153 £153

Total saving £215,409 £607,502

Total cost of NEIT (approx.) £160,000 £439,120

Net saving so far (not including medication) £55,409 £168,381

37
High Impact Change 10 Impact on service delivery

Redesign and extend roles • service capacity has been greatly increased
• eduction of waiting for new referrals in the Memory
in line with efficient service Clinic to 4 weeks from receipt of referral
user and carer pathways to • increase by 50% of new service users are now
attract and retain an being seen: additional 200 people can be seen per
year by Memory Nurses in addition to Memory
effective workforce Clinic
• an additional 1000 follow-up appointments can be
This change aims to develop staff roles to undertaken each year by Memory Nurses in
make sure that the services provided meet addition to Memory Clinic
the needs of service users and carers and
to attract and retain skilled and motivated • response to increasing demand from GPs with
staff. rising referral rates, especially increasing referral
numbers for younger and earlier specialist
assessment (early onset dementia)
• three of the Memory Nurses are currently
Case study 1 Demonstrating the supplementary prescribers course and the other is
impact of employing a memory intending to start this course in 2006; and
nurse in older people's services • increased volumes of activity undertaken by the
memory nurses for far less average cost (average
Memory Assessment & Research £15 per staff contact cost of memory nurses as
opposed to average £50 per staff contact cost for
Centre, Hampshire Partnership
memory clinic).
NHS Trust
A memory nurse was employed at the Memory Impact on service users and carers
Assessment and Research Centre, following
publication of NICE guidance and the NSF for Older • memory nurses have been able to co-ordinate and
People. The role requires working at a number of facilitate the memory matters carers' education
levels within health services and performing a range course and extend the service; and
of functions that require a variety of interpersonal and • qualitative analysis showed that service users
communications skills not solely targeted at working (78%) and carers (91%) are either very happy or
with service users. quite happy for the memory nurse to be the main
contact regarding dementia medication rather than
The role is challenging due to its diversity and a doctor
coherent inter-working is needed to maintain and
improve upon aspects such as the communication of
individual patient information and the access to and Impact on staff & organisations
maintenance of service user records.
• increased communication and liaison with wider
A further aspect of inter-working within a system of older people's mental health (OPMH) services; and
healthcare is the need for other professions to • OPMH consultants now have better practical
understand and appreciate the nature and diversity knowledge and experience of dementia
of the memory nurse role and the factors and medication treatments.
requirements, which underlies its realisation.

This presents a particular challenge as it involves Impact on outcomes

explaining a new role at the same time as it evolves
and develops. • provided a cost effective way or providing and
monitoring dementia treatment in keeping with
One particular area worth noting is that the memory national guidance and advice; and
nurses were originally called community dementia • introduction of patient specific direction for
nurses (CDN's) but reported that sometimes the Donepezil with the Memory Nurses supplying
word "dementia" in the job title caused upset or Donepezil packs from MARC base which is less
distress to service users and carers. After discussion expensive than prescribing on FP10's (a saving of
it was agreed that the CDN job title should be £40 per 28 days pack of Donepezil 10mg).
changed to Memory Nurse.

38
Other impact measures and benefits Adult mental health support time and recovery
identified from the field: Workers (STR), Humber Mental Health Teaching
NHS Trust
Adult mental health senior nurse practitioner
(SNP), West Sussex Health and Social Care • collaborative working with positive assets has
NHS Trust resulted in 31% of STR workers with personal
experience of mental health services being
• SNPs undertake first line assessments and are employed
authorised to decide upon appropriate treatment • successfully recruited to all STR posts
plans. This avoids unnecessary contact with SHOs.
• retention of all STR workers with the exception of
• Where admission is required the project has promotions
developed a care pathway where SNPs can
authorize admission • positive media coverage of the role; and
• user focused approach to care.
Specialist liaison nurse, Barrow-in-Furness,
Morecambe Bay PCT STR workers, South Warwickshire PCT
• nurse led clinics working with consultants to create STR workers were introduced. There was a fairly
capacity and facilitate discharge positive response to how the new role impacted on
• easier to slot in any urgent requests indicating that service users. The STR role was identified as:
some capacity has been created for the consultant; • allowing the worker to be more proactive by being
and able to develop recovery plans on a one-to-one
• 285 appointments with a total of 204 attendances basis in line with care plans
(71.5% attendance rate) = 22% reduction in • allowing for more initiative from the worker
consultant overall caseload.
• emphasising recovery
• being able to spend more time with the client to
Feedback taken from a service user find out what means of practical support might
satisfaction survey help recovery in all aspects of their life
• having more time with service user to meet needs
“No I don't think there needs to • working with a personalised recovery plan allows a
be any improvements to these more structured way of working with service users
clinics as they are very helpful • the STR role legitimises some of the "extra" work
and understanding” that was already being done; and

Adult mental health BME STR workers, South

Warwickshire PCT
“I think she does a very good job
• culturally competent workforce that take a holistic
as she listens to what you have approach to the person/the family and understands
to say and explains things if you and appreciates cultural norms and values; and
have any problems. I think she • staff are enabled to feel confident in building
does a very good job” therapeutic relationships with BME service users by
seeking out the strengths of the individual but also
the communities they live in and the structures they
operate within.
“I think it's a good idea to have a
liaison nurse”

39
Adult associate mental health practitioner,
Hampshire wide collaborative

• addresses recruitment challenges

• offsets agency costs
• provides staff with the right skills, knowledge and
attitude to deliver care to service users
• trainees are based in setting where this facilitates
more experienced staff to extend and expand their
roles; and
• the trainee role becomes cost neutral.

40
Conclusions and
recommendations
The 10 high impact changes for mental health services illustrate where demonstrable
change can be achieved and how a range of benefits can be realised.
As the evidence base grows the discipline of service improvement will become more robust and
rigorous and this will enable health and social care communities to more widely learn and share
from experience.

The 10 high impact changes then provide a framework to underpin service improvement
programmes of work that builds on the good practice across the wide range of mental health
services and will support achievement of organisational priorities.

41
Supporting implementation of
High Impact Changes in
Mental Health Services
The Care Services Improvement Partnership (CSIP) has eight regional development centres
spread across the country. Every CSIP development centre has staff with service improvement
expertise that can advise and support local implementation.
CSIP is committed to supporting the development of service improvement capability and capacity in health
and social care and how this is undertaken will be negotiated locally and in response to local need and existing
resources.

North East, Yorkshire & Humber Development Centre

01904 717260
www.neyh.csip.org.uk

North West Development Centre

0161 351 4920
www.northwest.csip.org.uk

East Midlands Development Centre

01623 812930
www.eastmidlands.csip.org.uk

West Midlands Development Centre

0121 6784849
www.westmidlands.csip.org.uk

Eastern Regional Development Centre

01206 287593
www.eastern.csip.org.uk

London Regional Development Centre

0207 307 2431
www.londondevelopmentcentre.org

South East Development Centre

01256 376394
www.southeast.csip.org.uk

South West Development Centre

01278 432002
www.southwest.csip.org.uk

42
Local implementation will also be supported
by these following resources:
Directory of Service Improvement
CSIP has created an online directory of service improvement that brings together the wealth
of tools and techniques CSIP uses to support health care professionals, people that use
services and the people that support them, as they work in partnership to improve local
services. It brings together information on methodologies, networks, exercises, icebreakers,
and energisers, which are supported by real life examples. The directory can be explored and
utilized to improve services and make High Impact Changes. It helps answer questions like:
• Where should we start with service improvement?
• Who should we involve?
• What sort of tools or techniques could help us? And
• How will we know if things have got better?

