Mental Health Care Pathway (prototype) Self-hel p & Caring Primary care Other ag encies Psychological Therapy Servi ces (IAPT) Mental health services Service Pathways Hants Oxon Care pathways MENTAL HEALTH MENTAL HEALTH i Commissioning for mental health General hospit al services Coping with daily living problems E x i t f r o m s e r v i c e s Coping with daily living problems
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Mental Health Care Pathway (prototype) Self-help & CaringCaring Primary care Other agencies Psychological Therapy Services (IAPT) Mental health services.
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Mental health Services Children Adults Older people Learning disability Diagnoses Search Help
Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme.
Permission to use pathways developed by South London and Maudsley FT (SLAM) is awaited.
Developed by David Kingdon for NHS South Central with contributions from many individuals for which grateful thanks (comments welcomed to [email protected] )
There is often confusion about what is a mental health problem, mental disorder or mental illness. – A disorder (or problem) could be described as any condition that causes distress or disability
(physical or mental). However whether someone presents, or rarely is presented, for help or requires reduction in their responsibilities e.g. time off work, varies greatly from person to person and in relation to the cause of the disorder.
– Society has standards and mechanisms for deciding whether someone is ill or not – usually relying on the General Practitioner to make that decision.
– For example, depression is a disorder but need not be an illness. It can be very severe, e.g. after a bereavement, but the individual may request very limited support or intervention. On the other hand, relatively ‘mild’ depression may present and treatment may be appropriate in someone with limited coping abilities and little social support. It may be agreed that they are ill and psychological intervention, for example, be reasonable. Similarly for physical conditions, a bruise might be described as a disorder but not an illness – though it could become one if it causes swelling or severe discomfort.
Web-links that are provided as part of this programme are ones which we hope you will find useful but their inclusion should not imply that the relevant web content is endorsed by NHS South Central or other NHS organisations supporting the development of this programme.
Comments:- specific service websites will often have email addresses for comments, if not these can be made to [email protected]
• Emergency– Where there is immediate risk to life or serious physical injury, the emergency services should be
contacted using 999.– Examples would be where someone has taken or seriously threatening to take an overdose of
medication or made another suicidal action especially where they are showing signs of its effects, e.g. slurring or sleepiness (ask for ambulance); or where someone is threatening aggression, holding a weapon or committing or about to commit an assault (ask for police).
• Urgent– Where someone is very distressed or may be talking about harming themselves or someone else,
immediate attention may be necessary– If they are currently under the care of mental health services, contact should be made with those
services (local services can be located through NHS Choices ) or their general practitioner or NHS Direct.
– If not under the care of services, contact should be through the person’s general practitioner (or NHS Direct ) or if the person is in a public place (not their own home), the police can be contacted and may intervene.
– A relative of a patient can ask local mental health services for a Mental Health Act assessment by a psychiatrist and approved mental health practitioner
• Routine– Most services accept referrals from General Practitioners and so these referrals usually occur
after discussion about mental health care needs at an appointment with a GP (local services can be located through NHS Choices ).
– Some services accept self-referral (e.g. Psychological Therapy Services , Drugs & Alcohol or Early Intervention in Psychosis teams)
– Some people are referred from the Courts, Prisons or by the Police.
Underpinning values10 Essential Shared Capabilities.• Working in Partnership.• Respecting Diversity.• Practising Ethically.• Challenging Inequality.• Promoting Recovery.• Identifying People’s Needs and Strengths.• Providing Service User Centred Care.• Making a Difference.• Promoting Safety and Positive Risk Management.• Personal Development and Learning.
• Southampton University Hospital Trust• Royal Hampshire County Hospital
• Basingstoke Hospital
– Oxfordshire• Radcliffe
Voluntary:• National
– AgeUK– Alcohol Concern – Alzheimers society– Centre for Mental Health – MENCAP– Mental Health Foundation– MIND– RETHINK – Voluntary Services– YOUNG MINDS
• Local– MIND (Oxon Solent)– Restore (Oxon) – No Limits (Soton)– Voluntary Services (Oxon Soton)
• Housing & Employment– City limits (Soton)– Shelter
How satisfied are you with your mental health?How satisfied are you with your physical health?How satisfied are you with your job situation?How satisfied are you with your accommodation?How satisfied are you with your leisure activities?How satisfied are you with your friendships?How satisfied are you with your partner/family?How satisfied are you with your personal safety?How satisfied are you with your medication?How satisfied are you with the practical help you receive?How satisfied are you with consultations with mental health professionals?
