DD 38/96

Replaces: SWSG1/1992, Index Ref: F13

General Managers of Health Boards
Directors of Social Work/Chief Social Work Officers of Unitary Councils
Directors of Housing/ Chief Housing Officers of Unitary Councils

Copy to :
Chief Executives: Unitary Councils
Chief Executives, NHS Trusts
Chief Executive, Scottish Homes
General Manager, Common Services Agency
General Manager, The State Hospitals Board for Scotland
Appropriate Professional and Voluntary Bodies
The Association of Chief Police Officers in Scotland
Holders of SWSG Guidance Package

October 1996

Dear Colleague

COMMUNITY CARE: CARE PROGRAMME APPROACH FOR PEOPLE WITH SEVERE AND ENDURING MENTAL ILLNESS INCLUDING DEMENTIA

Summary

1. This Circular provides revised guidance on the joint arrangements for implementing the Care Programme Approach (CPA). An introduction and background to the CPA is set out in Annex 1 to this Circular. The arrangements for implementation are described in Annex 2.

Background

2. The aim of the CPA is to ensure that individuals with severe and enduring mental illness (including dementia) who also have complex health and social care needs, receive on-going care and supervision. This should incorporate appropriate packages of services and accommodation to meet their needs, which are fully co-ordinated by the agencies and professionals involved.

3. General Managers of Health Boards, Directors of Social Work/Chief Social Work Officers and Directors of Housing are requested to bring this Circular to the attention of all agencies and staff with responsibility for purchasing or providing mental health services, including housing associations and other relevant independent sector agencies and organisations.

Previous Guidance

4. This circular builds on and supersedes the guidance contained in Scottish Office Circular SOHHD DGM 1992/9: SWSG 1/1992, dated 7 February 1992, "Community Care: Guidance on Care Programmes for People with Mental Illness Including Dementia", which is hereby cancelled.

Action

5. Scottish Office Circular SOHHD DGM 1992/9: SWSG 1/1992 required health boards and local social work authorities to introduce a CPA for people with a mental illness, including dementia. That requirement remains. The revised guidance in this Circular seeks to ensure that the CPA is targeted at those people most in need; and that the implementation of the arrangements for CPA receive a high priority. Local authorities and health boards are now invited to review their arrangements and practices for implementing CPA to ensure that they accord with the revised guidance in this Circular. A detailed description of those people to whom the CPA should apply is contained in Annex 2 to this Circular.

6. Directors of Social Work/Chief Social work Officers, General Managers of Health Boards and Directors of Housing are required to provide evidence by 30 April 1997, in a joint response to Mr Gavin Anderson, Social Work Services Group, that:

• the social work authority and health board(s) have reached agreement about which agency will have overall responsibility for co-ordinating the joint arrangements for implementing the CPA, and the name of that agency;

• effective arrangements and systems are in-place in their areas for implementing and monitoring the CPA for people with mental illness and dementia;

• the arrangements are, or will be, incorporated within community care plans, mental health strategies and contractual arrangements with NHS Trusts and other providers, (including any implications for housing and housing management plans);

• the arrangements have been jointly agreed by health, social work and housing;

• the arrangements accord with the guidance described in Annex 2 to this Circular;

7. The NHS Management Executive will examine the progress Health Boards are making in implementing CPA policies and practices through its performance monitoring arrangements including, where appropriate, the annual accountability reviews.

8. The Scottish Office Social Work Services Inspectorate (SWSI) medical, nursing and housing colleagues, will undertake a joint survey of progress in implementing the CPA, if necessary. SWSI will also undertake an inspection of the social work components of the CPA.

9. The Scottish Office Development Department will examine strategic action by housing authorities in housing plans and housing management plans submitted to the Department.

Related Guidance and Reports of the Pilots

10. A full list of related guidance including reference to the reports of the pilots schemes, is set out in Annex 3 to this Circular.

Enquiries

11. Any enquiries about the terms of this circular should be addressed, in the first instance, to Mr Neil Rennick, Social Work Services Group, Room 48C, James Craig Walk, Edinburgh, EH1 1DG (Tel : 0131 244 5389).

GAVIN A ANDERSON KEVIN J WOODS DAVID HENDERSON

Social Work Services Group Director of Purchasing, Housing Group

NHS Management

GUIDANCE ON THE CARE PROGRAMME APPROACH FOR PEOPLE WITH SEVERE AND ENDURING MENTAL ILLNESS INCLUDING DEMENTIA

Paragraph Contents

Annex 1 THE CARE PROGRAMME APPROACH

1. INTRODUCTION AND BACKGROUND.

7. Progress with Implementing the CPA Since 1992.

11. Resources

14. Good Practice

Annex 2 THE ARRANGEMENTS FOR IMPLEMENTING A CARE PROGRAMME APPROACH

1-3. Aim, Objectives and Outcomes.

