Enclosure 8
DRAFT
SECTION B
THE SERVICES
Clusters 16 and 17
LHP MH PbR Service Specifications Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE: 18768
B0
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
SECTION B PART 1 - SERVICE 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.
Service Specification No.
Service
LHP/ Cluster 16 & 17
Cluster 16 Psychosis and Affective Disorder (High
Substance Misuse and Engagement)
Cluster 17 Psychosis and Affective Disorder - Difficult to
Engage
Commissioner Lead
Provider Lead
2013/2014
Period
Date of Review
1.
Population Needs
1.1 National / local context and evidence base

Psychosis is a serious mental illness involving alterations to a person’s thinking,
sensory experiences and behaviour. Adolescence and emerging adulthood are high
risk times for developing mental disorders: in England 7,500 young people develop
an emerging psychosis each year. The early phase of the psychosis is a critical
period affecting long-term outcomes. The majority of people with psychosis will come
into the secondary care system via other clusters in the psychosis super cluster.

This service specification has been developed in accordance with current research
and best practice guidelines; it forms an integral part of the PbR super cluster B
(Psychosis) which consists of four sub-super clusters a-d and clusters 10-17. See
MHCT v 3.0 for more details.

Acute presentations (covered by another service specification, sub-super cluster B.c,
clusters 14 & 15) are often “florid”, an example being that a patient experiences
overwhelming auditory hallucinations that may be commanding them to act in bizarre
or dangerous ways, accompanied by paranoid ideation, and severe self-neglect.

A less acute presentation (covered by another service specification sub-super cluster
B.b, clusters 11-13) may involve social withdrawal and general neglect of their care
needs as they become increasingly preoccupied with unusual ideas and experiences,
and possibly hallucinations.

This service specification will cover care packages/services that are suitable for
patients in sub-super cluster B.d - Very Severe Engagement: namely, Cluster 16
(Psychosis and Affective Disorder – High Substance Misuse and Engagement) and
Cluster 17 (Psychosis and Affective Disorder – Difficult to Engage).
LHP MH PbR Service Specification Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE:18768
B1
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
2.
Applicable Service Standards
2.1 Legal and regulatory framework

The Service will operate according to:
o The Mental Health Act
o The Medicines Act
o Safeguarding Procedures

The service will be registered with CQC.

Psychiatrists will be revalidated and GMC compliant. Other professionals will remain
compliant with their relevant professional standards and be revalidated as required.

The trust will have an indemnity scheme.

The trust will have a governance system to manage complaints and incidents and
meet the training and supervision needs of its staff.
2.2 Applicable national standards e.g. NICE, Royal College

Where appropriate the service will offer care in keeping with national guidelines.
These include the Care Programme Approach and NICE Guidance which is available
to underpin clinical practice (although this will be dependent on commissioning
intentions). For clusters 16 and 17 the following NICE guidance are likely to apply –
detailed in MHCT Clustering booklet (link below) and detailed as follows:
http://www.nice.org.uk/guidance/cg/published/index.jsp

Service user experience in adult mental health: improving the experience of care for
people using adult NHS mental health services www.nice.org.uk/cg136

Psychosis with coexisting substance misuse www.nice.org.uk/CG120

Schizophrenia: ‘Core interventions in the treatment and management
schizophrenia in adults in primary and secondary care’www.nice.org.uk/CG82

Bipolar disorder: ‘The management of bipolar disorder in adults, children and
adolescents, in primary and secondary care’ www.nice.org.uk/CG38

Medicines adherence ‘Involving patients in decisions about prescribed medicines
and supporting adherence’ www.nice.org.uk/CG76

Substance
misuse:
‘Alcohol
dependence
and
harmful
alcohol
of
use’
www.nice.org.uk/CG115

Alcohol-use disorders: physical complications www.nice.org.uk/CG100

Drug misuse: psychosocial interventions www.nice.org.uk/CG51

Drug misuse: Opioid detoxification www.nice.org.uk/cg100

Self-harm: ‘The short-term physical and psychological management and secondary
prevention of self-harm in primary and secondary care’ www.nice.org.uk/CG16

Self-harm (longer term management) www.nice.org.uk/CG133
LHP MH PbR Service Specification Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE:18768
B2
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
2.3 Applicable local standards
3.

The service will comply with all relevant CQUINs agreed with the CCG during the
annual commissioning process.

Assessing for physical health co-morbidities common to mental health disorders.
Scope

3.1
The scope of the service consists of adults who meet the criteria for care
commissioned as part of the MH PbR element of the contract and are assessed as
needing care packages detailed within cluster 16 and 17. The initial assessment is
outside the scope of this specification and is commissioned separately.
Clinical presentation
Cluster 16 (Psychosis and Affective Disorder – High Substance Misuse and
Engagement)

This group has enduring, moderate to severe psychotic or bipolar affective symptoms
with unstable, chaotic lifestyles and co-existing problem drinking or drug taking. They
may present a risk to self and others and engage poorly with services. Role
functioning is often globally impaired.
Cluster 17 (Psychosis and Affective Disorder - Difficult to Engage)

This group has moderate to severe psychotic symptoms with unstable, chaotic
lifestyles. There may be some problems with drugs or alcohol but not severe enough
to warrant care associated with cluster 16. Patients in this group have a history of nonconcordance, are vulnerable and engage poorly with services.