1. Couldn’t be worse2. Displeased3. Mostly dissatisfied4. Mixed 5. Mostly satisfied6. Pleased7. Couldn’t be better8. No response
TREATMENT•Formulate problems/diagnosis.•Identify interventions and time frame. (Care Planning)•Practical help with basics of daily living and crisis plan•Consider psychiatric review & review medication •Consider fitness to drive or use machinery•Reconsider self-directed support (personalisation)•Psychological interventions including cognitive work, CBT, crisis planning, relapse prevention, problem solving, stress management
• Occupational interventions to support independent living
• Consider input required from adult services, work and other agencies
• CPA review (repeat HoNOS)• Physical needs reassessment • Ongoing Risk Assessment• Consider MHA & need for
acute pathway• Side effect monitoring, improve
concordance• Caseload & clinical supervision
Report & manage any complaints • Review NICE guideline for
from a height, gunshot wound): Organic psychosis: Schizophrenia and other functional psychosis where the disorder is affecting management in General Hospital: Depression or
anxiety interfering with physical healthcare or recovery: Adjustment reactions interfering with physical healthcare or recovery: Eating disorders leading to admission: Behavioural
disturbance if mental health issues are thought relevant: Somatoform, dissociative and fictitious disorders if there is frequent attendance or co-morbid physical disease requiring ongoing in-patient or out-patient care from General Hospital: Diagnostic dilemmas where mental disorder is a possibility: Patients where psychological factors are thought to be
affecting communication or other aspects of care by General Hospital staff: Capacity advice if mental health issues are thought relevant or the decision is complex and the General Hospital
consultant wants further advice after their own assessment: Alcohol and other substance misuse if other mental health problems are present (e.g. severe depression remaining after
detoxification, hallucinations remaining after detoxification)The following types of problems should not be referred but be highlighted to the GP for management after discharge: Mild depression or anxiety: Pre-existing mental illness not
affecting care in General Hospital: Alcohol and other substance misuse
REFERRALS OUTSIDE THE WORKING HOURS OF THE TEAM
Only patients requiring crisis/urgent clinical advice or assessment by a mental health specialist after initial
assessment and attempts at management by the responsible medical team will be accepted outside working
hours. It is expected that the referral will be made by a doctor of at least middle grade seniority. Referrals from General Hospital wards:
The referring doctor should contact the the duty psychiatric service (nurse bleep holder in Antelope House
(bleep 1504)). The call will be passed to the senior psychiatrist on call who will provide telephone advice and,
if necessary, come to see the patient. Referrals from the Emergency Department:
The referring doctor should contact the Crisis Resolution/Home Treatment Service
Crisis referrals from General Hospital out-patient clinics or occupational health
Mental health assessment should be arranged by the patient’s GP or rarely Emergency Department, who can
then access community mental health resources if required.
REFERRALS TO PSYCHOLOGICAL MEDICINE OUT-PATIENT CLINICReferrals for routine out-patient assessment can be accepted for patients aged 18-65 years requiring ongoing out-patient or in-patient follow up
from General Hospital.Referrals to the out-patient clinic should be made by letter from the Consultant (or Specialty trainee after discussion with the consultant)
responsible for the patient detailing reasons for referral and summary of physical health issues. It is helpful to attach recent clinic letters (the service does not have access to eDOCs).
If the referral cannot be seen due to another service being thought more appropriate or lack of capacity in the service then this decision will be communicated by letter to the referrer and GP. Patients requiring urgent out-patient assessment (for example due to active suicidal ideas or acute
psychotic symptoms) cannot be seen by the service. This initial mental health assessment needs to be undertaken by the GP.Advice for General Hospital staff regarding patients already receiving treatment from another mental health should be sought from that mental
health team. If it is thought that a specialist assessment from the Psychological Medicine team would be helpful due to the complexity of interaction between physical and mental health issues then the specific reasons for referral to the service and the details of the existing mental
health team need to be included in the referral letter. The letter should also be copied to the community mental health team. The following problems are suitable for referral: Prolonged or severe adjustment disorder impairing physical, occupational or social functioning;
Moderate depression or anxiety disorder impairing functioning or self care of the physical health condition; Somatoform and dissociative disorders resulting in frequent admissions or attendance to the Emergency Department or out-patients; Psychological issues impacting on self
care e.g. poor adherence; Psychological problems affecting physical health or health care utilisation where the patient does not yet accept referral to psychological therapy services but agrees to attend the Psychological Medicine clinic.
