SECTION B PART 1 - OUTCOME SPECIFICATIONS
Mandatory headings 1 – 5. Mandatory but detail for local determination and agreement.
Optional heading 6. Optional to use, detail for local determination and agreement.
All subheadings for local determination and agreement.
Outcome Specification No.
Service
Mental Health Specialist Services
Commissioner Lead
Provider Lead
1. Population Needs
Local
Locally defined
2. Key Outcomes
No Health Without Mental Health sets out a clear and compelling vision, centred around six
objectives:
(i)
More people have better mental health
(ii)
More people will recover
(iii)
Better physical health
(iv)
Positive experience of care and support
(v)
Fewer people suffer avoidable harm
(vi)
Fewer people experience stigma and discrimination
Each objective in the Implementation Framework (see Appendix) is relevant to secondary mental
health services although some will be held jointly with primary health care and public health
especially physical health care, early intervention, destigmatisation and suicide prevention.
2.1 Strategic Outcomes
Commissioner, providers and other stakeholders should work together to develop strategies for the
below:
More people have better mental health:
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Improve self-reported wellbeing through development of strategy to measure emotional
wellbeing (e.g. in association with ONS initiative)
Implement use, data collection and dissemination of results of Patient Reported Outcome
Measures (e.g. Warwick Edinburgh Scale or DIALOG) in users of secondary mental health
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(ii)
services (target 40% of service users in year 1)
Implement strategy to develop use, data collection and dissemination of results of Health Of
The Nation Outcome Scale (HoNOS)
Extend use of specific Outcome Measurement from IAPT to secondary care for common and
severe mental health problems (establish pilot projects and develop data streams)
More people will recover
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(iii)
Increase proportion of service users of working age retaining employment & if not currently
working returning to work and/or meaningful activity
Increase proportion of people with mental illness or disability in settled accommodation (e.g.
measured using HoNOS scale)
Increase the proportion of people who use services who have control over their daily life
(establish strategy to measure and improve)
Better physical health
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(iv)
Reduce excess under 75 mortality rate in adults with severe mental illness by implementing
strategy with primary care and acute services to measure SMIs and improve outcomes.
Positive experience of care and support (prioritise and negotiate proportion improvement)
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(v)
Improve patient experience by increasing patient satisfaction and increasing those that
report feeling safe and secure and managing their own condition (using CQC Patient Survey,
NHS Survey)
Improve carer quality of life by increasing carer satisfaction (using Carer Survey, NHS Survey)
Fewer people suffer avoidable harm (establish local baseline)
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Reduction in safety incidents involving severe harm or death (e.g. suicide and undetermined
deaths measured over 3-5 year cycles) through strategy to ensure prompt (negotiable – eg
within 45 days) critical incident review and feedback to staff involved with regular collation
and consideration by clinical governance structures.
Provide right treatment at right time in line with the evidence base.
2.2 Specified Outcomes
Please note these outcomes are a list of examples (including the percentages) and are not
proposed as mandatory. Local Commissioners will need to prioritise according to local need.
Percentages or numbers need to be decided locally and where current measures do not exist,
baseline data should be collected and increase or decrease negotiated within the timeframe of the
contract. The percentages stated are “educated guesses” and will vary locally
Treating and caring for people in a safe environment; and protecting them from avoidable harm.
Optimise health and well-being by supporting individual goals
Collaboration with informed service users and carers
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90% of all service users are effectively involved and engaged, and their views made explicit
within individual care planning processes (including the use of Advanced Directives where
appropriate)
Increase by 10% numbers of those receiving peer support enabling help in self-management
4% reduction in the discrimination experienced by people with mental health problems from
surveys conducted by “Time to Change” in 2010 and 2011.
90% of identified carers are offered assessment using a Caregiver Strain Index
Improve overall, Carers reported quality of life (ASCOF) by 10%.
Improve by 10% patient experience of community mental health services (CQC Patient
survey)
Improve by 10% the overall satisfaction of people who use services with their care and
support (NHS Survey )
Increase by 10%, the proportion of people who use services who say that those services have
made them feel safe and secure (NHS Survey)
Strengths based assessments and intervention
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90% service users offered choice of developing their own WRAP (Wellness, Recovery Action
Plan
98% of service users in settled accommodation are recorded on assessment
98% of service users in employment are recorded on assessment
Increase by 10% the proportion of adults receiving secondary mental health services in paid
employment using evidence based models.