Patients present with a range of needs at the outset and these needs change over the
course of their illness.

An outline of the patient journey is detailed in Appendix 1.
3.2 Aims and objectives of service

The service will aim to be NICE compliant (though recognition of past and current
funding will determine to what degree) and other evidence based assessment
treatments for people suffering from psychosis, delivered in a variety of settings close
to people’s homes so far as it is clinically effective and safe to do.

The service will record data for the MHMDS and nationally agreed outcomes as
determined by the National Outcomes Framework.
3.3 Service description / PbR compliance
LHP MH PbR Service Specification Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE:18768
B3
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)

The patient journey will start with an assessment following which the patient will be
appropriately clustered. The initial assessment is outside the scope of this
specification.

Patients allocated to clusters 16 and 17 will be eligible for a range of interventions as
defined by the care packages agreed with the CCG for clusters 16 and 17.

The indicative episode of care for clusters 16 and 17 is 3 years with reviews every six
months, as detailed in the MHCT Clustering booklet v 3.0 (2013-14).
3.4 Care Transition Protocols

“The points at which the appropriateness of the current cluster allocation is
reconsidered should not be arbitrary. It should occur at natural and appropriate points
in the individual’s care pathway. Typically these are termed as reviews but, it is
important to note that reviews can be relatively informal as well as formal, and can be
in response to unforeseen changes in need i.e. unplanned as well as pre-planned”
Care transition protocols
Cluster 16 – from MHCT 2013-14 v 3.0
Cluster 17 – from MHCT 2013-14 v 3.0
3.5 Discharge Protocols / PbR compliance
Example of local discharge protocol from MHCT v 3.0 (2013-14 )

The care package will run for at least three years. Discharge will be determined by,
amongst other factors: (from transition protocols)
o
o
o
Requires no psychotropic medication or has been on a stable dose for 1 year
Scores 0-1 on MHCT item 6 (Hallucinations and Delusions)
Has required no inpatient/ CRHT packages for past 12 months
LHP MH PbR Service Specification Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE:18768
B4
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
o
o

Residual risks can be managed by primary care
Scores 0-1 on MHCT item D (Engagement)
The actual services to be provided by the trust will be set out in the trust’s care
packages for clusters 16 and 17, and will be available to patients who remain within
these clusters for the cluster review period.
3.6 Interdependencies with other services
Other mental health services
Carer assessment
Drug and Alcohol treatment services
Forensic psychiatry
Social Services Department (for section 117 / financial support)
Local Authority or other social housing provision
Safeguarding Children
Education Department
Local Industry
Support at work
Voluntary sector programme
Physical health support
4.
Key Service Outcomes
4.1 Reporting and Outcomes
5.

Services will be monitored and reported by individual care cluster. This includes
process and outcomes measures as specified in the Mental Health PbR guidance and
Outcomes Framework issued annually by the Department of Health.

These include the CROM, PROM and PREM measures for which collection methods
are to be agreed locally.
Location of Provider Premises

The service will be provided from premises and locations that will ensure the
delivery of high quality care in the most efficient manner possible for the CCG’s
residents. Any proposal to provide care in a different manner and from
different locations from those from which the service is currently provided will
be discussed and agreed with the CCG before any changes are implemented
LHP MH PbR Service Specification Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE:18768
B5
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
Appendix 1: The Patient Journey
The diagram on the following page represents steps or stages in a patient’s “journey”, or
alternatively progress along a care plan at Sub Super Cluster Level. It is not a structural
depiction of a team, or teams, their staff or premises. Rather, it depicts steps that may be
followed linearly or with repeat steps as the service seeks to take a patient from a period
of mental distress to one of normal, everyday functioning.
•
Although depicted linearly it is important to note there may be “backward”
movement to earlier stages if relapse occurs.
•
This may happen “acutely” in times of crisis.
•
The time spent at each stage will depend on the patient’s response to
psychological intervention / medication/ containment.
•
These interventions will be initiated / adjusted / maintained according to the
patient’s “behavioural” presentation, including their internal experience. (Note this
is a significant difference from physical health pathways, where specific
investigation results will dictate specific interventions, often with a specified time
course. There is considerably more trial and error with subjective assessment
and negotiation at each stage.)
•
The end stage of the pathway is an agreement with the patient that “recovery” has
been achieved and the remaining tasks are long-term maintenance, or possibly
discharge, if symptom free or stable.
LHP MH PbR Service Specifications Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE: 18768
B8
2013/14 NHS STANDARD CONTRACT
FOR ACUTE, AMBULANCE, COMMUNITY AND MENTAL HEALTH
AND LEARNING DISABILITY SERVICES
(MULTILATERAL)
LHP MH PbR Service Specifications Feb 2013
2013/14 NHS STANDARD CONTRACT- (MULTILATERAL)
SECTION B – THE SERVICES
GATEWAY REFERENCE: 18768
B8