The following problems should be managed via the GP (who may refer to community mental health services); Urgent referrals – e.g. strong suicidal ideas, active psychosis; Mental health problems in patients who will not be receiving ongoing care from General Hospital; Mild depression or
anxiety; Depression or anxiety disorders unrelated to the physical health condition; Substance misuse; Somatoform or other medically unexplained symptoms not resulting in frequent presentation to General Hospital
TEAM RESPONSE TO REFERRALSOn receipt of referral admin staff will check if the patient is already known to local mental
health services, obtain any recent mental health correspondence and notify clinical staff of the referral.
If the clinician receiving a referral requires more clinical information to prioritise response then they will contact the referrer or other mental health teams as required. If the patient will not be seen the same day then a clinician will telephone the referrer to check that the patient
is settled and, if appropriate, give advice regarding how to contact out of hours services should the clinical situation deteriorate. If the referrer is unavailable then the clinician will
liaise with ward nursing staff.If referrers telephone the team for advice or to discuss a referral admin staff are expected to take down the following information: Name of patient; Hospital and NHS numbers; Age; Name of the referrer and bleep or other contact number; Ward location; Is it an acute crisis
needing immediate discussion with a practitioner?Supervision policy.
TRANSFER TO GENERAL HOSPITAL FROM A MENTAL HEALTH IN-PATIENT UNIT
HPFT Clinical Policy 57 & SUHT details expectations and responsibilities for HPFT and General Hospital staff for patients transferred to General Hospital for physical healthcare from a
mental health in-patient unit. If a patient needs constant (1:1) observation due to their
mental health needs in General Hospital then the responsibility for providing this is local mental health trust if the patient was transferred from a MHT bed. Responsibility lies with General Hospital if the patient was admitted from the community or
another acute hospital.Mental health act issues.
COMMUNICATION AND DOCUMENTATIONTeam members have a responsibility to follow team practices
regarding documentation.Document the clinical assessment, risk assessment, formulation, and management plan in the General Hospital notes and retain a photocopy for DPM notes; Discuss with DPM team as necessary; Recording of risk and clinical assessment has to be accurate; Ask patient to complete consent form to receive a copy of correspondence to GP; Complete the checking of information, ethnicity and accommodation forms; Ensure admin staff have recorded the
referral on the daily referral log sheet; Complete contact record for computerised notes (RiO) which admin staff then enter; Brief letter to the GP faxed on the day of assessment for
self harm; Full assessment letter at time of discharge from the team for patients seen for reasons other than self harm; Complete audit assessment form post discharge (Appendix
6); Dictate letter to the referrer, GP, patient and other professionals involved in the patient’s care after all initial and final out-patient appointments. Letters should also be sent after each appointment with medical staff and at intervals or if significant new information arises during
intensive psychosocial interventions undertaken by practitioners.
REFERRAL ROUTEReferrals should be made by faxed referral form with letter (unless assessment after admission for self harm) which
should always include:-reason for referral / question asked of the Psychological Medicine team; mental state assessment and other reasons leading to suspicion of mental illness or psychological problems impairing
management within General Hospital: reason for treatment in General Hospital: a summary of physical management and past admissions: results of recent investigations
If it is unclear whether a patient needs to be referred, or the referrer wants to discuss the referral for other reasons, then they should telephone the department. If there is no clinician present in the team base at the time, admin staff
will record the name and contact details of the referrer and arrange for a clinician to ring back. In crisis situations, the referral can be made solely by telephone discussion with a clinician in the team
Prioritisation of referrals: Initially on the basis of clinical urgency and risk and secondly on location in General Hospital in order: Emergency Department, Acute Medical Unit, other wards.
