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© Crown copyright 2008First published March 2008Produced by COI for the Department ofHealthThe text ofthis document may be reproduced withoutformal permission or charge for personal or in-house use.www.dh.gov.uk/publications Document PurposeBest Practice Guidance Gateway Reference Refocusing the Care Programme Approach AuthorDepartment ofHealth Publication DateTarget AudiencePCT CEs,NHS Trust CEs,Care Trust CEs,Foundation Trust CEs,Medical Directors,Directors ofNursing,Local Authority CEs,Directors ofAdult SSs,GPsCirculation List Following the national consultation,Reviewing the Care programme Approach(CPA),and having considered the issues identified,this guidance updatespolicy and sets out positive practice guidance for trusts and commissioners to review local practice to refocus CPA within mental health services.Cross RefReviewing the Care programme Approach 2006 Superseded Docs Action Required Janet DaviesDepartment ofHealthWellington House133 Waterloo RoadLondon,SE1 8UGwww.nimhe.csip.org.uk/cpa For RecipientÕs Use DH INFORMATION READER BOX PolicyEstatesHR/WorkforceCommissioningManagementIM & TPlanning / PerformanceFinanceClinicalSocial Care/Partnership Working set out the reasonsand aims of the current review of the CareProgramme Approach (CPA). It made clear thatthe ultimate aim was to ensure that there is arenewed focus on delivering a service with theindividual using the services at its heart Ð inwhich national policy is more consistently andclearly applied and where bureaucracy does notget in the way of the relationship between theservice user and practitioner. A clear response from everyone contributing tothe review of CPA was support for the principlesunderpinning a system of care assessment,planning and review in secondary mental healthservices. These principles are set out in the Mental(Standard Four)and Effective Care Co-ordinationin Mental Health Services: Modernising the CareProgramme Approach: A Policy Booklet. Morerecent documents about mental health andHealth 5 Years Onrecognised that serviceswere becoming increasingly responsive to theneeds and wishes of services users, yet urgedthat continued effort needed to be made. Otheremphasise, at their core, the need for services toempower individuals to achieve greaterindependence and improve their lives throughmore personalised care, more choice, and theirHowever, the review also found that, althoughmuch positive practice exists, there still remainvariations around the country in applying thesesound principles. In particular improvements carer engagement and involvement, and inare at risk. Refocusing the Care Programmeaims to build on the strong foundation of theEffective Care Co-ordination in Mentaland to reinforce them by: Section 1: Introduction Department of Health, National Service Framework for Mental Health: modern standards and service modelsDepartment of Health, Effective care co-ordination in mental health services: modernising the care programme approach Ð Department of Health, National Service Framework for Mental Health, Five Years OnDepartment of Health, The NHS Improvement Plan: Putting people at the heart of public servicesDepartment of Health, Independence, Well-being and Choice: Our Vision for the Future of Social Care for AdultsDepartment of Health, Our Health, our care, our say: a new direction for community servicesCSIP, Our Choices in Mental Health: a framework for improving choice for people who use mental health services and theircarers Statement of Values and PrinciplesTable 1The approach to individualsÕ care and support puts them at the centre and promotes socialinclusion and recovery. It is respectful Ð building confidence in individuals with an understanding oftheir strengths, goals and aspirations as well as their needs and difficulties. It recognises theCare assessment and planning views a person Ôin the roundÕ seeing and supporting them in theirindividual diverse roles and the needs they have, including: family; parenting; relationships;housing; employment; leisure; education; creativity; spirituality; self-management and self-nurture;Self-care is promoted and supported wherever possible. Action is taken to encourage independenceand self determination to help people maintain control over their own support and care. Carers form a vital part of the support required to aid a personÕs recovery. Their own needs shouldalso be recognised and supported.Services should be organised and delivered in ways that promote and co-ordinate helpful andpurposeful mental health practice based on fulfilling therapeutic relationships and partnershipsbetween the people involved. These relationships involve shared listening, communicating,understanding, clarification, and organisation of diverse opinion to deliver valued, appropriate,equitable and co-ordinated care. The quality of the relationship between service user and the careco-ordinator is one of the most important determinants of success.Care planning is underpinned by long-term engagement, requiring trust, team work andcommitment. It is the daily work of mental health services and supporting partner agencies, not just the planned occasions where people meet for reviews. Section 2: Personalised Mental Health Care A Shared VisionTo develop discussion on values in mental healthshared vision of how peopleÕs mental healthidentify a shared vision of how peopleÕsmental health problems should be understoodthat is recognised equally by different providergroups and by service users and their carers; raise awareness of the wide variety of differentapproaches to assessing mental healthproblems and wellbeing; andbuild mutual understanding of these differentapproaches as resources for drawing together,through a shared process between serviceusers, carers and service providers, ways ofunderstanding a mental health problem thatreflect the particular and often very differentstrengths and needs of individual service users.To make sure that service users and their carersare partners in the