4. STRATEGIC CONTEXT.

7. LOCAL POLICY AGREEMENT.

9. LEAD AGENCY

10. CRITERIA FOR ADMISSION TO THE CPA.

15. CPA and People with Dementia

16. Client Consent.

17. MANAGEMENT ARRANGEMENTS.

19. CPA, Care Management and Hospital Discharge

20. Information Sharing and Confidentiality Issues.

22. Services.

23. Crisis and Emergency Arrangements.

24. Transfer.

25. Lost to Follow-up.

26. Discharge Arrangements.

27. Standards.

29. Monitoring, Evaluation and Review.

30. Awareness, Training and Support.

31. OPERATIONAL GUIDANCE.

33. Key Worker.

35. INDIVIDUAL CARE PROGRAMME.

CPA Assessment Flowchart

CPA Review Flowchart

Annex 3 LIST OF RELATED GUIDANCE AND REPORTS OF THE PILOTS

ANNEX 1

THE CARE PROGRAMME APPROACH

INTRODUCTION AND BACKGROUND

1. The Government first set out its intentions for a CPA in the 1989 White Paper "Caring for People" (Command 849 - Paragraph 10.26). This was followed in 1992 by Circular SOHHD DGM 1992/9: SWSG 1/1992, "Community Care: Guidance on Care Programmes for People with a Mental Illness Including Dementia", which set out the arrangements for implementing the CPA.

2. The CPA is a crucial element in the Government’s policy for people with mental illness and dementia. Its aim is to ensure that properly designed and managed individual packages of care are arranged for people with severe and enduring mental illness, including dementia, who require health and social care in appropriate accommodation in the community. Although "Caring for People" referred specifically to people with long-term illnesses due to be discharged from hospitals for the mentally ill, it was always envisaged that the CPA would equally apply to people already in the community who require structured programmes of health, and social care and accommodation. A more detailed definition of those people to whom the CPA should apply is given in Annex 2 to this Circular.

3. The White Paper made clear that, in the case of hospital patients, it was important to ensure that no discharge took place until the health board had formally notified in writing the social work authority of their intentions, and the social work authority had arranged for the needs of an individual for social care support and accommodation to be assessed. That requirement remains. The Government has consistently restated the view that no one should be discharged from hospital care until suitable alternative packages of health, social care and accommodation are available in the community and properly resourced.

4. Health boards have a general statutory responsibility to provide for the health care of the people in their areas whilst local social work authorities, for their part, have a duty under Section 8 of the Mental Health (Scotland) Act 1984 (the 1984 Act) to provide support and after-care services to persons who are or have been suffering from mental illness. Mental health is one of three priorities for the NHS in Scotland in 1996/97. Health Board, NHS trusts and local authorities 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. Guidance in NHS MEL (1996)22 clarifies the responsibilities of the NHS in continuing health care.

5. The Mental Health (Patients in the Community) Act 1995 introduced a new concept into the 1984 Act: formalised multi-disciplinary care in the community for people with a mental disorder. The purpose of the Community Care Order (CCO) is to ensure that a patient who has immediately previously been liable to be detained in hospital under the 1984 Act without special restrictions, receives appropriate medical treatment from the health service and social care from local authorities to which he or she is entitled under Section 8 of the 1984 Act. The provisions take account of the key principles of the CPA and the CCO guidance indicates that "it will be good practice for the care plans of all patients on leave of absence or subject to a CCO to comply with the requirements of the CPA".

6. There have been a number of important developments in the provision of mental health services across agencies. Changes in the balance of care have lead to a greater provision of residential facilities in the community and a reduction in large long stay NHS institutions. In-patient provision is increasingly being used to treat people with acute episodes of mental illness, for people with special needs or where individual or public safety considerations are important. Within the community, the development of Community Mental Health Teams (CMHTs) has helped to bring mental health professionals nearer to primary care and to people with mental health problems living in the community. Community Dementia Teams have a similar role with regard to people with dementia. The CPA is an important component of these changes.

Progress with Implementing the CPA Since 1992

7. Since 1992, The Scottish Office has conducted two monitoring exercises. The 1993 and 1994 reviews of progress both showed that the implementation of the CPA was not progressing as it should across Scotland.