Increase by 10% the proportion of adults receiving secondary mental health services
occupied in Meaningful Activities such as hobbies, social activities with family and friends,
exercise, sport and other leisure activities
Increase by 10% the proportion of adults receiving secondary mental health services in
suitable accommodation
Reduce by 10% the length of stay in inpatient services due to accommodation issues
Increase by 20% the use of Personalisation includes prevention, early intervention, and selfdirected support where people are in control of arranging and managing their own support
services
100% or services users offered Patient Reported Outcome Measures (such as INSPIRE)
Timely, safe and effective interventions
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98% of service users who are subject to CPA to have a CPA review within timescales reflecting
in national guidance
Services in secondary care that are readily accessible and available for 24 hours a day, 7 days
a week when in crisis
Ensure 70% of service users have a joint crisis plan (these differ from written care plans used
as standard within the Care Programme Approach
Self-referral to enable people to get help without lengthy procedural delays especially
important for people from BME
Decrease by 20% the use of antipsychotic medication specifically for borderline personality
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disorder or for the individual symptoms or behaviour associated with the disorder (although
short-term use may be helpful during a crisis).
Decrease by 20% the use of poly-pharmacy (two or more drugs of same BNF category) and
medication above BNF recommended levels.
Increase by 30% the use of Psychological Therapies for severe mental illness including
psychosis, bipolar and Personality Disorders as an adjunct to medication.
Increase by 30% the use of Family Therapy for severe mental illness including psychosis and
bipolar disorder as an adjunct to medication.
Increase by 30% the use of Social Prescribing for severe mental illness including psychosis and
bipolar disorder as an adjunct to medication.
Increase by 30% the use of Dialectical Behavioural Therapy and/or Interpersonal Therapies
for borderline personality disorders as an adjunct to medication
100% of inpatient units have environmental risk assessments in place (annual audit)
100% of inpatient units meet Infection control standards (annual audit)
ECT outcomes as per Technology Appraisal 59 (April 2003) “Guidance on the use of
electroconvulsive therapy” NICE
90% of service users have up to date CPA
10% reduction in completion medicines reconciliation on admission within 24 hours (quality
contract)
10% reduction in drug omissions in inpatient unit
100% of nurses medicines competency completed
95% of clinical staff complete rapid tranquiliser training
98% compliance with Insulin prescription standards
98% of Lithium prescribing meets NPSA guidance
Optimise physical health and Prevent people from dying prematurely
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98% physical health screening offered on admission or as soon after as possible unless
consent is not obtained
98% of service users to be registered with a GP and be assisted to access an annual health
check
10% reduction in premature death in people with serious mental illness
95% of adult patients who smoke have received smoking cessation advice and been offered
smoking cessation intervention
95% of inpatients being assessed for healthy weight resulting in 100% appropriate referral to
weight management services and provision of lifestyle information
98% Inpatients and 90% community are screened for alcohol misuse, and AUDIT tool
completed if concerns identified.
98% Inpatients and 90% community are screened for drug misuse, and referral to appropriate
substance misuse services complete.
Provide least restrictive interventions in safe environments
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Increase the numbers of people by 15% receiving home-based care or alternative to inpatient
admission who are in Acute crisis
100% access to Inpatient, PICU and health-based place of safety provision available when
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needed.
CRHT function is involved and agrees with 95% of decisions to admit to acute inpatient or
PICU provision
100% of service users offered access and information regarding advocacy services for those
detained under the Mental Health Act 1983 (amended 2007).
No unsuitable environments for acute care, including mixed sex accommodation
75% of people with complex and long-term mental health needs who are supported by
rehabilitation services to progress to successful community living within five years and
around 10% to achieve independent living within this period
Reduce by 20% those readmitted to inpatient care within 7 days and 30 days
Reduce by 10% people admitted who are restrained
Reduce by 10% the hours of seclusion as a percentage of total patient hours during admission
per year
Provide an annual audit of Mental Health Act Assessment and Mental Capacity Act
Assessments with a focus on appropriateness.