planning, development anddelivery of their care, they need to be fullyinvolved in the process from the start. Processesshould be transparent, consistent and flexibleand carers without over promising or underthe care planning process is meaningful to them,and their input is genuinely recognised, so thattheir choices are respected.The CPA review consultation process helped toidentify a number of areas of good practice.These are summarised in a Briefing Paper Annex B addresses some issues for involvingyoung people. However, most of what is set is a renewed attention by all to the evidence,principles and good practice to ensure thatactivity takes place through governancesystems, training and audit to ensure serviceuser and carer involvement and effect real change. www.nimhe.csip.org.uk/cpappwww.nimhe.csip.org.uk/cpappCommissioners and services should recognisethe positive role that advocacy can play inenabling effective service user involvement inthe development and management of their careservices to be delivered by Independent Mental 2 1 Refocusing the Care Programme Approach: Policy and Positive Practice Guidance are expected to contract for these service intheir areas and DH is currently considering howbest this can be achieved. The provision ofwhich there is current consultation. Ensuring Quality: Tackling Inequalities To help ensure that quality mental healthservices are provided to all, appropriate to theirindividual care assessment and planning, andthe service they provide. Public services haveclear legal requirements under Race, Genderand Disability legislation. DH would also urgeservices to adopt good practice when addressingof age, religion or belief and sexual orientationof the service user and carers. and implementation support programmes isand address issues of equality, including: which includes a standard onMainstreaming gender and womenÕs mentaland CSIP/NIMHE implementation programme outside services and the GovernmentÕsresponse to the Independent inquiry into theCSIP/NIMHE DRE programme. Department of Health, National Service Framework for Older PeopleDepartment of Health, National Service Framework for Children, Young People and Maternity ServicesDepartment of Health, Mainstreaming gender and womenÕs mental health: implementation guidance Department of Health, Delivering race equality in mental health care: An action plan for reform inside and outside servicesand the GovernmentÕs response to the Independent inquiry into the death of David BennettNIMHE/CSIP Delivery Race Equality Programme http://www.csip.org.uk/about-us/about-us/equality-and-diversity-.html (accessed on 25 Feb 2008)NIMHE/Mental Health Foundation. Inspiring Hope: Recognising the Importance of Spirituality in a Whole PersonApproach to Mental Health Section 2: Personalised Mental Health Care be at the heart of the approach, as will a focuson reducing distress and promoting socialinclusion and recovery. In the remainder of this guidance we use the term (new) CPA to describe this refocus.However, in future publications the term CPAwill be used to describe the revised descriptionof support and co-ordination for people withmore complex needs. Who Will Need (new) CPA?of (new) CPA should not be significantly differentfrom those currently needing the support ofenhanced CPA. The current characteristics of thoseneeding enhanced CPA are described as individualsengagement; intense intervention; support withdual diagnoses; and who are at higher risk. However, we know that there are differentinterpretations of this locally leading to someindividuals, and some key groups (see below),some individuals who are concordant withtreatment, well supported in the communityand/or have recovered from a complex episodeof mental illness are inappropriately identified asneeding enhanced CPA. To provide clearer guidance to services so that they can better target engagement, co-ordination and risk management support(new CPA) to individuals that most need it, thecurrent list of characteristics has been refinedand a new list set out in Table 2. This list wasreached by looking at the current description of characteristics for enhanced CPA, combinedthe CPA review consultation document and in consultation responses. The list was validatedby working with a range of multi-professionalThe list is not exhaustive and there is not athat should indicate the need for (new) CPA.But there was clear consensus among thosetesting the list that it should provide the basis ofa reliable and useful tool. However, it is alsocritical to stress that clinical and professionalusers will need the support of (new) CPA. CPA and eligibility for servicesthat the list in Table 2 should current local eligibility criteria to make initialdecisions on an individualÕs need for secondarymental health services. The list in Table 2 shouldengagement, co-ordination and riskmanagement (i.e. needing (new) CPA). Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Table 2 (continued)Experiencing disadvantage or difficulty as a result of:Parenting responsibilitiesPhysical health problems/disability Ethnicity (e.g. immigration status; race/cultural issues; language difficulties; religious practices); sexuality or gender issues Refocusing the Care Programme Approach: Policy and Positive Practice Guidance that some key groups who should meet thecharacteristics of enhanced CPA (or new CPA)are not being identified consistently and thatservices are sometimes failing to provide thesupport they need. Consultation respondentsagreed that information should be sought fromindividuals in these groups so that holisticneeds, and appropriate liaison and supportarrangements put in place. Many respondentsalso urged that service users with significant caringresponsibilities should be added to the list of keygroups. So, the key groups are service users: who have parenting responsibilitieswho have significant caring responsibilitieswho are in unsettled accommodationThe needs of individuals from these key groupsshould be fully explored to make sure that therange of their needs are