8. The Scottish Office wrote to social work authorities, health boards and housing authorities in September 1994 and again in June 1995, to remind them of their duties in implementing the CPA and to ask them to address the deficiencies highlighted in the monitoring exercise. In addition, remedial action was proposed.

9. Pilot schemes were established in Glasgow and Stirling in Spring 1995. Managers and practitioners from social work, health and housing were invited to draw on, test and develop a model framework of good practice which provided the "Essential Elements" that should be contained within any CPA. The model addressed a number of key issues such as eligibility criteria, professional and administrative requirements, agency responsibility, content of individual care programmes and operational matters. The pilot schemes reported at the end of 1995. The outcomes confirmed that the model framework was generally robust and the "Essential Elements" within that framework have formed the basis of the revised guidance in Annex 2 to this Circular.

10. The Scottish Office is aware that further work has been undertaken locally within most areas in Scotland to develop CPA arrangements and guidance. Generally, however, this still falls short of full and effective implementation throughout board and local authority areas. Accordingly, this guidance now requires authorities and health boards to achieve progress towards implementation as set out in paragraph 6 of the covering Circular.

Resources

11. This Circular places no new responsibilities on health boards, social work or housing authorities but rather provides revised guidance on how existing responsibilities should be implemented. Social work authorities should consider the provision of community care facilities for people with severe mental illness within the resources available to them, including those made available under the National Health Service and Community Care Act 1990: Mental Illness Specific Revenue Grant (MISG), which is designed to accelerate the provision of facilities for people with mental health problems in the community. Successive guidance has emphasised the importance of relating services supported by MISG to the reprovisioning of social care services to replace psychiatric hospital care. That continues to be a priority. Guidance on the current MISG grant round for 1996 - 1997 is contained in Circular SWSG 19/95, "Mental Illness Specific Revenue Grant (MISG)", dated 21 November 1995.

12. Substantial NHS resources are also available to help with the provision of services and facilities for people with mental health problems. The NHS provides community health services at its own hand. Resource transfers are made to local authorities and others by the NHS in conjunction with the transfer of responsibility for the provision of social care services. Transfers of responsibility should always be accompanied by resource transfers. In some cases, bridging finance may be available to assist Health Boards with double running costs incurred by long stay hospitals as patient numbers reduce. The creation of new services in the community may also be supported by MISG. All these sources of finance should, of course, only be sought following agreement between local health, social work and housing agencies. The latest Guidance on Bridging Finance is contained within NHS MEL(1993)67 and ENV 12/93. The revised arrangement for resource transfer are set out in a letter dated 14 November 1995 from the NHS, Director of Finance to General Managers of Health Boards.

13. Community care is one of the four key national issues identified by Ministers for which housing authorities are required to prepare strategies, and set annual output targets against which progress can be measured. The availability of appropriate accommodation is an important aspect of the CPA arrangements for individual clients. Housing authorities should consider the provision of housing for people with severe and enduring mental illness, including dementia, within the resources available to them. Scottish Homes may also be able to assist with community care projects, either as a provider or through its enabling role. Sources of funding for community care housing projects are set out in the Circular ENV 27/1994; SWSG 7/1994; NHS MEL (1994)79: "Community Care: The Housing Dimension", August 1994.

Good Practice

14. The sharing of knowledge and good practice in CPA is one of the ways in which progress can be assisted. The database of good practice in community care at the Nuffield Centre at Glasgow University exists to share good practice in all aspects of community care, and is available to all statutory and non-statutory agencies and individuals across the community care spectrum. The Database currently holds a number of examples of good practice in the field of mental health. The Database is also keen to enhance the range of information it holds and The Scottish Office would encourage all managers and practitioners, service planners and providers, users of services and their carers, to nominate examples of good practice. Organisations or individuals who wish to either nominate good practice examples or to access information currently held should contact the database direct: Tel: 0141 330 4554 .

15. The Dementia Services Development Centre at Stirling University also provides an information service on all aspects of dementia including a database of research, publications and services. The Centre undertakes research, development and training activities and is an important source of advice and assistance in the field of dementia. Full details of the Centre’s activities may be obtained by contacting them direct: Tel 01786 467740.