To access the regularly updated directory, visit www.csip.org.uk/serviceimprovementdirectory

Integrated service improvement programme

The ISIP Road Map for Transformational Change provides guidance on the process of change and sign posts
to tools and techniques. The web site also contains the ISIP stepped guidance to assist in planning and
delivery of benefits led service improvement. www.isip.nhs.uk

Each strategic health authority has an ISIP lead who can provide you with information and support in using the
ISIP methodology to support planning and delivery of service improvement.

Service improvement competencies

The Mental Health National Occupational Standards (NOS) state the competencies describing good practice in
the delivery of mental health services and are mapped against the NHS Knowledge and Skills Framework.

The NOS can inform decision making in a range of areas including service and role redesign. Interactive tools
and resources available to help individuals and organisations develop and measure performance outcomes
include the skills required to provide service improvement interventions. These can be accessed through Skills
for Health www.skillsforhealth.org.uk/mentalhealth

43
Literature and context review
to the 10 High Impact Changes
notably education, social services, youth justice
High Impact Change 1 services as well as health. In a study of children
Treat home based care and support as identified by services as having "concerning" mental
the norm for the delivery of mental health problems, Clark et al (2005) found that 55 of
the 60 participants in the study had a diagnosable
health services mental health problem, with over half having more
than one psychiatric disorder. Yet at one year follow
Crisis resolution teams are intended to augment
up, 50% of the children had had no contact with
existing services, not replace them (Johnson et al
mental health services at all and mental health
2005). But it is important to note that the evidence
services accounted for only 5% of the total
suggests that inpatient admissions (and costs) only
service costs.
reduce for crisis resolution teams if accompanied by
a staged reduction in inpatient beds (Ford et al 2001).
High levels of need were identified at baseline by
Pressures to maintain bed numbers might therefore
the Health of the Nation Outcome Scale for
affect the ability of crisis resolution teams to reduce
Children and Adolescents and the Salford Needs
admissions and costs; because if beds are available,
Assessment Schedule for Adolescents, and these
they can always be filled (Lawton-Smith 2004).
persisted over time (although this does mask wide
variation, with some young people getting better
Plus... and some getting worse).
Glover et al (in press) 2005 have carried out a The authors concluded that there was a need for a
naturalistic observational study of the recent more formal needs assessment for children to ensure
implementation of home treatment services in the UK. resources are targeted appropriately, and a shared
They found that crisis resolution teams were more perspective on child mental health between the
effective in reducing admissions for women and older various agencies potentially involved.
working age adults, and also when the teams had
been established longer. Although expressed differently, Kaplan (2002) described an evaluation of a
this is similar to the finding of Burns et al (2001) that multidisciplinary community mental health team for
those home treatment services that reduced adolescents, although, notably, the team did not
hospitalisation were more sustainable. In other words, contain nurses. The team provided assessment,
the longer the team is established, the more likely it is it outreach and a range of interventions. Waiting times
will reduce admissions – and if it reduces admissions, were reasonable, with over 50% of first appointments
the more likely it is that the team will be sustainable. provided within two weeks of "case assignment".
Evidence of impact of home-based care across the full Two-thirds of clients had fewer than 8 sessions
range of mental health services needs to be developed and outcomes at discharge showed significant
or more effectively captured in light of the gaps identified improvements in global functioning and in the
within the evidence base. Particularly the impact of older original referral problem; there was also a
people’s community services, personality disorder reduction in deliberate self-harm. A small sample
services, CAMHS and adult mental health. of adolescent users and parents provided
satisfaction ratings, with the large majority rating
However the message for service improvers is clear: give the service highly.
teams time to establish and ensure the whole system is
geared up to reduce admissions – this includes making Finally, the evaluators estimated cost savings based
some reduction in the number of hospital beds. on likely out of borough (ECR) admissions prevented
by the team. They found that the team prevented
ECR admissions for between 6 and 9 patients,
Plus... saving an average of £22,500 per patient based on a
Community-oriented services for children and young 3 month stay.
people tend to be delivered by many agencies,

44
High Impact Change 2 High Impact Change 3
Improve the flow of service users and carers Manage variation in service user
across health and social care by improving discharge processes
access to screening and assessment
A recent toolkit issued by NIMHE/CSIP (CSIP 2005)
A large-scale American study, found that people emphasises the role of day services in supporting
who were given their future out-patient recovery through employment and meaningful
appointment time on the same day as their initial daytime activity, and also as an alternative to
contact, were significantly less likely to miss the hospitalisation in a crisis. The toolkit cites research
appointment, than those who had to wait to that suggests effective day services can facilitate
receive their appointment (Gallucci et al 2005). early discharge and reduce inpatient admissions by
up to 23%.
The longer patients had to wait to receive notice of
their appointment, the more likely they would miss the In a methodical review of the literature on delayed
actual appointment. For people who received their discharges, Glasby & Lester (2004) found that
appointment time on the same day, the did not attend delayed discharges are multi-factorial in nature, with
( DNA) rate was 12%; for people who received their a wide range of community and other services
appointment the following day, the DNA rate increased required to enable timely and effective discharges to
to 23%, and for people who waited 7 days, the DNA take place. These include housing options, day care,
rate was 42%. After that the rate levelled out. secure services and community support.

The conclusion is that the first appointment time needs Moore & Wolf (1999) also held this view: acute
to be given to the service user as soon as possible inpatient care is part of a spectrum of care and a
following the initial contact, preferably on the same day. range of care options for different levels of need and
different kinds of problem needs to be in place in
Another approach was used in a psychology service order to avoid costly delays in discharge.
where, with only three psychologists, waiting lists
were excessively long (Woodhouse 2005). Referrals
were audited against factors predictive of positive
outcomes (Carr 1999, cited by Woodhouse 2005). High Impact Change 4
Manage variation in access to all mental
It emerged that the cases being prioritised were those
where the referral letter described predictors of health services
negative outcome. In other words, prioritised cases
were those least likely to respond to treatment. The Many older people are referred via general hospital
referral and assessment system was changed with a physicians; therefore there have been initiatives
view to improving efficiency, using an opt-in approach to improve general hospital psychiatric liaison
to appointments and adapting waiting list prioritisation (Draper 2000).
to reflect characteristics predicting a good outcome.
For example, the introduction of a psychiatric
The author compared findings in the year preceding
consultation liaison nursing service for older people in
the introduction of the new system with the first year
one general hospital, resulted in increased referrals
of the new system. Opt-in rates stabilised at 70%,
and decreased waiting times for a psychiatric
and non-attendance reduced significantly.
consultation (down from a mean of 18 days to 6
Following introduction of the opt-in appointment days wait (Collinson & Benbow 1998).
system, average wait for a first appointment dropped
There is mounting evidence of variations in access,
from 58 weeks to 45 weeks. A year after the
treatment, experience and outcomes for different
introduction of the revised prioritisation criteria, the
social, cultural and economic groups in relation to
average waiting time reduced to 19 weeks, and by
mental health services.
the following year had stabilised at 13 weeks. The
results were statistically significant.
For example, black people and homeless people are
less likely to enter mental health services via primary
A Cochrane review (Reda and Makhoul 2001) looked at
care (Bhugra et al 2004, Holland 1996); black people
studies into improving attendance. They found only three
are more likely to be detained under the Mental
relevant trials, all American. However, they did conclude
Health Act and have more complex pathways into
that a simple prompt close to the appointment time may
psychiatric care (Bhui et al 2003)]; Asian people are
encourage attendance, and a simple orientation type letter
less likely to have their mental health condition
the day before the appointment may be more effective,
recognised in primary care (Commander et al 2004);
and more cost-effective, than a telephone prompt.
women report poor experiences in mental health