The team aims to respond within the following time frame: Crisis: 1 hour (usually within 30 minutes): Urgent: same day (if the referral is received late in the day then response is likely to be by telephone advice that day and direct
assessment the next day): Routine: 3 days (usually within 1 working day)
USE OF THE MENTAL HEALTH ACT IN THE GENERAL HOSPITAL
• If a patient is transferred from a mental health in-patient unit whilst detained under the Mental Health Act (MHA), responsibility remains with the mental health trust if the patient has been transferred under section 17 leave. The doctor responsible for the patient’s mental health care (Responsible Clinician as defined by the MHA) remains the Consultant Psychiatrist, or other professional if they are the RC, in the mental health unit. DPM clinical staff will liaise with the in-patient unit regarding mental health assessment and will complete a weekly summary to fax to the mental health unit for discussion of the patient in ward rounds.
• If a patient is detained under the MHA whilst in General Hospital, then General Hospital has legal responsibility for mental health care. They will therefore have responsibility for arranging tribunals etc.
• The section papers need to be formally received by the site co-ordinator in SGH for the section to be valid.• Section 5(2) is a doctor’s holding power and can be applied by any fully registered medical practitioner (not FY1
doctor) to detain any admitted patient (not anyone in the Emergency Department) who the doctor suspects of having a mental illness necessitating detention under a more prolonged section of the MHA. When the section is placed, the site co-ordinator should be involved and they should notify the Approved Mental Health Practitioners (AMHPs) in Southampton Home Treatment Service so that a full MHA assessment can be arranged. The section 5(2) lasts up to 72 hours.
• Sections 2 and 3 of the MHA enable detention for 28 days for assessment or 6 months for treatment of a mental disorder. They only provide legal power to treat physical problems if these are a direct cause or consequence of the mental disorder.
• The site co-ordinators will fax a notification of sectioning using section 2 or 3 of the MHA to the Department of Psychological Medicine the next working day. The Liaison Psychiatrist (LP - Dr Butler) will take on the MHA role of Responsible Clinician for adults aged 18-65 years. For older adults a clinician in DPM needs to speak to the relevant OPMH Consultant to take on the Responsible Clinician role. For leave periods, LP (Dr Butler) will have notified the team of the Consultant Psychiatrist covering the Responsible Clinician role.
• For section 2 or 3, only the Responsible Clinician (LP or other nominated Consultant Psychiatrist) can allow leave from General Hospital grounds (which needs a section 17 leave form completing) or discharge of the section.
• As for other patients, clinicians in DPM have a responsibility to advise General Hospital on levels of observation, psychiatric treatment and other management of the mental health problems for patients detained under the MHA in General Hospital.
OPMH Medication Management• Depression treatment guidelines for Older Adults• Antidementia drug treatment guidelines• Guidelines for Rapid Tranquilisation for Older Adults• Prescribing Lithium• Oral Antipsychotics• Prescribing guidelines for treatment of behavioural problems in Dementia• DVLA Guidelines on fitness to drive• Choice and Medication (UK Psychiatric Pharmacists Information site)
• Medicines Control, Administration and Prescribing Policy• Antibiotic Prescribing Guidelines • Cholesterol Guidelines • Clozapine initiation – inpatient & community • Prescribing guidelines for BPD (under development)• Risperdal Consta forms &monitoring guidance for clients receiving treatment for psyc
• Antibiotic Prescribing Guidelines • Cholesterol Guidelines • Choice and Medication (UK Psychiatric Pharmacists Information site)
• Clozapine initiation – inpatient & community • DVLA Guidelines on fitness to drive• Guidelines for Rapid Tranquilisation • Medicines Control, Administration and Prescribing Policy• Oral Antipsychotics • Prescribing guidelines for BPD (under development)• Prescribing Lithium• Risperdal Consta forms &monitoring guidance for clients receiving t
All eligible patients should be offered PI. Patient choice, non-response to previous therapy & medication, and severity determine ‘dosage’ and expertise of therapist.
1. Connect… With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.
2. Be active… Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.
3. Take notice… Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.
4. Keep learning… Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you enjoy achieving. Learning new things will make you more confident as well as being fun.
5. Give … Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, as linked to the wider community can be incredibly rewarding and creates connections with the people around you.