examined, understoodand addressed when deciding their need forsupport under (new) CPA. The default positionfor individuals from these groups wouldnormally be under (new) CPA unless a thoroughThe decision and reasons not to includeindividuals from these groups should be clearlydocumented in care records. Services should also consider whether there areany groups locally that might benefit from thistargeted approach, e.g. in some areas the needsof refugee and asylum seekers might warrant asimilar approach. The Mental Health Act and (New) CPACommunity Treatment (SCT), or subject toGuardianship under the MH Act (section 7)status should be supported by (new) CPA. Mental Health Act Ð Section 7 www.hyperguide.co.uk/mha/s7.htm If this is not considered appropriate for anyparticular individual the reasons should beclearly documented in care records. When (new) CPA is No Longer NeededServices should consider at every formal reviewwhether the support provided by (new) CPAcontinues to be needed. As a service userÕs needschange, or the need for co-ordination support isminimised, moving towards self-directedsupport will be the natural progression and theneed for intensive care co-ordination support and(new) CPA will end. However, it is importantthat service users and their carers are reassuredthat when the support provided by (new) CPAis no longer needed that this will not removetheir entitlement to receive any services for whichfrom the NHS, local council, or other services. Services should also be careful that the supportof (new) CPA is not withdrawn prematurelybeing. A thorough risk assessment, with fullservice user and carer involvement, should beundertaken before a decisions is made that thesupport of (new) CPA is no longer needed. It is also critical that there should be a process(new) CPA or secondary mental health servicesends. The additional support of (new) CPAan appropriate review and handover (e.g. to the lead professional or GP);exchange of appropriate information with allconcerned, including with carers;plans for review, support and follow-up, as appropriate;and who to contact, in the event of relapse orthat personÕs mental well-being.Where (new) CPA is appropriate in prison orsafeguards should be continued for an appropriateperiod when the individual is released ordischarged. Automatically removing the supportof (new) CPA at this point could compromisethe safety and treatment of the individual at avulnerable point in their care pathway.In reviewing a care plan as part of dischargeplanning from hospital, prison or otherresidential settings, appropriate liaison withessential. The period around discharge is a This underlines the need for thorough reviewand assessment prior to discharge and effectivefollow up and support after discharge.Table 3 summarises the main similarities anddifferences between service responses to serviceusers needing the support of (new) CPA andthose that do not. Section 3: Refocusing the Care Programme Approach In reviewing policies and practice used to record the needs and plans ofservice users not needing (new) CPA can consider the refined definition of (new) CPAto ensure individuals with higher supportneeds are identified and appropriatelysupported; and that individuals not this level of support are also appropriatelycared forreview key groups and consider need for(new) CPAbe clear on the links between need for CPAensure systems are in place for service usersto be appropriately and safely allocated toand from CPA Section 3: Refocusing the Care Programme Approach Everyone referred to secondary mental healthservices should receive an assessment of their which aims to identify the needs and wheresuch as screening (assessment) or triagethey will understand) and the referrer promptly.If it is agreed that the personÕs needs are bestcare plan should be devised and agreed with theservice user and, where appropriate, their carer.This section of the guidance refers to theassessment and re-assessment which will thenoccur as part of the CPA process. It does notcover the part of the care pathway prior to thedecision about whether secondary care isrequired, or whether CPA is required.needs a multi-disciplinary health and social careassessment and care plan may cover dependingplanning; needs arising from co-morbidity;personal circumstances including family andcarers; housing needs; financial circumstancesThe assessment and planning process shouldaim to meet the service userÕs needs and choicesand not just focus on what professionals andservices can offer. It should address a personÕsaspirations and strengths as well as their needsand difficulties. Trust and honesty shouldunderpin the engagement process to allow forcarers and providers of services. To reduce documentation and cut down onassessment and care plan that will follow theservice user through a variety of care settings toensure that correct and necessary informationgoes with them. More use of joint assessmentsand review, with common documentationwww.nimhe.csip.org.uk/cpappAlthough improvements are being madestill report not being given a telephone numberthey could use to contact someone from NHS 6 Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Healthcare Commission, Survey: community mental health services show improvements but concerns remain over social. 