Supporting individuals to maintain independence and maximise opportunity
Quality and accessibility of information
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An annual audit of Information available for service users, family and carers using a variety of
media including leaflet and web based
Decrease by 10% un-validated notes on RIO (or other information systems)
Decrease by 10% un-outcomes appointments notes on RIO (or other information systems
NB: Validated notes are those that are signed off by clinicians. Outcome within the information
system report on the pathway used and may also be used linked to payment systems.
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95% caseload with a care cluster allocated
95% caseload with completed cluster assessment
95% caseload with cluster reviews completed in time
95% diagnosis recorded
Health Of The Nation Outcome Scale (HoNOS) [collected as part of Payment-by-Results
clustering] (target 90% initial score & 50% repeat score in year 1)
Staff skills and supervision
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70% of staff are trained to be competent, using DANOS competencies in the assessment and
clinical management of substance misuse
70% of staff are trained in Psychological awareness
20% of staff are trained in Psychological Therapies
Reduce the levels of staff sickness absence by 10%
95% of clinical and support staff receive evidence based supervision.
95% of clinical and support staff receive training in Safeguarding Adults and Children
95% of clinical staff receive training in clinical skills (risk assessment, care planning)
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95% of clinical and support staff receive appraisals
Effective, recovery-oriented, risk assessment and management
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Conduct biannual reflective practice sessions in all teams, focussed on risk (including positive
risk taking)
Conduct biannual reflective practice sessions in all teams, focussed on recovery approaches
98% of risk assessments are up to date
70% of risk assessment and management is done in collaboration with service user and carer
90% of Critical Incident Reports completed within 45 days
90% of Complaints dealt with within agreed timescales
90% of Serious Incidents Reports dealt with within agreed timescales
Effective multi-agency partnerships
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95% of working age service users are offered opportunities to access support around
employment/education/accommodation
100% of teams has plans in place to support working relationships with CAMHS, OPMH, SMS,
primary care, police, housing, third sector MH services, service user and carer support/
involvement groups
2.3 Process measures:
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Improve rate of access to NHS mental health services(through MHMDS)
Decrease population rate of detained patients (MHMDS)
Improve ethnicity balance amongst detained patients (MHMDS)
Assess effectiveness of safety incidents reporting (MHMDS)
Assess appropriateness of numbers of absent without leave in detained patients (MHMDS)
Increase proportion of service users with severe problems offered NICE-compliant
psychological interventions (phased plan to reach 100% over x years)
3. Scope
3.1 Population covered
(Please note that this could be delivered by a variety of Specialist Mental health Providers)
Intended users of the secondary care mental health specialist pathway will have multiple, complex
needs including a number of the following:
 A clinically diagnosable mental health problem
 Severe problems can present as ‘common mental disorders’ (Clusters 4-7) and also
psychoses, bipolar disorders (11, 12-17) & emotional difficulties (‘personality disorders’)(6-8).
 History of violence or persistent offending
 Significant risk of persistent self-harm or neglect
 Poor response to previous treatment
 Dual diagnosis of substance misuse and serious mental illness
 Dual diagnosis of learning disability and serious mental illness
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Dual diagnosis of developmental disorder and serious mental illness
Detained under Mental Health Act (1983) on at least one occasion in the past 2 yrs
Unstable accommodation or homelessness with a serious mental illness
Enduring Interpersonal Difficulties, in the context of existing mental health problems;
Unresolved Difficulties including those related to mood, anxiety, abuse and eating disorders;
Mental health problems exacerbated by personality disorder;
Complex Picture Of History Of Abuse, e.g. Sexual, in the context of existing mental health
problems;
Chronic Post Traumatic States (Unresolved);
Recurring Patterns of Psychological Difficulty.
Within the secondary care mental health specialist pathway there are four distinct functions:
 To promote recovery and integration of service users with complex and multiple needs within
a culturally competent service
 Assessment, Treatment and Interventions for those with time-limited disorders who can
benefit from specialist interventions.
 Assessment Treatment and Interventions for those with more complex and enduring needs.
 Advice and Signposting - giving advice on the management of mental health problems by
other professionals – in particular advice to primary care and a triage function enabling
appropriate referral.
Service Aims include acute care, crisis intervention, assertive outreach, early intervention and
community treatment:
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Early intervention and effective access
 To provide timely assessment and access to secondary mental health services.