45
inpatient units (Ford et al 1998); deaf people have (Commander et al 2005) and when users are
longer lengths of stay (Appleford 2003).However, engaged with the service (Meaden et al 2004).
there is very little robust evidence of service models
that could address these issues effectively. What They have been found to be as effective as other
seems like common sense may not make the case management models in relation to quality of life,
difference needed. For example, single sex units symptoms and social functioning outcomes, are liked
have been advocated as important for women to feel by service users and families and may be cost-
safer but Mezey's study found that women in single effective (Burns & Santos 1995).
sex secure units felt as intimidated as those in mixed
sex secure units, although they were in fact less Increased community contacts and engagement with
vulnerable to actual attack (Mezey et al 2005). severely mentally ill service users are seen as positive
aspects of delivering assertive outreach and case
Similarly, tools aimed at facilitating better management services, probably helping to avoid
understanding and implementation of culturally- hospital admission (see for example, Marshall &
sensitive services (eg Sathyamoorthy et al 2001) Lockwood 2004). In a multi-method study, Freeman
have not been systematically or scientifically et al (2002) found that assertive outreach had the
evaluated (McKenzie 2002). strongest evidence base in relation to promoting
continuity of contact over time, resulting in improved
Where there have been controlled trials, samples are outcomes and costs.
small and tend to compare results between two
groups from the same client group, so it is not clear Most evidence points to sticking to the Assertive
whether the outcomes would have been achieved Outreach model in order to achieve successful
with different client groups (see for example, Jacob outcomes. McGrew et al (1994) found that programs
et al 2002). Similarly, individual initiatives, such as with higher fidelity were more effective in reducing
services designed specifically for women, have hospital use. In a recent meta-analysis of 34 ACT
sometimes been evaluated but not scientifically studies, Latimer (1999) found high-fidelity programs
(generally without controls). showed 23% greater reduction in hospital days
compared with lower fidelity programs at one year
Many initiatives are in place, best described as follow up.
projects, often delivered in the voluntary sector, and
which can provide lessons for service developers.
For a review of projects for minority ethnic
communities in England, see Fernando (2005). High Impact Change 6
Increase the reliability of interventions
Direct Payments by designing care based on what is
Direct payments can enable people to have choice known to work and that service users
and control over the meeting of their social care inform and influence
needs, and this can be at less cost than their former
use of provided services. Direct payments require the A recent Cochrane systematic review (Joy et al
redistribution of resources to some extent away from 2004) reported that CR teams sometimes help to
provided services, as they are the alternative to these avoid repeat admissions, reduce family burden,
services and there is no additional money to finance are preferred by patients and families, are as
this choice. Where they have enabled people to effective as hospital-based systems and are
reduce hospital admissions, for example, they more cost effective.
present a 'whole system' saving which needs to be
balanced with the local authority's sole responsibility Johnson et al (2005) 2005 conducted an RCT of a
to make the direct payments. crisis resolution team compared with usual services.
They reported a significant reduction in hospital
admissions in the experimental team; their
experimental group had a mean of 6.4 bed days
High Impact Change 5 compared with 17.4 in the control group. Looking at
effects on the wider system, the authors reviewed
Avoid unnecessary contact and provide local admission rates generally. They found that in the
necessary contact in the right care setting 12 months before the introduction of the Crisis
Resolution team, there were 340 admissions in their
Assertive outreach teams have been found to locality. In the 12 months after the trial, when the
result in reduction in hospital days, particularly if crisis resolution team was fully functioning (explicitly
properly focused on the care of people with a when it was involved in all decisions to admit) this
history of heavy use of inpatient facilities had reduced to 237 admissions.

46
Increased community contacts and engagement with bank account, although there are strict record
severely mentally ill service users are seen as positive keeping and reporting regulations that must be
aspects of delivering assertive outreach and case adhered to and are regularly monitored.
management services, probably helping to avoid
hospital admission (see for example, Marshall & The freedom that direct payment gives me is
Lockwood 2001). In a multi-method study, Freeman immeasurable.
et al (2002) found that the assertive outreach model
had the strongest evidence base in relation to • First and foremost it gives me control. I don't have
promoting continuity of contact over time, resulting in to rely on a series of relatively inflexible community
improved outcomes and costs. care workers, or even the rather more preferable
option of independent, yet "untried and tested" (to
Rosenheck & Dennis (2001) found that homeless me) independent advocates. I employ staff of my
clients who have severe mental illness can be own choosing, who are available when I need them
selectively discharged or transferred to other services most. They follow my wishes and are not bound to
without subsequent loss of gains in mental health distant, rigid policies to which I have had no input.
outcomes, substance abuse, housing, or And they help me with the areas of life that I see as
employment. However, most evidence points to priorities for me, at that particular time, rather than
sticking to the assertive outreach model in order to being restricted in the tasks that they can do.
achieve successful outcomes. McGrew et al (1994)
found that programs with higher fidelity to the model • Secondly, it provides me with the support and
were more effective in reducing hospital use. In a confidence to live my life as I wish to live it, rather
recent meta-analysis of 34 ACT studies, Latimer than being constrained by fear, lack of confidence
(1999) found high-fidelity programs showed 23% and low self-esteem. I now live in my own home,
greater reduction in hospital days compared with hold down regular employment and have friends
lower fidelity programs at one year follow up. who do not need to worry about also being my
"carers". I go out independently, do voluntary work
Direct payments enable people to meet their needs with people with mental and emotional support
in personal, creative and innovative ways. The needs, and have learned how to trust, albeit a cat!
'service' a person receives is designed by them and
managed by them, with support to achieve this • Third, it acts as a form of mental health promotion
provided to the level which they require. Heslop and maintenance, rather than being part of all too
(2001) accounts her experience: familiar "crisis intervention" process, which, in my
experience, has come too late to be a very positive
"I am one of the small number of mental health or empowering form of help.
service users who receive direct payments. I am
directly supported in using the scheme by an advisor Yet for all the very positive aspects of receiving
from ILSA (Integrated Living Scheme Advice and direct payments there are also difficulties that it
Support Service), part of the West of England, Centre would be unfair not to address.
for Inclusive Living (WECIL) (See Mark, 1998). But the
use of direct payments has certainly meant that the • First, when feeling fragile and vulnerable, the whole
services and support I receive are truly user-centred, issue of recruitment and selection of PA's can
user-led and match my own particular needs. seem overwhelming and exposing. It is hard
enough to ask for help (from friends or
With the money that I receive from Social Services professionals) at the best of times, but to advertise
each month (reviewed on a 6 monthly basis) I employ for help and expose oneself to questions (however
2 Personal Assistants (Pas), one to work a certain well meaning they maybe) about your own support
number of hours/nights each week and the other on needs can be particularly difficult.
a "back-up" basis to cover more urgent situations
when support is needed. The actual hours of work • Secondly, when I am particularly distressed, for
are flexible, and generally planned a week in advance example, or placing myself in danger, my PA's may, at
according to what my plans for the week are. So, for times, need to override my wishes, which may create
example, if I have a therapy session, hospital a difficult tension. My solution to this has been to plan
appointment or merely a difficult day at work in out, with each PA at the start of their employment
prospect, we will prioritise cover for those particular what we should do on these occasions and each of
days. My allocation of direct payments money will my PA's has ready access to an information file that
also cover any necessary administration costs that I includes: things to do to help me when I maybe
incur, such as providing Employers Liability distressed, advice about what to do in a crisis
Insurance, paying tax and National Insurance situation, (including what to pack should I need to go
Contributions, paying for someone to take charge of into hospital!), who I would prefer to be contacted on
payroll issues, or paying recruitment costs. Overall what occasions and their contact details.
control of the money is in my hands, via a separate