2007 available fromhttp://www.healthcarecommission.org.uk/newsandevents/pressreleases.cfm All care plans must include explicit crisis andcarer can contact the right person if they needresponsible for addressing elements of care andsupport. Copies of the plans should be offeredand any other significant care provider, includingcarers, if appropriate. Further good practice onand carers and involvement and engagement iswww.nimhe.csip.org.uk/cpappDevelopments in policy, practice and legislationgreater attention to issues of choice; socialmanagement. The CPA review also highlightedcare planning that would benefit from renewedconsideration. Trusts should consider the rangeof issues highlighted below and review localpolicies and practice to ensure that they reflectcurrent national policy, legislation and goodpractice in the areas outlined. the core principles for promoting choice into choose their treatment, and that choiceapplies across the spectrum of care and settings.It emphasises the increasing importance of:which should be a standardoption for all those eligible to receive socialcare services. (DH, 2006)provides a comprehensivepeople to use their resources to design thetype of support that works for them inpilot of the IB system, and national roll out is expected shortly.www.individualbudgets.csip.org.ukwhich are a useful way to help plan for thefuture, and people should be supported indeveloping these where wanted. CSIP/NIMHE, Our Choices in Mental Health, 2006 Department of Health. Direct payments for people with mental health problems: A guide to action Section 4: Assessment and Care Planning Where appropriate, criminal justice agencies(particularly the Offender Manager ServicePublic Protection Arrangements) can provideessential support to risk assessment in relation tosome offenders and should be consulted as partdisability needs to be multi-agency, includingspeech and language therapists wherenecessary, so that a balance between riskwww.nimhe.csip.org.uk/cpappAssessments, care plans and reviews should takeaccount of the needs of individuals in respect ofage, disability, gender, sexual orientation, raceand ethnicity and religious beliefs. Supportinghealth services are parents with dependentchildren. These parents and their children mayface difficulties and barriers in accessing servicesmoment of assessment, and needs to reflect thecomplex interplay of stressors that can occur inEstablishing whether a service user is a parent atbe routine. Parents who are temporarilyseparated from their children (e.g. when inparenting, the parent and child relationship, thechild and the impact of parenting on the adultÕsmental health and what appropriate supportIt should also assess the indirect impacts ofmental illness e.g. financial problems, poorindividual has good relationships and supportfrom family, friends and the community toestablish whether there is a risk of the individual 7 www.nimhe.csip.org.uk/cpa Section 4: Assessment and Care Planning staff at assessment about the experience ofin a service userÕs life. The response, with briefdetails, should be recorded in case records/carereason(s) for not doing so should be recorded.carers, families and friends as well as on thefinancial disruption and restrict educational andemployment opportunities for both the carerof caring can also affect the physical andemotional health of the carer. Young carers under-achievement, absenteeism from school,Carers (including young carers) should beidentified at the service userÕs assessment andinformation provided to them about their rightto request an assessment of their own needs.Services should ensure co-ordination of usersÕand carersÕ assessments, care and support plansand the exchange of information whereagreement has been received to do this.A service userÕs own caring responsibilitiesshould also be explored and appropriateplace for the service user as a carer and for theperson they care for. www.nimhe.csip.org.uk/cpappService users have expressed concerns thatmedication issues are not always appropriatelyaddressed and reviewed, and information needsnot adequately met, in the assessment and careplanning processes.Non-concordance withmedicines is a high risk-indicator of relapse andto: dose/medicine not treating symptomseffectively; intolerable side effects/quality of lifepoor communication of the treatment plan withdifficulties in accessing medicines. Greater importance should be given to theassessment and the review of medication issuespharmacists should be involved in care planningas their input is recognised as improving  Healthcare Commission, Service User SurveyHealthcare Commission, Talking about medicines.The management of medicines in trusts providing mental health services Section 4: Assessment and Care Planning It is essential that everyone involved in the careof the service user understands who prescribesthe medication, where it is obtained from, theother medications are being prescribed forphysical health problems.In reviewing policies and practice in light ofAim to develop one assessment and careplan that will follow the service user througha variety of care settingsEnsure crisis and contingency planning andrisk assessment and management areintegral to the care planning process Consider the areas highlighted in thisSection to make sure that they areadequately addressed as appropriate inindividual assessments and care plansNote the PSA targets for settled Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Mental Health Trusts should ensure they havemechanisms in place to support staff in makingappropriate decisions about sharing information.The Social Exclusion Task Force socially excludedadults PSA and the report both state the importance of more effectivemental health problems, adults with learningdisabilities, ex-offenders, care leavers andAs many services users on (new) CPA are likelyto need support from a number of providers, itis critical that there is clear local understandingprotocols, so that organisations can worktogether effectively to meet their needs. The CPA review highlighted the particular needfor better local agreements between secondarymental health care and the following services. sets out their responsibilities to have reviewsystems in place in respect of individuals withbipolar disorders and psychosis. However, clearshared agreements between secondary mentalhealth services and GPs and primary care teamshealth service users to ensure that they haveprimary care input to the CPA processes isAgreements and protocols should be clear aboutwhich aspects of healthcare screening andmonitoring lie with each agency, and howinformation on assessment and care planning isshared, including arrangements for, and theresponsibilities of, any link workers/graduateprimary care workers. Protocols