 To provide effective signposting for patients who do not require secondary services.
 Proactive community engagement to reduce Duration of Untreated Psychosis
 To improve the early clinical outcome and functioning of young people with
psychosis through the implementation of evidence based interventions.
 Early assertive engagement with young people experiencing first episode psychosis;
Acute care
 Manage crisis effectively promoting the least restrictive environment and promoting
independence through effective ‘gate-keeping’
 Proactively manage the significant risks associated with complex problems.
 Provide effective alternatives to hospital admission and support treatment in the
community where appropriate.
 Provide a place of safety (S136 suites)
 Provide Psychiatric Intensive and Acute Care services
 Provide Approved Mental Health Practitioner services
 Reduce length of stay when hospitalisation is required working with Crisis Resolution
where appropriate.
Community care
 Provide ongoing support to service users with enduring mental health problems, who
need support to maintain themselves in the community
 Achieve effective engagement with service users with complex and multiple mental
health and substance misuse needs.
 Increase stability in the lives of service users and their carers/family.
 Improve social functioning
 To work with service users to manage their own mental health and maintain or
regain their independence.
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To promote service users social inclusion, including facilitating return to and remain
in employment.
To work with service users in reducing and managing risks.
Ensure comprehensive care planning for all service users.
Older people will have the same access to services (including acute and out of hours
services) as younger adults of working age who have a mental health problem. The
service will ensure access to specialist Old Age Psychiatry and Specialist Community
Nurses, and other professionals, where required (??may be seperately
commissioned).
Providing opportunity for clients to talk with people in the team who have had similar
experiences ?peer workers;
Assertive Outreach to support in resuming life in the community and longer-term
provision, in order to reduce the likelihood of future hospital readmissions and
relapse
Focussing on recovery to get people back into work, education and ‘life’ as soon as is
practicable and avoid the need for lengthy and expensive treatment in mental health
services;
To liaise closely with primary care provision and the other Mental Health Teams, in providing
the most appropriate level of intervention for the service user.
To provide evidence-based specialist interventions and treatment for service users with
severe mental health problems, which reduce the considerable disruption and distress in
their lives.
To provide support and consultancy to other mental health professionals to assist with
diagnosis, specialist treatment approaches and diagnostic formulation.
Working with colleagues in health, social care and education, as well as families and friends
of the young person.
Provide a culturally competent service which responds to individual service user needs which
may include ready access to interpreter services for minority languages and British Sign
Language.
Provide support and advice to primary care services to support them in:
 Providing joint educational opportunities for members of the primary health care team.
 Ensuring that regular clinical contact is sought between the primary mental health care
pathway and the Mental Health Pathway to discuss and share the management of service
users.
Ensuring that there are shared clinical governance topics between the Practice Development Plan of
the PHCT and the clinical governance framework of the Community Mental Health Pathway
3.3 Location(s) of Service Delivery (locally defined)
3.4 Days/Hours of operation (locally defined)
3.5 Referral criteria & sources (locally defined)
3.6 Referral route
3.7 Access to assessment times
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Crisis: 2 hours
Urgent: 72 hours
Routine: 7 days
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3.8 Any acceptance and exclusion criteria
 Brain damage or other organic disorders including dementia
 Crisis related solely to relationship issues
 Adults with a developmental disorder, where no co-morbidity exists.
 Anger control and violence without associated mental illness,
 Somatic problems such as chronic fatigue syndrome, chronic pain in the absence of
significant presenting anxiety and depression or clear psychological cause,
 Disorders of sexual preference (e.g. paedophilia, fetishism without associated mental illness,
 Gross addictive behaviour i.e. persistent drug or alcohol misuse or gambling in the absence of
severe mental illness
Services will not exclude people on the basis of age, gender, race or sexual orientation.
The trusts operational policy will explicitly address issues of staff safety including a statement of zero
tolerance for racial or physical abuse. This will ensure adequate assessment to ensure that treatment
is not withdrawn inappropriately e.g. when abusive behaviour is a manifestation of psychotic illness.