47
• Thirdly, one has to be organised in rather exacting multiple disadvantages in addition to their mental
ways! Employees timesheets need to be health problems] that it is now known as evidence-
submitted in order that they can be paid on time, based supported employment" (pp. 43).
receipts for expenditure need to be kept and filed,
regular returns need to be completed and monthly It is important to note that supported employment is
needs assessments reviewed. not just about employment for its own sake. In a
study of supported employment, Becker et al (1996)
Nevertheless, for all the pitfalls and potential found that 81% of service users in a SE scheme
difficulties, the Direct Payments Scheme has given expressed job preferences that were realistic and
me a life that I could not envisaged five years ago. It stable. People who were in job placements that
CAN work very effectively with mental health service reflected their preferences were more satisfied.
users, and the assumption that people could not
cope because of their diagnostic label needs
challenging. I hope that other mental health service
users will have the same opportunities as me to use High Impact Change 8
a truly user-centred and user-led option. It is high
time that we demanded it as one of a range of all too
Improve service user flow by
limited, or non-existent choices that are currently removing queues
available" (p8-9)
Hamilton et al (2002) reported a triage approach in
the form of a brief psychiatric screening clinic for
first attendees referred from primary care. Sixty
patients were allocated the screening clinic for a 20
High Impact Change 7 minute appointment compared with a traditional
Apply a systematic approach to enable hour-long assessment.
the recovery of people with long term Twenty nine (48%) did not attend (compared with
conditions 21% DNA for all patients) but because the allocated
appointment was only 20 minutes, this actually saved
In the Cochrane review of day services, Marshall more than 19 hours over a year. The 31 people who
et al (2001) compared prevocational training (PVT) did attend were seen in 10 hours and 20 minutes,
with Supported Employment (also known as saving a further 20 hours and 40 minutes. The overall
Individual Placement & Support or IPS). PVT saving to clinician time was more than 40 hours in
offers a period of training for employment whilst one year. At 6-month follow up, no patients required
Supported Employment places and supports admission or assessment following self-harm.
people with severe mental illness in ordinary jobs
in a competitive market. The review found that A recent survey found that in 49% of trusts, waiting
Supported Employment was significantly more times for a first appointment were 1-5 months, but in
effective in terms of numbers in competitive 18% of trusts, they were 6 months or more (Kerfoot
employment; clients earned more and worked et al 2004).
more hours.
A number of solutions have been tested, including a
Similarly, in an authoritative book on recovery, well-received brief consultation approach (Heywood
Schneider reviewed US and UK evidence into et al 2003) and triage clinics (Parkin et al 2003).
vocational rehabilitation interventions and their In the latter study, a triage clinic was implemented
outcomes (Schneider 2005). She found no in light of excessive waiting lists and high
conclusive evidence that sheltered workshops are dissatisfaction amongst users and clinicians with
effective in helping people into work, and indeed the length of the wait.
might be detrimental.
The aim of the triage was to assess the need for
She also found that education and training initiatives specialist CAMHS intervention, mainly with referrals
that actively focus on work (not social skills) were from primary care. In the study, 92 non-urgent
effective and that conventional prevocational training referrals were offered triage in an outpatient clinic.
was less effective than supported individual Median waiting time was 61 days, with 95% offered
placements (Individual Placement and an appointment within three months. DNA rates were
Support/Supported Employment) in achieving reduced by a third and a quarter of those seen could
employment outcomes. She argues that: be discharged at the end of the triage appointment.
Users and physicians were mainly satisfied with the
"IPS has such unparalleled evidence in its favour [for new system. The authors stressed the importance of
its effectiveness in enabling people to get real jobs competent and committed administrative staff as a
with real wages, even service users who experience critical success factor for the project.

48
Another approach was used in a psychology service They suggest therefore that three major changes are
where, with only three psychologists, waiting lists made in CBT delivery: 1) less intensive treatments
were excessively long (Woodhouse 2005). Referrals should be the first choice for the majority of clients 2)
were audited against factors predictive of positive more intensive packages of care should be provided
outcomes (Carr 1999, cited by Woodhouse 2005). for patients at serious risk, with more complex needs
or who have had an unsuccessful brief treatment
It emerged that the cases being prioritised were regime 3) therapist assisted multi strand or complex
those where the referral letter described predictors of therapies should be used where the previous stages
negative outcome. In other words, prioritised cases have been unsuccessful – but only where clients
were those least likely to respond to treatment. have been unable to benefit from simpler
approaches. They argue in summary that equitable
The referral and assessment system was changed CBT can only be delivered if systems are in place to
with a view to improving efficiency, using an opt-in maximise patient access, minimize initial therapist
approach to appointments and adapting waiting list contact and abandon exclusive reliance on traditional
prioritisation to reflect characteristics predicting a delivery systems.
good outcome.
Results of alternative modes of delivering treatment
The author compared findings in the year preceding are mixed but mostly promising. A systematic review
the introduction of the new system with the first year of the effectiveness of computerised CBT (CCBT)
of the new system. Opt-in rates stabilised at 70%, packages, for example, was carried out for a Health
and non-attendance reduced significantly. Following Technology Assessment (Kaltenthaler 2002). The
introduction of the opt-in appointment system, review looked at 13 papers but none of them
average wait for a first appointment dropped from 58 reviewed the cost-effectiveness of CCBT; therefore
weeks to 45 weeks. the authors also reviewed four sponsor submissions.

