Community Mental Health Teams

An Introduction

When the Mental Health Implementation Guide was launched in March 2001, it declared:

“Community Mental Health Teams , in some places known as Primary Care Liaison Teams, will continue to be the mainstay of the system. CMHTs have an important, indeed integral role to play in supporting service users and families in community settings. They should provide the core round which newer service elements are developed.”

Sections of the Guide issued at that time included model service specifications for these newer service elements - early intervention, crisis resolution/home treatment and assertive outreach teams.

Many colleagues involved in implementing service change in mental health have asked for similar guidance on CMHTs as they evolve within a whole system which includes functionalised teams. This document aims to respond to those requests.

We know that the level of development of CMHTs varies markedly around the country, as does the level of development of the newer functional teams. The emphasis in this document is on identifying the functions which a CMHT in such a whole system will need to perform rather than on specifying the precise structure: local flexibility and close working relationships between all key stakeholders will enable the best arrangements to be developed in each locality.

Who is the Service For? [61]

Adults of working age with the full range of mental health problems: age limits to be determined in line with locally agreed protocols for transitions from adolescent to adult and adult to older adult services.

The CMHT performs functions for two groups of people:

• Most patients treated by the CMHT will have time limited disorders and be referred back to their GPs after a period of weeks or months (an average of 5-6 contacts (Burns et al 1993)) when their condition has improved.
• A substantial minority, however, will remain with the team for ongoing treatment, care and monitoring for periods of several years. They will include people needing ongoing specialist care for:
• Severe and persistent mental disorders associated with significant disability, predominantly psychoses such as schizophrenia and bipolar disorder.
• Longer term disorders of lesser severity but which are characterised by poor treatment adherence requiring proactive follow up.
• Any disorder where there is significant risk of self harm or harm to others (e.g. acute depression) or where the level of support required exceeds that which a primary care team could offer (e.g. chronic anorexia nervosa).
• Disorders requiring skilled or intensive treatments (e.g. CBT, vocational rehabilitation, medication maintenance requiring blood tests) not available in primary care.
• Complex problems of management and engagement such as presented by patients requiring interventions under the Mental Health Act (1983), except where these have been accepted by an assertive outreach team.
• Severe disorders of personality where these can be shown to benefit by continued contact and support except where these have been accepted by an assertive outreach team or a specialised personality disorder team where there is one.

What is the Service Intended to Achieve?

Most mental health problems are dealt with within Primary Care (Goldberg & Huxley 1992) with less than a fifth of those identified as having such a problem referred on for secondary opinions and treatment.

Three distinct functions are required:

• Giving advice on the management of mental health problems by other professionals - in particular advice to primary care and a triage function enabling appropriate referral.
• Providing treatment and care for those with time-limited disorders who can benefit from specialist interventions.
• Providing treatment and care for those with more complex and enduring needs.

In some areas, these functions are provided by separate teams (e.g. a Primary Care Liaison Team providing (i) and (ii) , and a Rehabilitation and Recovery team providing (iii)). In other areas, the CMHT performs all three functions, sometimes by designating sub-teams within the CMHT. The best structure is a matter for local discretion, but clear pathways to care should be described by locally agreed protocols.

Whatever structure is adopted, using an integrated multidisciplinary approach, with adequate outreach, the “CMHT function” can:

Increase capacity within primary care through collaboration.

• Reduce the stigma associated with mental health care.
• Ensure that care is delivered in the least restrictive and disruptive manner possible.
• Stabilise social functioning and protect community tenure

The CMHT Should Be Able To:

Provide support and advice to primary care services to support them in:

