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Introduction

Suggested managed care network for early intervention

Recommendations based on the National Service Framework for Mental Health

Ten point Service Specification based on Regional IRIS Strategy Guidelines

Introduction

This section is intended to assist in the objective of planning effective early intervention services for people with an emergent psychosis. It is provided for senior mental health commissioners in health and local authorities and for those commissioning from primary care structures — the primary care groups and trusts.

Primary care has to tackle the dilemma of separating a relatively unusual event for any one GP (typically two patients with first episode psychosis per year) from much commoner ‘alarm-bell’ symptoms. Primary core is not just GPs and there are other agencies working in the community such as social workers, teachers, youth services, police and probation services each with their own needs for training, and for referral policies whether that be via the GP or direct to the specialist assessment. Planning should take account or the breadth of potential ‘points of first contact’.

Secondary care should offer: prompt assessment; assertive engagement by key working (Care Programme Approach) to ensure good communication; work in remission and to support carers to detect early relapse and access help; least restrictive and least invasive approaches which work sensitively with this client group in low stigma settings, promoting psycho-educational and social support whilst minimising institutional approaches.

Thus, a radical shift in professional approach is needed to facilitate early referral before diagnostic certainty. This departure from traditional practice is mirrored by developments now occurring for serious physical illnesses: for instance raised community awareness combined with primary care guidelines for meningitis; ‘one-stop’ clinics to assist early detection and prompt treatment or serious physical causes for symptoms e.g. breast lump, rectal bleeding, chest pain.

We present our recommendations in three parts:

A. Suggested managed care network for early intervention

B. Recommendations based on the National Service Framework for Mental Health

C. Service Specification based on the regional IRIS strategy guidelines

A. Suggested managed care network for early intervention

Whether early intervention is provided by a dedicated specialist service or a generic ‘mainstream’ service the essential requirement is for integrated working between primary, specialist and community agencies. We recommend this be implemented through a managed care network bringing together professionals from different disciplines unconstrained by traditional service barriers to focus on the needs of this specific client group identified by multi-disciplinary audit.

Conceptually, such a framework could fit within an early intervention approach thus:

Managed Care Framework For Early Intervention

Point of first contact Who’s providing it? Is it youth sensitive? How accessible is it? Are there agreed referral protocols? Is access to skilled assessment available?		Interface with skilled assessment Is it acceptable for young people? Is it non­stigmatising? Is it easy to access? Is the assessment collaborative? Are early treatments encouraged?		Effective service response Are engagements of client and family assertive? Do interventions suit the early phase of psychosis? Is it client centred and community based? (i.e. not solely specialist sevices). How is CPA used for this client group?
Audit: e.g. Are care pathways measured; and ore they used to evaluate service configuration and training needs? Is duration of untreated illness routinely assessed? Are there standards set for response time, interventions given follow-up/use of CPA? Are outcomes orientated to be client and carer focused (for this specific client group)? How many days under mental health sectiona are clients exposed to?

= Care Pathway of person with first episode of psychosis

• This client group are young: their legitimate aspirations as young people should be central to an approach which diminishes stigma and social exclusion.
  
  
• Multi-disciplinary planning and working are essential for successful early intervention — the commissioning process should increasingly involve primary care through PCGs and PCTs.
  
  
• Recognition or the importance of a ‘whole systems’ approach in any local solution —i.e. the effectiveness of the care pathway will be limited by the weakest link in the above diagram.
  
  
• Support and encourage innovative solutions from those with local knowledge - the practitioners and those receiving services
  
  
• The audit process by the nature of its client-centred focus should be the vehicle for continuously informing local training and service development needs

B. Recommendations based on the National Service Framework for Mental Health

In commissioning terms, the starting point for early intervention should be the local Health Improvement Plan. Clinical governance should reflect the evidence base presented in other ports of this strategy.

The Early Intervention approach is closely aligned to:

Standard One

Promoting mental health — work with young people to reduce stigma, and to help achieve social inclusion.

Standard Two

Access via primary health core team — support ‘points of first contact’ in terms of awareness and empowering access to specialist assessments in low stigma settings.

Standard Three

Helplines - in supporting ‘points of first contact’ use of NHS Direct and development of local protocols for access in difficult circumstances such as out of hours.

Standard Four

Care Programme Approach (CPA) — assertive engagement by key working with these clients to ensure good communication, work in remission and support for carers to detect early relapse and access help.

Standard Five

Least restrictive and least invasive — work sensitively with this client group in low stigma settings, promoting psycho-educational and social support whilst minimising institutional approaches.

Standard Six

All individuals who provide regular and substantial care — empowering and supporting family and carers (one of the key evidence-based tenets of ‘early intervention’) recognising their own specific needs.

Standard Seven

Suicide among individuals at greatest risk — this client group are particularly vulnerable and early intervention specifically seeks to reduce this risk.