A year after the introduction of the revised The authors found some evidence that CCBT was as
prioritisation criteria, the average waiting time effective as CBT delivered by a therapist, and more
reduced to 19 weeks, and by the following year had effective than usual treatment, for people who were
stabilised at 13 weeks. The results were statistically depressed, anxious or phobic in primary care
significant. populations. Where data were available, they found
that CCBT reduces therapist time and can be of use
A number of studies have looked into the feasibility of where access to a CBT therapist is limited.
delivering services in imaginative ways that reduce
reliance on practitioners, especially those in short They conclude that CCBT may be a useful
supply but great demand. component of stepped-care approach, offered as
one of the first options to patients presenting in
CBT is one such area of high demand. Lovell & primary care. In terms of cost-effectiveness the
Richards (2000) critically review the evidence for authors' findings were limited and they urged caution
improving access to CBT services via multiple access in interpretation. Notwithstanding this note of caution,
points. They note that the number of CBT they found that the cost of implementing reasonably
practitioners is nowhere near enough to treat the vast effective CCBT packages ranged from £21,691 -
numbers of people with disorders that CBT can treat £25,192 for the first year, depending on the
effectively. They also point to evidence that delivery of practitioner involved (priced at the time of
CBT services based on traditional outpatient clinics is publication).
unhelpful for three main reasons: 1) up to 25% of
patients do not attend initial appointments (Zegleman In support of this approach, a very recent trial
1988, cited by Lovell & Richards 2000); 2) session evaluated the use of computer assisted therapy for
duration is based on convenience not evidence 3) major depression (Wright et al 2005). The authors
open ended sessions not necessarily more effective found that a multi-media computer-assisted form of
than limited number of sessions (Barkham et al 1996, CBT for depression was as effective as standard
cited by Lovell & Richards 2000). CBT. Service users improved in terms of clinical
outcomes and drop-out rates were low, although the
The authors argue that:1) studies increasingly sample was small.
suggest there is little difference in effectiveness
between simpler behavioural and more complex
cognitive treatments for a range of disorders 2) there
is evidence for delivering brief CBT interventions
through alternative delivery systems (including
telephone and computer) that traditionally would
have been treated using frequent, prolonged face-to-
face sessions (numerous studies cited).

49
 There is growing recognition that people presenting
High Impact Change 9 with psychotic symptoms for the first time need
Optimise service users and carers flow specialized treatment. However there is recognition
through the service using an integrated that early intervention (EI) will never be delivered by
specialist EI services alone. Its achievement hinges
care pathway approach on changing the care pathway of this young client
group and their families by more integrated working
An example of using care pathways to audit and
between primary, specialist and community agencies.
investigate patterns of care is reported by
Commander et al (2004). The authors compared
EI Service implementation in the UK is still in
the pathways of white and Asian people with
progress and evidence of their effectiveness is
depression and anxiety to throw light on areas of
therefore limited.
strength and weakness within the system and any
differences in how the system operated for these
Rationale for EI: Typically those experiencing a first
patient groups.
episode of psychosis can expect one to two years
delay from onset to engagement and treatment in
The other use of the term care pathways (sometimes
specialist care, by which time over 50% require use
referred to as integrated care pathways) refers to a
of the Mental Health Act and approaching 80% can
systematic approach to delivering care. The aim is to
become hospitalised (Johnstone, E et al 1986). In a
provide a rational system for patient care especially in
review of the evidence, Birchwood et al (1998) argue
cases where care is complex, crosses organisational
that deterioration in mental health occurs most
boundaries and/or requires input from a number of
aggressively in the first 2-3 years, representing a
different professionals. Evidence for the use of care
'critical period' for concentrating treatment efforts
pathways in mental health in the UK is limited and
which maximise the potential for recovery and
mainly descriptive. Jones (2000) reported the
prevent relapse. From this has derived a fundamental
evaluation of an attempt to introduce care pathways
treatment objective, namely to reduce Duration of
for people diagnosed with schizophrenia; the author
Untreated Psychosis (DUP).
found that lack of staff engagement and pressure on
the service generally prevented the approach from
From this has arisen a justification for therapeutic
being implemented.
optimism in EI translated into various treatment
strategies; new medication regimens; psycho-
However, the same author argued later that a care
education of patients and families; social
pathway may bring other benefits, such as
interventions to support access to education;
standardized care and a greater control over the
employment and housing.
delivery of care (Jones 2001). Brett & Schofield
(2002) describe a care pathway approach for older
Evidence base for EI treatment: There is increasing
mentally ill people which has apparently resulted in
evidence to suggest that EI may reduce the harmful
improved, more consistent care that users and carers
consequences of psychotic disorders (Ho et al 2003) and
appreciate, but the evidence is anecdotal.
as such, EI services work closely to a recovery model.
Browning & Hollingberry (2000) describe developing
A recent systematic appraisal of the evidence for early
care pathways for eating disorders, acute mental
intervention work was published in the Cochrane
health admissions and acute psychosis over three
Database (Marshall & Lockwood 2006), and is in the
years. They report that the process increased
process of being updated. The reviewers analysed the
awareness of best practice and evidence-based care
research on duration of untreated psychosis and its
throughout the team. Additionally, service users and
relationship to outcomes for clients and found strong
carers were more aware of what to expect. A recent
evidence that the longer the period of DUP the worse
paper reported interesting findings from a Scottish
the outcomes for clients.
implementation of integrated care pathways (ICPs) in
community teams in Scotland (Rees et al 2004). The evidence for intervening early to prevent
psychosis was found to be fair with some promising
The aim was to enhance joint working across health
preliminary findings. There is encouraging evidence of
and social care, reduce duplication and standardise
the impact of EI teams, for example in terms of
quality of care within the region. Whilst staff
reducing bed stays and in improved mental states.
responded positively to the idea of the ICP, the
researchers found that in practice they were not This review looked at a number of randomised
implementing it. The authors concluded that controlled trials of EI, published or in the process of
operational procedures such as ICP cannot overcome reporting. A relatively recent trial from the Early
problems at strategic and organisational levels.

50
Psychosis Prevention and Intervention Centre (EPPIC)
in Melbourne compared outcomes for people with an
High Impact Change 10
early psychosis who were assigned to specialist Redesign and extend roles in line with
EPPIC care or standard care (Yung et al 2003). The efficient service user and carer
standard care group had longer duration of untreated
psychosis, were more likely to be admitted and use
pathways to attract and retain an
of the police in the admission process was higher effective workforce
compared with the EPPIC group. Again from EPPIC,
the Personal Assessment and Crises Evaluation Challis et al (2004) reported a randomised
(PACE) trial looked at the effectiveness of treating controlled trial to test the value of employing a
young people identified as being at ultra high risk of specialist clinician to assess older people before
developing psychosis. entering a care home. The authors found that the
assessment uncovered mental health problems
The PACE study showed that it is possible to delay that had formerly not been recognised, and that
and potentially avert progression to full diagnostic outcomes improved. There were significantly fewer
threshold for psychotic disorder from 35% to 10% in days spent in nursing home care and significantly
a sample of 59 in 'ultra high-risk' individuals using fewer visits to A&E for those in the intervention
low dose neuroleptics and CBT.i Subsequently, group. NHS costs were significantly lower for the
Morrison et al demonstrated that almost the same intervention group, even taking into account the
conversion rate to psychosis (i.e. 12%) could also be additional cost of the clinician's assessment.
achieved with CBT alone using the PACE criteria.
According to a recent survey, a fifth of trusts had
The TIPS project evaluated community education outpatient CAMHS clinics within primary care
about psychosis in an epidemiological 'case-control' settings and one third of CAMHS services had
study in Norway, finding a reduction in DUP and a developed primary mental health worker posts
concomitant reduction in psychosis symptoms at (Bradley et al 2003). A recent study did find that
onset of treatment and 3 months follow-up. introducing primary health workers created a more
efficient CAMHS service (Whitworth and Ball 2004).
Three RCTs have focused on providing intensive Non-attendance rates decreased (from 45% to 9%),
assertive outreach-based care to young people (16- attendance increased (55% to 78%), and patterns of
30yrs) during the 'critical period'. The OPUS study in referrals to secondary care were altered so that Tier
Denmark found advantages in terms of readmission, 2/3 work was more likely to be focused on
symptoms and quality of life for integrated, sustained appropriate cases.
treatment over treatment as usual.

