CANCELLED BY SWSG16/96

7 February 1992

Dear Colleague

COMMUNITY CARE: GUIDANCE ON CARE PROGRAMMES FOR PEOPLE WITH A MENTAL ILLNESS INCLUDING DEMENTIA

1. Summary

1.1 This circular provides guidance on the introduction of the care programme approach for people with mental illness including dementia.

2. Background

2.1 The Government’s intention regarding the care programme approach in Scotland was announced in paragraph 10.26 of the White Paper "Caring for People" (Cm 849). The arrangements themselves are described in Annex A to this circular.

2.2 Although "Caring for People" referred specifically to people with long-term illnesses due to be discharged from hospitals for the mentally ill, the arrangements in this circular are also designed to apply to people with long term mental illness who may or may not attend specialist psychiatric services but who are found, following a broad inter-agency assessment, to require structured arrangements for health and social care in the community and to avoid or significantly reduce, the prospect of early hospital admission.

2.3 The guidance in this circular is aimed specifically at the planning of individual packages of care for people with long term mental illness.

2.4 The main purpose of care programme is to ensure that an individual with a mental illness receives the most appropriate package of service to meet his or her needs. As indicated in paragraph 10.27 of the White Paper, it is important to ensure that in the case of hospital patients no discharge takes place until the Health Board have formally notified the local authority of their intentions and the local authority have had an opportunity to arrange for the needs of the individual for social work support to be assessed. However, the introduction of care programmes is only one aspect of the development of wider care management systems described in Circular SW11/1991: HHD/DGM(1991)40 (Community Care in Scotland Assessment and Care Management) which was issued on 17 June 1991. The arrangements will require Health Boards and local authorities jointly to satisfy themselves that the combined availability of the relevant community based health services and social work services will allow the individual concerned to live satisfactorily in the community and that effective arrangements are made as to how these needs are met; and that the arrangements are monitored and reviewed to take account of any change in circumstances.

2.5 Health Boards have a general statutory responsibility to provide for the health care of the people in their areas whilst local authorities, for their part, have a duty under Part III of the Mental Health (Scotland) Act 1984 to provide after-care services to person who are or have been suffering from mental disorder. In addition, both groups of agencies are required in terms of the National Health Service (Scotland) Act 1978 to co-operate with one another to secure and advance the health of the people of Scotland.

2.6 Steady progress has been made over recent years in the development of a wide range of specialist, high quality psychiatric services. Those include a widening provision of out-patient facilities (some in health centres) day hospitals, assessment units in general hospitals, the development of liaison psychiatry for patients in general hospitals, well established hospital based social workers as well as community based mental health officers and a steady build up of community psychiatric nursing services designed to offer treatment and support to patients and their informal carers.

2.7 Consideration of the care programme approach may be equally appropriate in the case of people with long term mental illness currently receiving services in any of these settings as well as for patients for whom discharge from long-stay care is being planned. For people with a long term mental illness who would otherwise have been hospital in-patients, community based health and social care should be planned so as to ensure a satisfactory quality of life as far as possible. It will not be acceptable for community care arrangements to be offered which entail a lower standard of care and support than the person needs and would receive in hospital and which does nothing to enhance the person’s quality of life.

3. Care Programme Approach

3.1 Accordingly, the arrangements will require local authorities and Health Boards to give particular attention to the establishment of the care programme approach when developing their community care plans for people with mental illness and dementia. The arrangements are to be implemented within the overall framework of, and responsibilities for, community care planning including planning agreements. Local objectives for each care group, the timescale for achieving them and resource commitments will have been considered and decided upon in the process of establishing and reviewing planning agreements. These agreements will be crucial in making good any deficiencies in local community care services within a reasonable timescale. Local authorities are asked to give the necessary priority, within the existing resources available to them and by drawing on the resources of private and voluntary sector providers, to the development of community care arrangements which can form a realistic and effective basis for care programmes. Arrangements should ensure that it is possible to deal in a simple efficient way with individuals who may neither wish for nor need a fully developed care programme.

3.2 Scottish Guidance circular (SWSG11/91: HHD(DGM)1991/40) provides guidance on assessment and care management in relation to "any persons who appear to require community care services". The principles which should apply in respect of mentally ill people who may be discharged from hospital into the community are set out in paragraph 15 of that circular. Paragraphs 1.4 and 12.2 of the circular also emphasise that local authorities

have the "lead role in setting up arrangements (for assessment and care management) ... and for securing the involvement of other agencies in the assessment procedure in order to decide what should be done, by whom and by when".