ANNEX 2

THE ARRANGEMENTS FOR IMPLEMENTING A CARE PROGRAMME APPROACH

Aim

1. The aim of the Care Programme Approach (CPA) is to ensure that individuals with severe and enduring mental illness, including dementia, who also have complex health and social care needs, receive continuing care and appropriate supervision. This will incorporate the delivery of appropriate packages of services and accommodation which are fully co-ordinated by the agencies involved. The CPA provides care management arrangements which identify and respond to priority needs for support and services and for close liaison between relevant agencies.

Objectives

2. The objectives of the arrangements for CPA are to ensure that:

• there is effective collaboration and working within and between agencies and professionals;

• service users and, where appropriate, their carers are involved as far as possible in individual care decisions and arrangements.

• CPA targets those people most in need, or most at risk to themselves or others;

• people receive a full multi-agency assessment and regular reviews of their needs;

• people receive a sustainable care plan which ensures their needs are met;

• people receive care and support for as long as they need it; including follow-up of those at risk of being lost to the system;

• people receive a fully co-ordinated and comprehensive range of services and support;

• all aspects of the arrangements are regularly monitored and evaluated to ensure that they are fully effective.

Outcomes

3. Experience with the pilot schemes confirms that effective CPA arrangements lead to improvements in inter-agency collaboration, and allow better co-ordination of care and access to services for those on care programmes.

STRATEGIC CONTEXT

4. Arrangements for the CPA should be clearly identified within, and be consistent with, community care plans, housing plans and housing management plans, and mental health and dementia strategies, jointly agreed between planning partners. They should be fully consistent with the objectives, agreements, priorities, targets and timetables within these plans and strategies.

5. Health Boards and social work authorities, in developing service specifications and contracts with service providers, should specify their requirements for the range, level and quality of services and ensure that quality control arrangements are in place. Contractual agreements and service specifications should also make clear the managerial and operational requirements which should be in place; procedures for developing individual packages of care including accommodation; access to services; and arrangements for monitoring, evaluation and review. Health Boards and social work authorities should also co-operate with housing authorities and Scottish Homes on the provision of new housing for, or the allocation of existing houses to, people included in the CPA. There are also implications for councils’ housing management service. There should also be agreed performance indicators in place to assess both the effectiveness of the CPA arrangements and the outcomes for service users. This might include monitoring the number of people included on the CPA; how many are lost to follow-up, or return to in-patient hospital care; improvements in compliance with regard to medication, or attendance, etc. Local management groups should develop indicators relevant to their procedures and local circumstances.

6. Groups representing users and their carers should be involved in the strategic planning arrangements and also within the local management arrangements.

LOCAL POLICY AGREEMENT

7. A local policy agreement should set out the arrangements for implementing the CPA at a local level. This should be fully consistent with the broader strategies and agreements in community care plans, housing plans and housing management plans, and strategies for mental health and dementia. While the mechanism for developing a local policy agreement will vary from area to area depending on arrangements for joint planning, it is important that agreement is secured at the highest level within each agency. Where health board and local authority boundaries do not coincide, agreements should make clear how local arrangements will operate to ensure consistency of approach across these boundaries.

8. Agreements should:

• set out the aims and objectives of the CPA and how these are to be achieved;

• be jointly agreed by managers and practitioners in health, social work and housing;

• clarify those to whom the CPA should apply;

• set out the roles and responsibilities of each of the agencies involved in implementing CPA; including the agency with lead responsibility for co-ordinating the arrangements for implementation;

• include an action statement which spells out which agencies does what, by when and who will be responsible for funding;

• set out the arrangements to monitor, evaluate and review arrangements for CPA to ensure that they are effective in delivering agreed outputs and outcomes and targets and timetables for full implementation, and for ensuring that users and carers are part of the overall evaluation process.

LEAD AGENCY

9. Arrangements have varied over lead responsibility for the CPA. However, experience has shown that no single agency has overall responsibility. There is a joint agency responsibility, at all levels, for ensuring that the CPA is fully implemented. The key to the effective delivery of the CPA is good co-operation and co-ordination within and between agencies. It is important, therefore, that the local policy agreement should identify which agency has responsibility for co-ordinating the joint arrangements for implementation. The Scottish Office will require evidence that local agreements on lead responsibility are in place. These agreements do not alter the respective roles and responsibilities of statutory agencies for the provision and funding of support and services to individual clients.

CRITERIA FOR ADMISSION TO THE CPA

10. The criteria for admitting people to the CPA should be jointly agreed by all the agencies involved in implementation and should be clearly set out in the local policy agreement and in operational guidance. The CPA should apply to adults (over 16 years) with severe and enduring mental illness including dementia, who also have a range of complex needs that require continuing care and oversight and co-ordination of services within and between agencies. The CPA will include people who may be in hospital or in the community, whether they are receiving compulsory or voluntary treatment and care. No one should be included in the CPA without the agreement of a consultant psychiatrist (see paragraph 14). The Scottish Office is currently considering what separate arrangements should be made for children.