In the UK, the Lambeth Early Onset (LEO) study

evaluated the effectiveness of an early intervention
service which is compliant with the 2001 Policy
Implementation Guide recommendations. A team
delivering specialised care for patients with early
psychosis has been found to be superior to standard
care for maintaining contact with services and
reducing readmissions to hospital (Craig et al 2004).

The Croydon Outreach & Assertive Support Team

(COAST) found disappointing results. Trends in bed
use and quality of life were better for COAST service
users compared with service users receiving
treatment as usual, but differences were not
statistically significant (Kuipers et al 2003).

51
Acknowledgements High Impact Change 6
• The Haven Project, Core partnerships: – North
We are grateful to the following NHS and Essex Mental Health Partnership NHS Trust, local
social care services and organisations for service user groups, local and commissioning
PCTs, local voluntary agencies, A&E Dept, Essex
contributing case study material and data.
Police, Colchester Borough Council. Extended
Partnerships: – Psychology Dept., North Essex
High Impact Change 1 Mental Health Partnership NHS Trust
• Easington Crisis Resolution Team, Tees, Esk & • The Service User Network, funded by the
Wear Valleys NHS Trust Department of Health's National Pilot Programme
• Crisis resolution home treatment teams and crisis for Personality Disorders, hosted by South West
house, South Warwickshire PCT and Rethink; London and St George's Mental Health Trust.
• South Essex Partnership NHS Trust
• Acute Day Hospital Banbury, Oxfordshire & High Impact Change 7
Buckinghamshire Mental Health Partnership Trust • Café On the Hill, West London Mental Health NHS Trust
• Maidstone Crisis Resolution Home Treatment Team, • Employment and Education Service, North
Kent & Medway NHS & Social Care Partnership Trust Yorkshire Social Services
• Humber Mental Health Teaching NHS Trust • Community Support Service, North Yorkshire Social
• Rapid Access Service, Wakefield Older People’s Services
Mental Health Services, South West Yorkshire • CPA system, South Warwickshire PCT
Mental Health NHS Trust
• 5 Boroughs crisis and home treatment teams, South
West London & St Georges Mental Heath NHS Trust High Impact Change 8
• Nabcroft Older peoples Service, Kirklees, South • Adult Mental Health Directorate, Mersey Care NHS
West Yorkshire Mental Health Trust. Trust
• Greenwich CAMHS, Oxleas NHS Trust
High Impact Change 2 • Gables CMHT, Devon Partnership NHS Trust.
• Newcastle & North Tyneside Perinatal Service,
Northumberland, Tyne and Wear NHS Trust
• Primary Care Mental Health Service, Hambleton
High Impact Change 9
and Richmondshire PCT • Centre for the Health of the Elderly,
Northumberland, Tyne and Wear NHS Trust
• Preston Primary Care Mental Health Team,
Lancashire Care NHS Trust • Nabcroft Older Peoples Service, Kirklees, South
West Yorkshire Mental Health NHS Trust
• Bucks Early Intervention Service, Oxfordshire &
Buckinghamshire Mental Health Partnership Trust. • Gloucestershire Recovery in Psychosis service,
Gloucestershire Partnership NHS Trust and
Cheltenham Community Projects
High Impact Change 3 • Northumberland Early Interventions Team (NEIT),
• Southwark Adult Mental Health Services, South Northumberland Care Trust.
London & Maudsley NHS Trust
• Adult Mental Health Care Group, Sheffield Care Trust. High Impact Change 10
• Memory Assessment & Research Centre,
High Impact Change 4 Hampshire Partnership NHS Trust
• East Cambs and Fenland Locality, Cambridgeshire • adult mental health senior nurse practitioner, West
& Peterborough Mental Health Trust. Sussex Health & Social Care NHS Trust
• specialist liaison nurse, Morecambe Bay PCT
• Support Time Recovery (STR) workers, Humber
High Impact Change 5 Mental Health & Teaching NHS Trust
• Tooting and Furzedown Community Mental Health • STR service, South Warwickshire PCT.
Team (CMHT), South West London & St Georges
Mental Heath NHS Trust • Black and Ethnic Minority workers, South
Warwickshire PCT
• Newcastle Adult Inpatient Services,
Northumberland, Tyne and Wear NHS Trust • associate mental health practitioner, Hampshire
Wide Collaborative.
• Pharmacy Services, Mersey Care NHS Trust.

52
 Laurie Bryant
The High Impact Change Service User Lead, Corporate Development Team, CSIP
working group Maurice Burns
Associate Director for Commissioning, CSIP Eastern
The development of this work programme
Jenny Connelly
and especially the NIMHE discussion paper former Head of Modernisation and Partnerships,
has involved a number of people whose Oxfordshire & Buckinghamshire Mental Health
contributions have been invaluable: Partnership Trust
Jenny Dalloway
Jackie Ardley Locality Director, CSIP West Midlands
Director of Corporate Development, CSIP Lu Duhig
Richard Ford Carer Lead – Corporate Development Team, CSIP
Director, CSIP South East Development Centre Julia French
Roger Batterbury former Service Improvement Lead, CSIP East Midlands
10 High Impact Changes Project Officer, CSIP Bernie O'Hare
South East Development Centre former Service Improvement Lead, CSIP North West
Keith Baulcombe Development Centre
Mental Health Development Manager, West Hull PCT Mark Norman
Fionuala Bonnar Service Improvement Lead, CSIP South West
Service Improvement Lead, London Catherine Pearson
Development Centre Head of Redesign, Bedfordshire and Luton
Julie Clark Community NHS Trust
Service Improvement Lead, CSIP North West Fran Redman
Jo Davis Development and Redesign Lead, SW Peninsula SHA
10 High Impact Changes Programme Lead, CSIP Steve Stericker
Corporate Development Team & Specialist Mental Service Improvement Lead, CSIP North East,
Health Care Development Lead, CSIP North East Yorkshire and Humber
Yorkshire & Humber Clive Stevenson
Wayne Eckersley Service Improvement Manager, London Development
Service Improvement Lead, CSIP Eastern Centre
Patrick Geoghan Judy Wolfram
Chief Executive, South Essex Partnership NHS Trust Trust Service Improvement Lead, Oxleas NHS Trust
Mike Gill We would like to acknowledge the early work
Service Improvement Lead, Humber Mental Health undertaken by North Warwickshire PCT and South
Teaching NHS Trust Essex Partnership NHS Trust
Kam Kalirai
former Head of Service Improvement NIMHE We are grateful to the following for their
Kate Kennally collaboration, advice and support:
former Area Programme Lead - Pathways and Process Robin Murray-Neill, direct payments lead, NIMHE
Redesign, CSIP South East Development Centre National Social Inclusion Programme
Ruth Kent Frankie Pidd, commissioner for mental health,
Knowledge Officer - Corporate Development Team, CSIP Department of Health
Nathan Lee Danielle Procter, stakeholder management,
Deputy Director of Service Development, Mersey Integrated Service Improvement Programme (ISIP)
Care NHS Trust
David Shiers, GP Advisor to CSIP West Midlands
Joe Mairura and co-director of the National Early Intervention
Service Improvement Lead, CSIP East Midlands Programme, NIMHE and Rethink
Susannah Strong, senior communications and
We would also like to attribute thanks to: editorial advisor, CSIP.
Steve Appleton Thanks are also extended to Edana Minghella for her
Head of Delivery and Service Improvement, Thames guidance and undertaking the literature review.
Valley SHA