Individual Care Programmes

3.3 The majority of people with a severe form of mental illness including dementia, for whom community care programmes will require to be developed will come to the attention of services as a result of an initial contact with health services, whether it be through their General Practitioner, out-patient contact with the specialist psychiatric services or following a period of in-patient treatment in a psychiatric hospital. Many will be on psychotropic medication, and the majority will require supervision by skilled psychiatric professionals trained to monitor changes in mental state.

3.4 Therefore for most cases the responsibility for triggering action to develop a care programme will rest with Health Boards. However, where an individual’s need for a care programme first comes to the attention of a social work department it will be for that Department to initiate appropriate action. Once community care assessments begin to be carried out in accordance with section 55 of the National Health Service and Community Care Act 1990, the care programme and assessment arrangements will require to be co-ordinated. The Government intend to implement section 55 by 1 April 1993. General guidance on such assessments is provided in the circular issued jointly by the Social Work Services Group and the NHS Management Executive on 17 June 1991 (SWSG11/91: HHD/DGM(1991)40). Whilst the lead role will be taken by local authorities all community care assessments involving health problems must be carried out in close association with relevant health professionals. While health professionals have the ultimate responsibility for the assessment and provision of community health services, these should be planned and, provided in co-operation with social workers, other local authority professions and the independent sector when there is a need for a combination of social and health care services. Much good work is already underway in terms of the care programme approach and many Health Boards and local authorities have already developed the concept of multi-agency teams providing comprehensive community based mental health services. The aim should be to build upon these areas of collaborative working.

4. Proposed Action

4.1 By 1 June 1992 Health Boards must have drawn up, in consultation and agreement with local authority social work departments, local care programme policies to apply to all in-patients with long-term mental illnesses considered for discharge and all people seen by the specialist psychiatric services after that date who are found to require structured arrangements for health and social care as described in paragraph 1.2 above. Health Boards must also ensure that these policies are implemented by all health care providers from whom they purchase long-term illnesses, ie those already in the community but not in touch with the specialist psychiatric services, should be developed in line with good practice. This should have regard to what is said in paragraph 2.1 above about resources and about he need to ensure simple and efficient arrangements for those people who may not need or want a care programme as such.

4.2 By 30 June 1992 Health Boards must confirm to the NHS Management Executive Unit that they are operating their arrangements for implementing the care programme approach.

5. State Hospital

5.1 Additionally with regard to the State Hospital, it is proposed that the Management Committee will wish to ensure that each patient’s care plan enables any transfer to NHS or local authority social work facilities required by particular patients to be identified and arranged in good time. References to Health Boards in Annex A should be construed as references also to the State Hospital where the context requires.

6. Resources

Given the statutory position described in paragraph 1.5 above, the introduction of the care programme approach places no new duties on Health Board’s or local authorities but rather provides formal guidance on how the duty of after care should be considered and discharged in particular cases. Local authorities will want to consider the provision of community care facilities for the mentally ill within the resources available to them but will want to take account of the fact that a specific grant is available to accelerate the provision of facilities for the mentally ill in the community. Guidance on the grant is contacted in Circular SW10/1990. Account was taken of the full cost of the specific grant in arriving at the local government finance settlement. Bridging Finance is also available to Health Boards to help meet the double running costs involved in building up community facilities while hospital facilities are being slimmed down. In such circumstances Health Boards may wish to transfer resources to Local Authorities to enable community facilities to be built up. Guidance on cash transfers is being drafted and will be issued for consultation.

7. Related Guidance

7.1 This circular and the attached guidance builds on but does not affect the terms of SWSG Circular 10/1988 of 1 June 1988 to Directors of Social Work and which was copied to General Managers of Health Boards and dealt with management issues affecting the discharge of patients from psychiatric hospitals. This referred to the need to ensure that there are comprehensive and fully agreed arrangements for hospital discharges based on fully effective contacts between health professionals and social work staff well before the proposed time of discharge as well as at or around the actual discharge date.