3.9 Interdependencies with other services (needs referral to local provision)
EXAMPLES
There is an expectation that key organisational arrangements will be in place which is consistent and
equitable across the population of. These include:
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Single management and unambiguous lines of responsibility;
Consistent gate-keeping procedures;
Consistent care planning arrangements across the pathway;
Single assessment at point of entry, including risk assessment, which is consistently revised;
Discharge planning from the start;
A clear purpose for each admission to the pathway;
Effective and consistent communication mechanisms between clinicians, teams, and
agencies.
4. Applicable Service Standards
4.1 Applicable national standards e.g. NICE, Royal College
 No Health Without Mental Health (2011)
 Joint Commissioning Panel for Mental Health. Practical Mental Health Commissioning: A
framework for local authority and NHS commissioners of mental health and wellbeing
services London: The Royal College of Psychiatrists, 2011.
 NICE Clinical Guidelines for mental health (www.nice.org.uk)
 DH Personality Disorder: No Longer a Diagnosis of Exclusion (2003)
 1999 Managing Dangerous People with Severe Personality Disorder (DSPD)2003 Personality
Disorder: No longer a diagnosis of exclusion
 2003 Breaking the Cycle of Rejection: The Personality Disorder Capabilities Framework
 2006 Reaching Out: An action plan on social exclusion
 2007 Mental Health Act
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2009 The Personality Disorder Knowledge and Understanding Framework
2009 The Bradley Report: Lord Bradley’s review of people with mental health problems or
learning disabilities in the criminal justice system
National Institute for Health and Clinical Excellence (NICE) (2009a) Antisocial Personality
Disorder Treatment, Management and Prevention, clinical guideline 77.
National Institute for Mental Health in England (NIMHE) (2003a) Personality Disorder: No
longer a diagnosis of exclusion – Policy implementation guidance for the development of
services for people with personality disorder.
NIMHE (2003b) Breaking the Cycle of Rejection. The Personality Disorder Capabilities
Framework.
NSF Policy Implementation Guide :- Assertive Outreach, Crisis Resolution and Home
Treatment and Acute care
Refocusing the Care Programme Approach DH 2008
Star wards: http://www.starwards.org.uk/
Productive mental health ward:
http://www.institute.nhs.uk/quality_and_value/productivity_series/the_productive_mental_
health_ward.html
NHS Outcomes Framework
Adult Social Care Outcomes Framework
A Recipe for Care - Not a Single Ingredient (Department of Health 2007)
Age Equality (CSIP – 2007)
Department of Health (2001, March). The Mental Health Policy Implementation Guide
Department of Health (2006, April). From values to action: The Chief Nursing Officer‘s review
of mental health nursing
Institute for Innovation and Improvement: Delivering Quality & Value Focus on Acute
Admissions in Adult Mental Health
Institute for Innovation and Improvement: Delivering Quality & Value Focus on Psychiatric
Intensive Care Units (PICUs)
Department of Health and CSIP (2007, January) Guidance Statement on Fidelity and Best
Practice for Crisis Services
Department of Health, (2008, 28 November) Commissioning IAPT for the whole community:
Improving Access to Psychological Therapies
Everybody’s Business (Integrated Mental Health Services for older adults: a service
development guide published by Care Services Improvement Partnership, November 2005)
Healthcare Commission (2007) Acute in-patient service review
Healthcare Commission (2007). The Pathway to Recovery
Mental Health Services Mapping work and the DH Situation Reports (SITREPS) on delayed
discharges.
National Institute for Health and Clinical Excellence (2003, April) Guidance on the use of
electroconvulsive therapy - Technology Appraisal Guidance 59.
Social Care Institute for Excellence (2007). Dignity in Care Campaign
The Royal College of Psychiatrists’ Research Unit (2008, December) The ECT Accreditation
Service (ECTAS)Standards for the administration of ECT – Sixth edition
Virtual Ward website at www.virtualward.org.uk: Acute Care Pathway Discussion Paper
Emotional Wellbeing: Cases for change
http://www.emotionalwellbeing.southcentral.nhs.uk/component/content/article/6resources/367-mental-health-commissioning-pack
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4.2 Applicable local standards
Locally Defined
5. Location of Provider Premises
The Provider’s Premises are located at:
[Name and address of the Provider’s Premises OR details of the Provider’s Premises OR state “Not
Applicable”]
6. Price
[Insert details including price where appropriate of Individual Service User Placement]
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