• Provide support and advice to primary care services to support them in:
• Providing joint educational facilities for all members of the primary health care team.
• Ensuring that regular clinical meetings occur between the PHCT and the CMHT to discuss and share the management of patients.
• Ensuring that there are shared clinical governance topics between the Practice Development Plan of the PHCT and the clinical governance framework of the CMHT.
• Establishing effective liaison with local Primary Care Team members and other referring agents to shape referrals and support local care.
• Providing prompt and expert assessment of mental health problems
• providing effective, evidence based treatments to reduce and shorten distress and suffering.
• Ensuring that inappropriate or unnecessary treatments are avoided.
• Establish a detailed understanding of all local resources relevant to support of individuals with mental health problems and promote effective interagency working.
• assisting patients and carers in accessing such support, both to reduce distress but also to maximize personal development and fulfilment.
• providing advice and support to service users, families and carers.
• gaining a detailed understanding of the local population, its mental health needs and priorities, and provide a service that is sensitive to this and religious and gender needs.
• provide a culturally competent service, including ready access to interpreter services for minority languages and British Sign Language.

Liaison and Links with Other Teams (Crisis Resolution/Home Treatment, Assertive Outreach, Early Intervention Teams)

CMHTs will increasingly have close working relationships with a range of specialised community mental health teams. A number of these are described in this policy implementation guide. It is not possible to give prescriptive guidance on these relationships.

However, mutually agreed and documented responsibilities, liaison procedures and in particular transfer procedures need to be in place when crisis resolutions/home treatment teams, assertive outreach teams and early intervention teams are being established. These arrangements will need to be subject to regular review and revision. Currently in many services the CMHT is the common gateway to these teams (other than the early intervention team where access may be direct.).

Close working with drug and alcohol services will be needed for users with a dual diagnosis, though people with a severe mental illness and co-morbid substance misuse should receive care from mainstream services. Reference should be made to the new section of the Mental Health Policy Implementation Guide concerning good practice in dual diagnosis. (DH 2002).

Hours of Operation

Working hours are generally from 9 - 5 week days with flexible out of hours working for specific tasks (e.g. evening work for a relative support group). Some teams work with moderately extended hours e.g. 8a.m. -7p.m. , embracing G.P. surgery times, and this is to be strongly recommended for improved primary care liaison.

No crisis provision is made out of hours by the CMHT and patients and carers would access the local emergency services (crisis resolution teams, help lines, A&E etc).

Referrals

CMHTs are secondary services and accept referrals for assessment from GPs, primary care team members, social services and all other components of the mental health services (e.g. CAMHS, Forensic services, psychology, other specialised mental health teams ).

Links should be established with local police and voluntary agencies so that exceptional direct referrals can be facilitated

Risk Assessment and Policy on Violence

CMHTs should have a written policy outlining procedures for managing different levels of risk (e.g. joint visiting).

The operational policy should explicitly address issues of staff safety including a statement of zero tolerance for racial or physical abuse. This should ensure adequate assessment to ensure that treatment is not withdrawn inappropriately e.g. when abusive behaviour is a manifestation of psychotic illness

Staff Training

CMHTs must see that their training needs are given appropriate priority within the joint training plan. Induction periods are needed for new staff (even if they have come from another CMHT) and should include a primary care placement.

Users and carers should be involved in the delivery of staff training, which should include:

• Skills in delivering the interventions listed above.
• Team building, team working and peer support.
• Principles of the service including gender and anti-racist training.
• Medication management - including local policies on administration, storage, legal issues, concordance training and assessment of side effects.
• Use of the Mental Health Act and alternatives to hospitalisation.
• Engaging and interacting with other services - both within the mental health trust (or PCT where it provides the service) and with other agencies such as primary care, or the police and probation services.
• Suicide awareness and prevention techniques and approaches.

Information for People Who Use the Services

All patients and their family and carers should be provided with information on the services both in printed form and also as part of individualised engagement. This should include:

• Description of the service, the range of interventions provided and what to expect.
• Name and contact number and details of the care co-ordinator and other relevant members of the team.
• Contact details for out of hours advice and help.
• Care plan.
• Specific information about their disorder and any drug being used, including side-effects.
• Relapse plan and crisis plan.
• Contingency plans.
• Information on how to express their views on the service and make complaints.
• Information about patient/user forums and PALS.

Continual Service Improvement

Regular audit of the service should be undertaken to ensure that gaps in service provision are filled and that targets are met and incrementally improved. Audit should often involve feedback from service users and carers.