7.2 Any enquiries about health aspects of this circular should be addressed to Mr G Russell, Scottish Office Home and Health Department, Room 29B2 St Andrew’s House EH1

3DE (telephone 0131 244 2576) and in relation to social work matters, to Mr F Stewart, Social Work Services Group, Room 52, James Craig Walk, Edinburgh, EH1 3BA

(telephone 0131 244 5460).

Yours sincerely

KEITH McINTOSH GAVIN ANDERSON

Health and Policy and Social Work Services Group

Public Health Directorate

ANNEX A

GUIDANCE ON THE CARE PROGRAMME APPROACH

1. Introduction

1.1 This Annex sets out how the care programme approach works and gives guidance on some key issues to be addressed in implementation.

1.2 The care programme approach is being developed to seek to ensure that in future people with mental illness who are living in the community, whether or not following discharge from hospital, receive the health and social care they need, by:

1.2.1 introducing more systematic arrangements for deciding whether a person referred to the specialist psychiatric services can, in the light of available resources, and the views of the person and, where appropriate, his/her carers, be cared for in the community.

1.2.2 ensuring suitable arrangements are made, and continue to be made, for the continuing health and social care of those people who can be treated in the community.

1.3 As a general principle, the care programme approach should not be applied to people who are able to make satisfactory arrangements of their own or who make it clear that they do not want one.

2. How the care programme approach works

2.1 Health Boards and social work departments must ensure that a system for establishing individual care programmes for people with a long term mental illness is agreed for their area. This should be fully consistent with local arrangements for community care assessment and care management. Therefore, all care programmes should commence with a carefully arranged assessment process designed to secure an appropriate contribution from all agencies likely to be involved in providing, or arranging the provision of, services. In particular they should involve the following key elements:

2.1.1 systematic arrangements for consultant psychiatrists to assess the mental care needs of patients considered remedy for discharge, and for regularly reviewing the health care needs of those being treated in the community;

2.1.2 similar arrangements for social workers to assess and regularly review what social care people need to give them the opportunity of benefiting from being cared for in the community;

2.1.3 systems for ensuring that agreed health and, where necessary, social care services are provided on a continuing basis to those people who can be cared for in the community.

2.2 Housing is also a vital element in the care programme approach. Many people who have been receiving treatment for mental illness will look to their local housing authority, a housing association or voluntary organisation for accommodation following discharge. It is therefore important that housing providers should be involved at an early stage in community care planning and at the client level in the preparation of an individual’s care programme. The individual, or perhaps a relative or carer acting on his or her own behalf may wish to make arrangements direct with a housing provider and in these circumstances should be encouraged to make an early approach to potential landlords: hospital staff and social workers should stand ready to advise in appropriate cases. Potential landlords should be advised, so far as confidentiality will allow, of the person’s ability to sustain a tenancy and should also be given details of the care manager (see paragraph 7.1 below) so that early notification of any housing-related or other problem can be given.

2.3 In addition to the key elements referred to in paragraph 2.1 above which should be included in all care programmes, the provision of daytime activities for such people discharged from hospital which would contribute towards such people leading ordinary lives, will be often be an important requirement as well. Daytime activities such as attendance at further or community education facilities or helping other people in a voluntary capacity can make a useful contribution to rehabilitation and can facilitate social reintegration to the wider community; for some people with mental illness, these can lead to better prospects of obtaining sheltered or open employment. Education authorities may be able to offer learning programmes or make suggestions which meet individual needs and integrate with other elements of the care plan. Assistance to local authorities for developing day time and other community based services is available through the Mental Illness Specific Grant.

3. Implementation

3.1 It will be for relevant health and social staff to decide whether the resources available to them can enable acceptable local arrangements to be made for supporting individual people in the community. If it is not possible for the time being to meet a person’s needs for treatment in the community - both in terms of continuing health care and any necessary social care - in-patient treatment should be offered or continued although (except for people formally detained under the Mental Health (Scotland) Act 1984) it is for individual patients to decide whether to accept treatment as an in-patient. Health Boards will need to ensure that any reduction in the level of in-patient facilities does not outpace the development of alternative community services. Furthermore, improvements in hospital care must continue and standards must not be allowed to deteriorate to enable the development of community care.

3.2 There are, however, some specific issues which health care providers, and social work departments will need to address in determining their local arrangements. These relate to:-

inter-professional working

involving service users and their carers

keeping in touch with users and ensuring agreed services are provided

information systems.