11. The CPA should target those people most in need, taking account of the nature of their diagnosis, the extent and durability of their disability, and personal and public safety considerations. People who should be considered will be suffering from one or more of the following conditions: psychosis; severe neurosis; dementia; brain injury; personality disorder complicated by severe and enduring mental illness (some enduring illnesses may be episodic).

12. In addition to the above, people who should be considered for CPA will also have a range of complex health and social care needs which may arise from a number of factors; they may be at risk to themselves, or at risk by others, or a risk to the public. They may have associated problems with relationships, employment, accommodation or homelessness. They will be assessed as requiring on-going care and supervision, and a co-ordinated multi-agency response to their needs.

13. People should also be considered for the CPA if they are supervised in the community under the Mental Health (Scotland) Act 1984 (under the powers of leave of absence, guardianship or Community Care Order), or the Criminal Procedures (Scotland) Act 1995 (under the powers of leave of absence or conditional discharge). Agencies charged with implementing the CPA should consider whether there is a need for separate arrangements within the CPA to accommodate people who fall within these categories and for people with a tendency to dangerous or violent behaviour who do not fall within the requirements of these Acts. In such cases, arrangements should be clearly identified within the local policy agreement and in operational guidance.

14. It will be the responsibility of the consultant psychiatrist, in consultation with other professionals involved (including the GP), and the user and carers where appropriate (or their advocates), to make the final decision in respect of the individual’s inclusion/exclusion from the CPA. Where disputes arise between consultant psychiatrists and other professionals about decisions on whether to include or exclude individuals, these should be referred to the joint management group.

CPA for People With Dementia

15. Not all people with dementia will require the level of support and supervision provided by the CPA. For those being considered for inclusion, it is recognised that many people with dementia receive services and support which are distinct from those provided to people with other types of mental health problem. In developing local policy agreements (see paragraphs 7 to 10) management groups should consider the need for specific admission criteria and operational arrangements for the inclusion of people with dementia who are at particular risk.

Client Consent

16. Consent is not necessarily a pre-requisite for a person’s inclusion in the CPA but this should be sought wherever possible. There may be occasions where people are unable to provide informed consent because of temporary or permanent incapacity. In other cases, some people may already be subject to compulsory supervision (see paragraph 13). In such situations decisions to include people, who otherwise meet the criteria above, should be based on judgements within the multi-disciplinary team about the person’s and the public’s best interests and welfare. Where an individual is not already under compulsory supervision and refuses to consent to inclusion in the CPA, consideration may be given to a possible requirement for an application for compulsory arrangements.

MANAGEMENT ARRANGEMENTS

17. A joint management group should take responsibility for planning, co-ordinating and implementing the CPA in accordance with the local policy agreement. Existing joint arrangements may be used for this purpose. Alternatively, some areas may decide to convene a multi-agency/multi-disciplinary management team whose sole remit is the planning, co-ordination and implementation of the CPA. Experience in the pilots has shown that there is significant benefit in having a specified management team for the CPA, at least in the initial phases of development. In either case, the group must have clear authority for planning, co-ordinating and implementing the CPA and their remit should reflect this. It follows, therefore, that individuals within the group will have authority delegated to them by their sponsor agencies to take the appropriate decisions to ensure that full implementation of the CPA is carried out. Such a group should be multi-agency and should be made up of senior managers and practitioners drawn from health, (including Boards, NHS trusts, GP representatives and a consultant psychiatrist) social work and housing authorities, relevant accommodation and service providers, and representatives of users and carers. Experience in the pilot schemes points to the benefit of police involvement in arrangements at strategic and local levels.

18. The remit of the group should also set out the roles and responsibilities of the organisations and individuals within the group. This should be fully consistent with the action statement in the local policy agreement and should identify who does what, for whom, by when, and who will be responsible for funding. Experience within the pilot schemes has shown that there is benefit in having a named officer who has responsibility for co-ordinating the work of the group and for ensuring that progress is maintained and action delivered. Experience has also shown that dedicated administrative support is helpful in the initial developmental phases and beyond.