should alsoinclude agreements on how mental healthprevention and health promotion programmes,e.g. reducing obesity through action onnutrition and exercise, smoking and substanceinclusion of Public Service Agreement (PSA)targets to improve settled accommodation andsevere mental illness in the NHS OperatingFrameworkprovides an additional impetus forcross-agency planning for the delivery of theseservices. Trusts should strengthen links with localhousing and employment organisations as partof individual and corporate care assessment andplanning processes. Local protocols should be in Social Exclusion Task Force, Think Family, Improving the life chances of families at risk Section 5: Whole Systems Approach If care and support plans for individual serviceusers and carers are detailed and robust enough,provide a picture of local need, including anyunmet need. This can provide information re-configuration. It is particularly important topeople with mental health problems as theseservices may be less developed, or not currentlyVocational services for people with severeall provide examples forPSA. Commissioning based on a thoroughservices that will meet needs and improveneeds of specific equality or minority groups e.g.minority groups; language and translationfor Health and Social Careto support delivery around a set of around 50 indicators to support themeasurement and delivery of outcomes thatcover the range of health and adult social care(PSA targets) aimed at improving the socialinclusion and recovery of adults with mentalhealth problems are:the proportion of adults receiving secondarythe proportion of adults receiving secondary Department of Health, Vocational Services for People with severe mental health problems: Commissioning GuidanceDepartment of Health, From segregation to inclusion: Commissioning guidance on day services for people with mentalhealth problemsCSIP National Social Inclusion Programme, Outcome Indicators Framework for Mental Health Day ServicesDepartment of Health, Health and Social Care Outcomes and Accountability Framework Section 5: Whole Systems Approach The Capable Workforce All of the workforce in secondary mental healthcare need a range of competencies, experienceThe Ten Essential Shared Capabilities (ESC)service users and carers together withpractitioners, provides in one overarchingstatement the essential capabilities required to f Working in partnershipPromoting recoveryIdentifying peopleÕs needs and strengthsProviding service user centred careMaking a differencePromoting safety and positive risk takingwhat should be included as core in the curriculaof all pre and post qualification training forprofessional and non-professionally affiliatedstaff as well as being embedded in inductionand continuing professional/practitionerdevelopment for all staff. To support educators and the workforceeducational and workforce development toolsThe 10 Essential Shared Capabilities: (NIMHE 2006). An introductory programmeCreating and Inspiring Hope; ESC RecoveryA training resource aimed atunderstanding the importance of ÔrecoveryÕapproaches in mental health practice.(DH 2007) which explores the skills that all staff need to promote socially inclusive Supporting The WorkforceDepartment of Health. Ten Essential Shared Capabilities Ð A framework for the whole of the Mental Health Workforce10 Essential Shared Capabilities: A Learning Pack for Mental Health PracticeCreating and Inspiring Hope: Integrating recovery values and principles into every day practicetraining programme for the mental health workforce. (2006) Available from CCAWI Ð www.lincoln.ac.uk/ccawi. Department of Health, Capabilities for Inclusive Practice programmes in organisations.(NIMHE 2007) a learning resource whichto deliver race equality. ESC Dual Diagnosis Traininga training programme reviewing theapplication of the 10 ESC in offering serviceshealth problems.CAMHS Cultural Competence Toolkitcovering cultural awareness; culturalis available from www.camhs.org.ukAll the above can be downloaded free of chargefrom www.lincoln.ac.uk/ccawilinks to ESC learning resources. In addition anumber of supportive initiatives are also inproduction or planned, such as:Creating Capable Teams Approach(NIMHE 2007) a Workforce Planningresource, which uses the ESC as a foundationin providing best practice guidance to working and new roles in mental health.www.newwaysofworking.org.ukLearning and Development Toolkitof the range of workforce and educationwww.newwaysofworking.org.ukUnderstanding Framework which will providecurricula for education and training in relationto forensic and non-forensic PersonalityDisorder practice. Proposals to develop additional learningexplore Gender Equality in Mental Health. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance The Ten Essential Shared Capabilities Induction Module http://visit.lincoln.ac.uk/C6/C12/CCAWI/ESC%20Learning%20Materials/Induction%20Module%20October%202007.pdf Essential Shared Capabilities Learning Materials: Race Equality & Cultural CapabilityEssential Shared Capabilities Learning Materials: Dual DiagnosisDepartment of Health, New Ways of Working, Creating Capable Teams (CCTA): best practice guidance to support theimplementation of New Ways of Working (NWW) and new rolesDepartment of Health, A Learning and Development Toolkit for the whole of the mental health workforce across bothhealth and social care Setting the Standards for Educationdeveloped nationally or locally, should be theinvolvement of service users and carers in itsdevelopment and delivery. To achieve equitablecarers from minority or equality groups shouldbe ensured. The National Continuous Quality ImprovementTool for Mental Health Educationeducation commissioners and providers ensureprogrammes are consistent with the MHNSF. It provides guidance on the meaningfultheir carers in the planning, design, delivery andevaluation of education programmes. Thisincludes user and carer involvement in courseThe role of care co-ordinator is pivotal to thesuccess of (new) CPA. To strengthen the