53
References
Appleford, J. (2003) Clinical activity within a specialist Clark A, O’Malley A, Woodham A, Barrett B & Byford
mental health service for deaf people: Comparison S (2005) Children with Complex Mental Health
with a general psychiatric service. Psychiatric- Problems: Needs, Costs and Predictors over One
Bulletin. Vol 27(10) Oct 2003, 375-377. Year Child and Adolescent Mental Health Volume 10,
No. 4, 170–178
Becker DR, Drake R E, Farabaugh A, Bond G (1996)
Job preferences of clients with severe psychiatric Collinson Y & Benbow S (1998) The Role Of An Old
disorders participating in supported employment Age Psychiatry Consultation Liaison Nurse.
programs. Psychiatric Services. Nov;47(11):1223-6. International Journal Of Geriatric Psychiatry 13: 159-
163.
Bhugra D, Harding C, Lippett R (2004) Pathways into
care and satisfaction with primary care for black Commander MJ, Odell SM, Surtees PG, Sashidharan
patients in South London. Journal of Mental Health. SP (2004) Care pathways for south Asian and white
Vol 13(2) Apr 171-183 people with depressive and anxiety disorders in the
community. Social Psychiatry and Psychiatric
Bhui K, Stansfield, S, Hull S, Priebe S et al (2003) Epidemiology. Apr;39(4):259-64.
Ethnic variations in pathways to and use of specialist
mental health services in UK: Systematic review. Commander M, Sashidharan S, Rana T and
British Journal of Psychiatry. Vol 182(2) Feb 2003, Ratnayake T (2005) North Birmingham assertive
105-116. outreach evaluation: Patient characteristics and
clinical outcomes. Social Psychiatry and Psychiatric
Birchwood M, Todd P, Jackson C (1998) Early Epidemiology. 40(12) 988 - 993
intervention in psychosis: The critical period
hypothesis. British Journal of Psychiatry. Vol Craig T, Garety P, Power P, Rahaman N et al (2004)
172(Suppl 33) Jun 53-59. The Lambeth Early Onset (LEO) Team: randomized
controlled trial of the effectiveness of specialist care
Bradley S, Kramer T, Garralda M, Bower P et al for early psychosis. BMJ 329;1067-1072
(2003). Child and adolescent mental health interface
work with primary services: A survey of NHS provider CSIP (with the Mental Health Foundation) (2005)
trusts. Child & Adolescent Mental health Vol 8(4) Redesigning mental health day services: A
170-176 modernisation toolkit for London. London: DH.

Brett W & Schofield J (2002) Integrated care CSIP/NIMHE (2005) The Ten High Impact Changes
pathways for patients with complex needs. Nursing for Service Improvement and Delivery: Making them
Standard; Jul 31-Aug 6, 16, 46; 36-40 relevant for mental health – A Discussion Document.
CSIP/NIMHE (unpublished discussion paper)
Browning R & Hollingberry T (2000) Mental health: for
Good measure. Health Serv J. Oct 5;110(5725):34-5 DH Workforce Directorate (2005). A national
framework to support local workforce strategy
Burns B J & Santos A B (1995) Assertive community development: A guide for HR directors in the NHS
treatment: an update of randomized trials. Psychiatric and social care. London: DH (Available from
Services Jul; 46(7): 669-75 www.dh.gov.uk)

Burns T, Knapp M, Catty J et al (2001) Home Department of Health (2006). Our health, our care,
treatment for mental health problems: a systematic our say: a new direction for community services.
review. Health Technology Assessment Vol. 5: No. 15 London: DH. (Available from www.dh.gov.uk)

Carr, A. (1999). Handbook of child and adolescent Department of Health (2001). National service
clinical psychology: A contextual approach. London: framework for older people. London: DH (Available
Routledge. (cited by Woodhouse 2005) from www.dh.gov.uk)

Challis D, Clarkson P, Williamson J, Hughes J et al Draper (2000) The Effectiveness of Old Age
(2004) The value of specialist clinical assessment of Psychiatry services International Journal of Geriatric
older people prior to entry to care homes. Age and Psychiatry Aug;15(8):687-703.
Ageing 33: 25–34
Fernando S (2005) Multicultural mental health
services: projects for minority ethnic communities in
England. 42 (3) 420-436.

54
Ford R, Durcan G, Warner L, Hardy P and Muijen M Johnstone, E.C., Crow, T.J., Johnstone, A.L. and
(1998) One day survey by the Mental Health Act Macmillan, J.F. (1986) The Northwick Park Study of
Commission of acute adult psychiatric inpatient first episode, schizophrenia: I. Presentation of the
wards in England and Wales British Medical Journal. illness and problems relating to admission. British J
317;1279-1283 of Psychiatry; 148: 115 - 120.

Ford R, Minghella E, Chalmers C, Hoult J et al (2001) Johnson S, Nolan F, Pilling S, Sandor A, Hoult J,
Cost consequences of home-based and in-patient- McKenzie N, White IR, Thompson M, Bebbington P
based acute psychiatric treatment: Results of an (2005) Randomised controlled trial of acute mental
implementation study. Journal of Mental Health. 10(4) health care by a crisis resolution team: the north
Aug 2001, 467-476 Islington crisis study. BMJ. Sep 17;331(7517):599.