CPA, Care Management and Hospital Discharge

19. The joint management group should ensure that the arrangements for the CPA are fully compatible with those for assessment and care management and locally agreed protocols for hospital admission and discharge. Joint multi-agency assessment tools should be developed where these are not already in use. It is important that each system supports the other and that duplication between systems is avoided. Joint referral procedures should be agreed and the various points of referral made explicit.

Information Sharing and Confidentiality Issues

20. The exchange of information on individuals’ included in the CPA is vital to ensure that effective supervision and support is in place. The joint management group should agree principles and protocols for confidentiality and sharing personal information about individuals between agencies. It is important that information is only made available on a "need to know" basis to those agencies who need it to fulfil their responsibilities. It is vital therefore to be clear about what should be recorded and who has access to it. It is important to ensure that the users right to confidentiality is understood and respected by all agencies. The sharing of information would be justified if it is necessary in the interests of the health and/or safety of the individual or others who may be affected by his or her actions. This should include the provision of appropriate information to service providers and, where relevant, carers.

21. General information about the CPA should be made available to service users and their carers. The keyworker and other agencies should consider what level of information each carers’ involvement in users’ care warrants. The information provided to users and carers should include the range of mental health and other services, including advocacy support and accommodation, and the standards of service people using them can expect. The information should be comprehensive enough to allow for informed consent to be given. Users and, where relevant, carers, should be informed of the arrangements for the users’ care and support under the CPA. The key worker should be identified along with details of crisis and emergency services, how these may be accessed and who to contact outside normal working hours. Information should be clear and should be made available in languages other than English and in a format which people with sight, hearing, learning or other disabilities can use.

Services

22. The CPA should receive a high priority within the broader arrangements for development of mental health services and access to them. Service provision should include a range of health, social work, housing and other options. A full inventory of the services and other resources available, including details of how these may be accessed, should be included within the local policy agreement and operational guidance.

Crisis and Emergency Arrangements

23. The joint management group should agree a protocol and detailed arrangements for dealing with crisis and emergency situations for people covered by the CPA. These should set out who does what for whom, the named staff and services that will respond in such circumstances and how to access them. Consideration should be given to arrangements for crisis and emergency cover outside normal office hours. Both the protocol and arrangements for dealing with crisis and emergency situations should be made widely available to staff in each agency involved in providing services to people with mental illness, including housing and the police, and should be clearly set out both within the local policy agreement and operational guidance.

Transfer

24. Where people move between local authority, health board or NHS Trust areas there should be clear arrangements for transfer of responsibility. No such transfer should take place until arrangements for continuing management, care and support are firmly in place. Guidance on the transfer of ordinary residence between local authorities is set out in circular SWSG01/96. Guidance on the responsibilities of Health Boards for the provision of health care services is provided in "NHS Scotland - the Function of Health Boards (Scotland) Order 1991". Where individuals move of their own volition without involving any local agencies, the management group should inform the appropriate agencies in the individuals’ new location as soon as they become aware of the move. Where a local authority identifies such individuals who have moved to their area, they should automatically be placed on the CPA until full reviews are completed.

Lost to Follow-up

25. The frequency and details of follow-up arrangements should be informed by individuals’ conditions and circumstances. Responsibilities should be agreed between the Key Worker and relevant agencies. Agencies involved in implementing the CPA should ensure that there are jointly agreed procedures for identifying those who are at risk of becoming lost to follow-up, for tracing people who become lost, together with criteria to trigger action in such cases. Triggers could include consecutive out-patient appointments being missed; non-attendance at day care or failure to respond to home visits. The procedures to be followed in such circumstances should be set out in operational guidance and should ensure that all attempts to trace people lost to follow-up are closely monitored and recorded. All relevant agencies should be informed as soon as possible of an individual’s loss to follow-up

Discharge Arrangements

26. People who no longer require to be covered by the CPA should be discharged from the arrangements. Discharge criteria should ensure that this does not happen by default but also that people do not remain on the CPA any longer than they need to. Risk assessment may inform discharge decisions. The arrangements and criteria for discharging people from the CPA should be jointly agreed by the agencies involved in implementation, and clearly set out in the local policy agreements, operational guidance and individual care plans. The decision to discharge an individual must be agreed with a consultant psychiatrist. Where people are discharged from the CPA all agencies involved in providing their care, including GPs, should be notified immediately. Appropriate arrangements should be made for the continuing support of people discharged from the CPA to ensure that their discharge is sustainable. Particular consideration should be given to ensuring that homelessness does not occur.