role,and to reduce local variation, work has beenundertaken to identify care co-ordinatorprinciples of practice, core functions andOccupational Standards and the Knowledge andSkills Framework). These are set out in CPAcompetences outline report.review and redesign care co-ordinator rolesand responsibilities within services;consider and review the distribution of apractitionerÕs workload and caseload, in thelight of care co-ordination responsibilities;agree local protocols for the delegation of specific tasks associated with care co-ordination, where the care co-ordinatorremains both responsible and accountable for the appropriate and effective delivery ofthe care co-ordination function;inform service governance processes; services, and people who support them.www.nimhe.csip.org.uk/cpapp 14 Brooker, Readhead and Curran 2005/2006 available from CCAWI http://www.lincoln.ac.uk/ccawi/CPA competencies outline report available from https://www.nimhe.csip.org.uk/cpa Section 6: Supporting The Workforce The role of the (new) CPA care co-ordinatorbest placed to oversee care management andresource allocation and can be of any disciplinedepending on capability and capacity. The careco-ordinator should have the authority to co-ordinate the delivery of the care plan and ensurethat this is respected by all those involved indelivering it, regardless of the agency of origin.It is important that they are able to supportHowever, it is not the intention that the care co-ordinator necessarily is the person that deliversthe majority of care. There will be times whenthis is appropriate, but other times when theactual therapeutic input may be provided by anumber of others, particularly where morespecialist interventions are required. Thisapproach supports the principles of New Waysof Working, which aims to use the skills of all inthe most appropriate, effective and efficientmanner.the care co-ordinator may be a crucial factor inestablishing trust and a therapeutic relationship. Services users should also be afforded a choiceof care co-ordinator which takes account of anycultural or religious needs. Local workforcestrategies should ensure appropriate team skillImplementing CPA: Successful care assessment and planning is amulti-disciplinary and multi-agency endeavour,although the role of the care co-ordinator iscritical. To support individuals, teams andorganisations implement this guidance, and toimprove integrated approaches to risk anddevelopment package for the range of staffwww.nimhe.csip.org.uk/risk Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Department of Health, New Ways of Working for Everyone Capacity and EffectivenessCapacity can be measured at organisation,assured care which can be delivered to serviceusers and carers by that team. It can beThe Creating Capable Teams Approach(CCTA) provides a means to produce a team level workforce plan which can then contribute to the organisationÕs overallUsing those skills in the most effective way,utilising the principles of New Ways ofWorking and a model of distributedresponsibility.Establishing efficient processes which minimisewasted, or non-value-adding, effort. Processredesign and the principles of Lean thinking(references appended) can assist with theproduction of easily understood andnegotiated care pathways which minimisebureaucracy.A truly person-centred approach to workingwith service users and carers.The availability, and creative use, of sources contribute to care plan delivery. Efficient communication processes and clinicaltechnology.Effective team leadership and management,including readily available supervision, adviceCommunity Mental Health Teamsopportunities afforded by New Ways ofWorking, technological change, and choicenot appropriate. Trusts should agree appropriateSome organisations use modelling tools to workout the effect on capacity of changing skills mixor team organisation. These still use judgementto determine appropriate workloads, and mustsupport, as well as direct contact, to ensuredeveloped Õcare packagesÕ for different types ofcapacity and capabilities required of the team. Department of Health, New Ways of Working, Creating Capable Teams (CCTA): best practice guidance to support theimplementation of New Ways of Working (NWW) and new rolesDepartment of Health, Creating Capable Teams Approach (CCTA): Best practice guidance in the implementation of New Ways of Working (NWW) and New Roles. Available at www.newwaysofworking.org.ukDepartment of Health, Mental Health Policy Implementation Guide: Community Mental Health Teams Section 6: Supporting The Workforce At practitioner level, tools which profile acaseload according to the time and intensity ofthe interventions required to meet the needs,throughput, avoiding the creation of waitingAgain, there are several such tools being used.have not yet been subjected to rigorous trials. www.nimhe.csip.org.uk/cpappIn reviewing policies and practice in light ofavailable to ensure all staff are competentservice-user and recovery focused servicesuse the national statement of care co-ordinator competences to strengthen therole locally and inform workforce planningon CPA and Risk and Safety: furtherconsider how capacity and effectiveness canbe improved  Refocusing the Care Programme Approach: Policy and Positive Practice Guidance clients or service users. How well CPA isimplemented can provide an overview and anefficient, effective and service user focused CPA means. Auditing and monitoring the quality of care willremain essential components of secondarycarers, whether needing the support of (new)CPA or not. The need for systems to measure the impact ofhas been included here. An approach toimproving the quality of services that does notdeliver equitable improvements to all.Trusts will need to continue to captureinformation about individuals receiving theirpurposes whether they are on (new) CPA or not. Trusts should have an appropriate central record of all service users receivingtreatment, care and support provided by them.This system, alongside electronic systems, will