4. Inter-professional working

4.1 It is important to recognise that good practice calls for effective inter-professional collaboration between psychiatrist, nurses, psychologists, social workers and general practitioners and other members of the primary care team. There will require to be proper consultation with patients and their carers. In some cases it will also be necessary to make reference to housing, education or employment services at an early stage in the rehabilitation process.

4.2 Where it is clear that continuing health and/or social care is necessary for a person for whom they propose to provide services in the community, there must be proper arrangements for determining whether the services assessed as necessary can be provided within available resources. The explicit agreement of all those expected to contribute to a person’s care programme (including carers, see paragraphs 6.1 and 6.2 below) that they are able to make the expected contribution is essential.

5. Involving service users

5.1 It is important that proper opportunities are provided for the person concerned to take part in discussions about the proposed care programmes, so that he or she has the chance to make a positive contribution to discussion of different possibilities and agree the programme to be implemented.

6. Involving carers

6.1 Relatives and other carers may be expected to know a great deal about the person’s earlier life, previous interests, abilities and social contacts and may well have personal experience of the course of his or her illness spanning many years. They make a major and valued contribution to the support received by many people with a mental illness in the community. Wherever this is consistent with the person’s wishes, professional staff should seek to involve carers in the planning and subsequent oversight of the patient’s community care and treatment.

6.2 Where a care programme depends on such a contribution, it should be agreed in advance with the carer who should be properly advised both about such aspects of the person’s condition as is necessary for the support to be given, and how to secure professional advice and support, both in emergencies and on a day-to-day basis. Respite care and other forms of support may also be necessary in order to avoid placing an excessive burden on informal carers.

7. Keeping in touch with users and making sure the services agreed as part of the care programme are provided

7.1 Once an assessment has been made of the continuing health and social care needs to be met if a person is to receive the services he or she requires in the community, it should be confirmed that all the professional staff expected to contribute to its implementation are agreed that it is realistic for them to make the required contributions. Thereafter it is necessary to have effective arrangements for the monitoring and review of the agreed services, for keeping in contact with the person and drawing attention to changes in his or her condition. The most effective means of undertaking this work will be through designating individuals to carry the care management responsibilities as outlined above. In establishing new arrangements Health Board and local authority staff will want to have regard to the practice guidance on care management and assessment recently published by Scottish Office SWSG and the Department of Health Social Services Inspectorate, and addressed to managers and practitioners.

7.2 A person designated to carry out care management may be a member of any of the professional disciplines mentioned in paragraph 4.1 but should be sufficiently experienced to command the confidence of colleagues from other disciplines so as to bring together the necessary skills to meet the needs for service agreed following assessment. Arrangements should also be made for an alternative point of contact for the person and any carer(s).

7.3 Sometimes mentally ill people will decline to co-operate with the agreed care programmes, for example by missing out-patient appointments. Informal patients are free to discharge themselves from patient status at any time, and sometimes with limited understanding of the likely consequences.

7.4 It is very important that every reasonable effort is made to maintain contact with the person and, where appropriate, carers, to find out what is happening, to seek to sustain the therapeutic relationship and, if this is not possible, to try to ensure that the person knows how to make contact with his or her care manager or the other professional staff involved. It is particularly important that the person’s general practitioner is kept fully informed of his or her developing situation and especially of any withdrawal (partial or complete) from a care programme. The general practitioner will continue to have responsibility for the person’s general medical care if he or she withdraws from the care programme. Often people only wish to withdraw from part of the care programme and the programme should be sufficiently flexible to accept such a partial withdrawal. It is also important that, within proper limits of confidentiality, health care professionals provide sufficient information to staff in social work teams, (including those from the voluntary and private sectors) about the situation to enable them to fulfil completely their responsibility for care of the person. Similarly, relatives and carers should also be kept properly informed.

8. Information Systems

8.1 Professional staff involved may decide that a suitable information system is required, such as a register of people for whom a care programme had been agreed as a means of keeping in touch and prompting action. System using a micro-computer are available and some relevant information about them is available from Research and Development for Psychiatry, 134 Borough High Street, London SE1 1LB, Tel: 071-403-8790. When establishing such a system, those concerned have a duty to consider how to ensure the proper confidentiality of information about individual patients. Good quality person-centred records are essential for the planning, monitoring and evaluation of individual care programmes in accordance with the Data Protection Act 1984 and associated Scottish Office guidance on confidentiality of person records.