Standards

27. The joint management group should identify standards of care to be achieved. For people on the CPA, these should be at least equal to the standards required for other service users. Standards should address individuals’ rights, process and service requirements. These should include identification of the key worker; accessibility of information and services; frequency of contact; consistency with the care plan; confidentiality; and the availability of advocacy support. The Glasgow pilot scheme has found it helpful to develop its own set of basic standards.

28. The joint management group should identify target assessment times and frequency of reviews. Standard timescales (minimum and maximum) should be agreed for assessment and review and these should be made explicit in the local policy agreement and operational guidance.

Monitoring, Evaluation and Review

29. The joint management group should ensure that systems are in place to monitor, evaluate and review the effectiveness of the arrangements across agencies. This should include the development of outcome indicators for the CPA itself, for services and individuals. Good client outcomes might include, for example, general improvements in the overall health and quality of life of the individual; their ability to sustain relationships or develop new ones; fewer admissions or re-admissions to hospital; stability of drug management, or the ability to sustain tenancies. User and carer input should be considered in monitoring. Experience of the pilot schemes has also confirmed the need to assess the longer-term outcomes of CPA.

Awareness, Training and Support

30. The joint management group should, as part of the local policy agreement, develop an awareness, training and support strategy. The main aim of such a strategy should be to ensure that all purchasing and providing agencies and their staff, and users and carers, are suitably informed of the aims and objectives of CPA and how they fit within the broader context of community care and mental health strategies. The objective of the strategy should be to ensure that the processes to be followed for implementation and lines of accountability and support are explicit, and that all staff have a clear understanding of their own and others’ roles and responsibilities. It should also ensure that staff have the necessary skills to be able to carry out their roles and responsibilities effectively. The strategy should set out a detailed programme and timetable for single and multi-agency/multi professional training and other events to achieve those objectives. It should also set out the arrangements for the dissemination of information about the CPA.

OPERATIONAL GUIDANCE

31. Operational guidance should be developed for key staff in the appropriate agencies and be designed to support effective inter-professional collaboration. The guidance should make procedures, practices and systems for implementing the CPA clear, accessible and understandable to managers and practitioners across agencies. The operational guidance must be fully compatible with the aims and objectives of the local policy agreement and action statements within that agreement. The guidance should identify the range of agencies and professionals involved, when they should be involved and how. It should also identify the arrangements for access to services including crisis and emergency services. Management arrangements and accountability of professionals within their own agencies and within multi-agency team should be agreed and made explicit within the guidance.

32. The guidance should set out the jointly agreed criteria for admitting people to and discharging them from the CPA, and for tracing those people who become lost to follow-up. Jointly agreed referral and transfer procedures should be made explicit and should spell out when and where a referral or transfer should be made, to whom, and the information required at each stage. It is essential that important information is not missed but also that users are not asked for the same information by different practitioners on the CPA. The jointly agreed principles of confidentiality, protocols and administrative arrangements for sharing information should be clearly set out in the operational guidance and should be made explicit at the beginning of each case review.

Key Worker

33. Operational guidance should identify the role of a key worker, his or her responsibilities and reporting arrangements. This will usually be a mental health professional but there may be circumstances where it is more appropriate for a professional from another discipline to assume this role. In individual cases the multi-agency/multi-disciplinary assessment team, in consultation with the service user and their carers, should consider and agree who is best placed to assume this role. Key workers, while being accountable to their line managers, will have responsibilities to professionals in other agencies who take part in the CPA. Some care management arrangements will allow access to devolved budgets and the guidance should identify how workers can obtain funding for individual packages of care.

34. The key worker’s main responsibility is to co-ordinate an individual’s care programme in close collaboration with the individual, their carer and the other members of the care team. This means ensuring that all parties are kept up to date with information about the individual’s progress and other relevant information, and that meetings and reviews take place at appropriate times. The key worker should have authority to trigger the required multi-agency review of the individual’s case. The consultant psychiatrist must be kept informed by the key worker of significant developments in relation to the individual’s mental illness and treatment needs. A key worker with appropriate qualifications, training and experience may have a major role in providing therapeutic support. Key workers may also, in some circumstances, act as an advocate for the individual to ensure that his or her rights, views and wishes are represented at meetings and case conferences. However, independent advocacy support should be available if requested or required. Key workers should have a clear understanding of the professional boundaries, roles and responsibilities of each of the other members of the care team.

INDIVIDUAL CARE PROGRAMMES

35. It is important that individuals and their carers, or advocates where appropriate, are involved in all stages of their care programmes.

36. An individual’s care programme should follow a full multi-agency/multi-disciplinary assessment of that person’s needs, including social, health, housing, education, occupation and income.