Freeman G, Weaver T, Low J et al (2002) Promoting Jones A (2000) Implementation of hospital care
Continuity of Care for People with Severe Mental pathways for patients with Schizophrenia. Journal of
Illness whose needs span primary, secondary and Nursing Management, Jul; 8(4): 215-25
social care: A multi-method investigation of relevant
mechanisms and contexts. NCCSDO Jones A (2001) Hospital care pathways for patients
with schizophrenia. J Clin Nurs. Jan;10(1):58-69
Gallucci G, Swartz W, Hackerman F (2005) Impact of
the wait for an initial appointment on the rate of kept Kalthenthaler E, Shackley P, Stevens K, Beverley C et
appointments at a mental health center. Psychiatric al (2002) A systematic review and economic
Services. Mar;56(3):344-6. evaluation of computerised cognitive behaviour
therapy for depression and anxiety Health
Glover G Arts G & Babu K (in press) Crisis Technology Asessment.;6(22):1-89.
resolution/home treatment teams and psychiatric
admission rates in England. Kaplan A & the SAFE team (2002). From a Short-Life
Project to a Mainstream Service: Convincing
Hamilton R, Gordon P and Naji S (2002) Service Commissioners to Fund a Community Adolescent
innovation: the first year of a brief psychiatric Mental Health Team. Child & Adolescent Mental
screening clinic in primary care. Psychiatric Bulletin Health Vol7, No. 3, 114–120
26 218-221
Kerfoot M, Panayiotopoulos C & Harrington R (2004)
Heslop, P (2001) Direct Payments for people with Social Services and CAMHS: A National Survey Child
mental health support needs. The Advocate, 8-9 and Adolescent Mental Health Vol 9, No. 4, 162–167

Heywood S, Stancombe J, Street E et al (2003) A Latimer E A (1999) Economic impacts of assertive

Brief Consultation and Advisory Approach for use in community treatment: a review of the literature. Can
Child and Adolescent Mental Health Services: A Pilot J Psychiatry. Jun;44(5):443-54.
Study. Clinical Child Psychology and Psychiatry, Vol.
8, No. 4, 503-512 Lawton-Smith S (2004) Out for the count. Health
Service Journal. p29. 15 July
Ho B-C, Alicata D,Ward J, Moser DJ, O’Leary DS,
Arndt S, Andreasen NC (2003) Untreated initial Lester H, Tritter JQ, Sorohan H (2004) Managing
psychosis: Relation to cognitive deficits and brain crisis: the role of primary care for people with serious
morphology in first-episode schizophrenia. American mental illness. 36(1):28-34
Journal of Psychiatry 160:142–148
Lovell K & Richards D (2000). Multiple Access Points
Holland AC (1996). The mental health of single and Levels of Entry (MAPLE): ensuring choice,
homeless people in Northampton hostels. accessibility and equity for CBT services. Behav
110(5):299-303 Cognit Psychother 28: 379-391.

ISIP (2005). Delivering quality and value: the ISIP Marshall M, Lockwood A The Cochrane Database of
guide to strategy and benefits. Systematic Reviews 2006 Issue 2 Copyright © 2006
The Cochrane Collaboration. Published by John
Jacob K, Bhugra D & Mann AG (2002) A randomised Wiley & Sons, Ltd.
controlled trial of an educational intervention for
depression among Asian women in primary care in Marshall M, Lockwood A (2004) Assertive community
the United Kingdom. International Journal of Social treatment for people with severe mental disorders
Psychiatry; 48(2); 139-48 (Cochrane Review). In: The Cochrane Library, Issue
3, 2004. Chichester, UK: John Wiley & Sons, Ltd.

55
Marshall M, Crowther R, Almaraz-Serrano AM, Tyrer Reda S and Makhoul S (2001) Prompts to encourage
P (2001). Day hospital versus out-patient care for appointment attendance for people with serious
psychiatric disorders. The Cochrane Database of mental illness. Cochrane Database Systematic
Systematic Reviews: Reviews. Issue 2 John Wiley & Reviews. (2) CD002085
Sons, Ltd Chichester, UK DOI:
10.1002/14651858.CD003240 Rees G, Huby G, McDade L & McKechnie L (2004)
Joint working in community mental health teams:
McGovern D, Hemmings P, Cope R. Long-term implementation of an integrated care pathway. Health
follow-up of young Afro-Caribbean Britons and White and Social Care in the Community 12 (6), 527–536
Britons with a first admission diagnosis of
schizophrenia. Social Psychiatry and Psychiatric Sathyamoorthy G, Minghella E, Ford R et al (2001)
Epidemiology 1994; 29: 8-19 Cultural Sensitivity Audit Tool for Mental Health Services.
London: Sainsbury Centre for Mental Health.
McGrew J H, Bond G R, Dietzen L, Salyers M (1994)
Measuring the fidelity of implementation of a mental Schneider, J (2005). Getting back to work: what do
health program model. J Consult Clin Psychol. we know about what works? In Grove, B., Secker, J.
Aug;62(4):670-8. and Seebohm, P (Eds.) New Thinking about Mental
Health and Employment. Radcliffe Publishing Limited,
McKenzie K (2002) A cultural sensitivity audit tool Oxford. Pp. 37-49.
(review).
Whitworth D and Ball C (2004) The Impact of Primary
Meaden A, Nithsdale V, Rose C. Smith J &Jones C Mental Health Workers on Referrals to CAMHS. Child
(2004) Is engagement associated with outcome in and Adolescent Mental Health.9, No. 4, 177–179
assertive outreach? Journal of Mental Health 2004
13(4): 415-24 Wiersma D, Nienhuis FJ, Slooff CJ and Giel R.
Natural course of schizophrenic disorders: A 15 year
Mezey G, Hassell Y & Bartlett A (2005) Safety of follow-up of a dutch incidence cohort. Schizophrenia
women in mixed-sex and single-sex medium secure Bulletin 1998; 24:75-85
units: staff and patient perceptions British Journal of
Psychiatry Dec;187:579-82 Woodhouse A E (2005) Reducing Waiting Times:
Using an Opt-In System and Changing Prioritisation
Moore C & Wolf J (1999) Open and shut case. Criteria, Child and Adolescent Mental Health
Health Service Journal. Jun 24;109(5660):20-2
Wright J H, Wright A S, Albano A; Basco M R et al
Morrison AP, French P, Walford L, et al. Cognitive (2005) Computer-Assisted Cognitive Therapy for
therapy for the prevention of psychosis in people at Depression: Maintaining Efficacy whilst reducing
ultra-high risk: randomized controlled trial. Br J therapist time. American Journal of Psychiatry; 2005;
Psychiatr 2004;185: 291-7. 162, 6. 1158 -1665

Mortensen PB Suicide among schizophrenic Yung AR, Organ BA, Harris MG (2003) Management
patients: Occurrence and risk factors Clinical of early psychosis in a generic adult mental health
Neuropharmacology 18: S1-S8 Suppl. 3 1995 service Australian and New Zealand Journal of
Psychiatry, Aug; 37(4): 429-36
National Institute for Clinical Excellence (2001)
Technology Appraisal Guidance - No.19. Guidance Zegleman, F E. (1988). Psychiatric clinics in different
on the Use of Donepezil, Rivastigmine and settings default rates. Health Bulletin, 46, 286–290
Galantamine for the Treatment of Alzheimer's cited by Lovell & Richards (2000)
Disease. London: NICE.

NHS Modernisation Agency (2004). 10 High Impact

Changes for service improvement and delivery: a
guide for NHS leaders. London: DH (Available from
www.dh.gov.uk)

NHS Modernisation Agency (2005). Improvement

Leaders’ Guides. London: DH (Available from
www.modern.nhs.uk)

Parkin A, Frake C & Davison I (2003) A Triage Clinic in

a Child and Adolescent Mental Health Service. Child
and Adolescent Mental Health. Volume 8 Issue 4 177

56