37. The individual care programme should comprise a care plan, drawn up by the key worker following a multi-agency, multi-disciplinary meeting of the relevant professionals and involving the user and carer, as appropriate.

38. The care plan should set out the objectives of care, and the nature and range of treatment and services (including accommodation and primary care) to be provided. It should also identify for each agency and particularly for the service user:-

- The frequency and nature of contact, care and support to be provided by the key worker and others;

- How the key worker can be contacted, and arrangements for cover in his or her absence;

- What services will be provided, by whom. Timescales and the names of staff involved should be specified as far as possible.

- The financial implications for agencies, where relevant, and any charges for which the user may be liable;

- Monitoring arrangements to oversee the effective implementation of the plan;

- Review procedures and the frequency of reviews;

- Arrangements for discharge from the programme;

- Follow-up arrangement following discharge, with agency/individual responsibility for action clearly identified with appropriate targets and time-scales.

39. Users and, where relevant, carers should be given copies of their care plans. Key workers should strive to ensure that users are involved as much as possible in drawing up and agreeing care plans.

40. The care plan is not an end in itself, but a means of clarifying expectations, responsibilities and roles to ensure a co-ordinated package of care is delivered, and is monitored and amended as appropriate.

41. Key workers may on occasions have to be proactive and assertive in maintaining contact with service users to ensure their continued take-up of services.

NB: The Assessment and Review Flowcharts provide an example of the possible progress of individual CPA arrangements. Local Management Groups will agree their own operational and administrative procedures.

ANNEX 3

CARE PROGRAMME APPROACH: LIST OF RELATED GUIDANCE

This Annex provides a list of guidance which should be read in conjunction with this Circular:

1. Circular SWSG10/90: Specific Grant for Revenue Expenditure on New Community Projects in the Mental Illness Field, dated October 1990: introduced a revenue grant scheme to accelerate the provision of facilities for people with mental health problems living in the community.

2. Circular SWSG 11/1991: HHD/DGM (1991) 40: Assessment and Care Management, dated 17 June 1991: introduced the arrangements for assessing an individual’s needs for community care services and the wider arrangements for care management.

3. NHS MEL (1992) 55: Community Care: Joint Purchasing, Resource Transfer and Contracting: Arrangements for Inter-agency Working, dated 15 September 1992: set out the arrangements for facilitating the transfer of resources from health boards to local authorities to accord with the transfer of responsibility of people who no longer need continuing specialist medical and nursing care. Since then, the ‘incentive’ system has ended and replaced by a new emphasis on jointly agreed community care plans and boards’ more detailed purchasing for developing care in the community.

4. NHS MEL (1993)67 AND ENV 12/93: 1993/94 Bridging Finance Scheme, dated 14 May 1993: introduced the third Bridging Finance scheme associated with the double running costs associated with the transfer of patients from long-stay hospitals into more appropriate community settings. It also set out the criteria against which bids for Bridging Finance by Health Boards would be judged in future years.

5. Circular ENV 27/1994, SWSG 7/1994, NHS MEL (1994)79: Community Care: The Housing Dimension, dated August 1994: emphasised the role of housing in community.

6. Letter from the NHS, Director of Finance to Health Board General Managers dated 14 November 1995: ends the current incentive system for encouraging resource transfers from Health Boards to local authorities and introduces new arrangements for transferring resources.

7. NHS MEL(1996)22: NHS Responsibility for Continuing Health Care, dated 6 March 1996: set out the role of the NHS in the organisation of continuing health care, by implication it also clarified the responsibilities of local authorities. It also formally introduced criteria for the NHS in patient care and a review procedure for patients who wish a second view on the clinical decisions regarding their continuing health care.

Copies of the guidance listed above may be obtained from Mr Neil Rennick, Social Work Services Group, Room 48C, James Craig Walk, Edinburgh EH1 1 DG (Tel: 0131 244 5389).

REPORTS OF PILOT WORK

8. The Report on the Operational Arrangements and Recommendations arising from the Glasgow Care Programming Pilot Project 1.7.95 to 31.12.95: copies of the report may be obtained from Mr Robert Davidson, Care Programming Project Manager, The Crail Street Centre, 155 Crail Street, Glasgow G31 5RB.

9. The Stirling Care Programme Approach Pilot - Final Report: copies of the report may be obtained from Mrs Irene Kavanagh, Service Manager, Community Care, Stirling Council, Drummond House, Wellgreen Place, Stirling FK8 2DY