provide reports to managers and staffconcerning caseloads and other relevantuntil such time as a full electronic record isavailable to provide a comprehensive list of all activity.All providers of specialist mental health servicesfor adults and older adults are mandated to(MHMDS). There will be acontinuing requirement to complete MHMDSreturns on every individual receiving secondarymental health care, even those not on (new)CPA. Dataset descriptors of ÒstandardÓ andÒenhancedÓ CPA will be amended to non-CPAand CPA in due course. routinely collect data on service usersÕ race,ethnicity, gender etc, so that the impact andaccessibility of service delivery for these groupscan be measured and action taken to addressinequalities, where necessary. Section 7: Measuring and Improving Quality NHS, Mental Health Minimum Datasethttp://www.ic.nhs.uk/ourservices/imposing-patient-care/mental-health/mental-health-minimum-dataset Regulatory bodies recognise the importance ofagreeing indicators that can be used as part ofpartners involved in the provision of secondarymental health care. If indicators only apply toeither the health or social care organisations thiswill not help to lever change across all theagencies with a central role to play in deliveringThe Healthcare Commission and the Social CareInspectorate undertook a joint review ofcommunity mental health services in 2005/6,which looked at aspects of CPA. There is scopewithin existing systems to develop a moreintegrated approach to how integratedapproaches such as CPA are assessed and thecommunity review was testimony to this. TheGovernmentÕs wider review of regulation plansto bring together the Healthcare Commission,the Commission for Social Care Inspection will provide a further opportunity to developthis approach.of service provision and CPA. A number of auditreporting into clinical governance and localdevelopment of audit from a service user the CPA Association (CPAA) standards andprotocol for CPA;the CPA Brief Audit Tool (CPA-BAT)developed for assessing the quality of CPAcare planning for service users who have beenmore than one compulsory admission tohospital in a period of three years. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Healthcare Commission & Commission for Social Care Inspection, No Voice, No Choice: A joint review of adultcommunity mental health services in EnglandDepartment of Health, An audit pack for monitoring the care programme approachhttp://www.cpaa.co.uk Sainsbury Centre for Mental Health & Mental Health Act Commission, The CPA Brief Audit Tool (CPA-BAT) forassessing the quality of CPA care planning for service users who are frequently detained The CPAA, as part of the CPA review, carriedcurrent process of audit of CPA within mental28 trusts responded. Although it is not possibleto draw conclusions for all trusts, from thissample there was sufficient information to beare that for local audits:only half include carersÕ views;audit reviews and reports generally feed intomanagement and governance review systemsopinion varied on the impact of CPA auditgreat impact (impact was viewed as oftenand in particular medical staff);the majority welcomed the proposal toAs a result of this survey, and general CPAreview feedback, DH is commissioning a reviewof local CPA audit tools and methods to judge if they meet the requirements of updated available in 2008. Key elements the review isa focus on service user and carer satisfactionprocesses;use of outcome measures, including user-defined outcomes, to measure success;improved attention to issues around housing,recovery needs;CPA systems; Section 7: Measuring and Improving Quality Until the review is undertaken and furtherguidance provided, trusts should continue withcurrent local audits, include findings from theNational Patient Survey, to review performanceand drive improvement within local teams. www.nimhe.csip.org.uk/cpappwww.nimhe.csip.org.uk/cpappIn reviewing policies and practice in light ofusers in secondary mental health care,note that review of Regulators will consider how a more integrated approachnote the review of local audit tools Ð further  Refocusing the Care Programme Approach: Policy and Positive Practice Guidance However, it is important that where CPA isconsidered relevant for children and youngpeople it is tailored to their requirements.Adults who have parenting responsibilities for achild under 18 years may require help withthese responsibilities. In such cases, councils mayalso have a duty to provide services underSection 47 of the Children Act 1989safeguard and promote the welfare of childrenin their area. Where appropriate the ÔFrameworkfor the Assessment of Children in Need andshould be used to explorewhether there are any issues relating to childrenin need and their parenting. Under the Childrena service may be provided to any memberof a childÕs family, if it is provided with a view tosafeguarding or promoting the childÕs welfare.Adult services have a continuing role ofsupporting parents when childrenÕs servicescarry out their responsibilities under the ChildrenAct. It is important that adultsÕ and childrenÕsservices work together to provide adequatesupport for parents.be involved with two assessment processes: the Single Assessment Process (SAP) and theCare Programme Approach (CPA). The aim ofSAP is to ensure a person-centred approach toassessment and care planning for older people,regardless of organisational boundaries. Servicesare at different positions in integrating thespecialist CPA and the more generic SAPmethodologies. Some are maintaining the CPAas a separate specialist assessment and careplanning framework, others are trying toincorporate key elements of the CPA as anintegral part of specialist assessment and careplanning under SAP. Annex C provides furtherguidance on the relationship between CPA and SAP. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Sainsbury Centre for Mental Health & Mental Health Act Commission, The CPA Brief Audit Tool (CPA-BAT) forassessing the quality of CPA care planning for service users who are frequently detainedChildren Act 1989 http://www.opsi.gov.uk/acts/acts1989/Ukpga_19890041_en_1.htmDepartment of Health, Framework for the Assessment of Children in Need and their Families The MHNSF standards and guidance apply toanyone else. While there are some excellentfind it difficult to access mainstream mentalSince 2004, the ÔGreen Light ToolkitÕhelped mental health services judge progressand plan action. A national programme ofhealth checks which inform the Person-centredshould form part of this plan and not be seen ason referral to the secondary mental healththe learning disability services and GP.www.nimhe.csip.org.uk/cpappwww.nimhe.csip.org.uk/cpappMovement of offenders between prisons (often at very short notice and to different areasand regions) and movements between prison,continuity of care due to poor exchange ofinformation. There can be a lack ofprofessionals regarding the criminal justicesystem and of Offender Managers regarding the mental health and social care systems. discontinuities in care and to offenders withmental health needs not receiving the care andsupport they need. In some circumstances thismay lead to increased risk of re-offending andincreased risk of harm to the public. It is therefore vital that relevant informationaccompanies the offender/service user duringtransition through the offender pathway andthat both CPA care co-ordinators and Offenderthe health and criminal justice systems. As theredisabilities in prisons there is also a need toensure that assessments for these individuals arelinked with the Person-centred Health Action  NIMHE/CSIP Delivery Race Equality Programme http://www.csip.org.uk/about-us/about-us/equality-and-diversity-.html Annex A: CPA and Other Assessment and Planning Frameworks National Treatment Agency The National Treatment Agency (NTA) endorses the CPA framework as an approach to co-ordinating the care of people with asevere mental disorder and substance misuseproblems within mental health services.71, 72, 73treatment providers should contribute to theCPA process where appropriate. NTA guidance also indicates that peoplereceiving treatment within substance misusemental health problems should have their careco-ordinated by the allocated key worker in thekey worker has the responsibility to develop acomprehensive care plan addressing the fulluser and carers. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance National Treatment Agency for Substance Misuse, Models of care for treatment of adult drug misusersNational Treatment Agency, Care planning guidanceDepartment of Health, Drug Misuse and Dependence: Guidelines on Clinical Management The educational needs of children and youngChildren, more than adults, are likely to besubject to multiple care plans and reviewmechanisms from multiple agencies e.g. Needs reviews, (childrenÕs) Common AssessmentFramework (CAF). All professionals andagencies need to work together to ensureand clarity of roles (especially who is leading) toavoid confusion and risk. CPA needs to be seenchildren with complex needs and agreementmust be made locally on how to co-ordinatemulti-agency care planning. To ensure continuity of care the care co-ordinator should follow the transition protocolsat their Trust for CAMHS to adult services.Children and Young PeopleÕsYoung peopleÕs involvement brings advantagesin terms of promoting user empowerment andchoice. However, to make young peopleÕsinvolvement in CPA a reality rather than anaspiration careful attention needs to be paid to,for example, the design of paperwork so thatservice users do not feel excluded. Children andtailored to them, to recognise their process ofKey issues in relation to the involvement ofyoung people are that:The review and other meetings should beinterpreters); information leaflets andpaperwork should be age-appropriate; staffin such a way as to ensure young peopleÕsviews are heard and taken into account.Young people should be supported in thisprocess, using advocates as necessary, andviews; the views of their parents and carersshould also be incorporated, and whereappropriate, distinguished from those of theprotocols for working together in this process,information sharing processes.Local teams are likely to have experience ofcross-agency meetings for Looked AfterChildren (LAC) and family group conferencesdeveloping care plans for children and young Refocusing the Care Programme Approach: Policy and Positive Practice Guidance key issues in relation to the assessment, careplanning and care co-ordination of older adultswith mental health needs who receive secondarymental health services. It is informed by currentthinking, policy and responses to the CPAreview consultation. It builds on the advice setEverybodyÕs BusinessThe range of mental health problemsdepression, anxiety, delirium, dementia,schizophrenia and other severe and enduringmental health problems, and drug and alcoholOlder adults and their carers shouldterms of the health and social care service theyreceive.social care needs associated with ageing,co-morbidity. These needs must be met withinand across services that currently often havehave choice and control over how their mentalhealth care is managed and have a say in howtheir problems are understood. Carers alsorequire their needs to be understood and haveinvolvement in care plans which affect them.broader health and social care needs in additionto those associated with mental health, or therewill be a danger that aspects of care may bemissed and remain unmet. An older personÕssocial care needs can be highly complex andordinated and focused service response acrossagencies may already be managing that personÕscare and the person does not necessarily alwaysrequire a lead co-ordinator from mental healthrepeated questioning. Staff need to be able torequire to deliver and direct care withoutunnecessary duplication or repetition. The Refocusing the Care Programme Approach: Policy and Positive Practice Guidance Annex C: CPA and Older Adults Department of Health, EverybodyÕs Business. (Nov 2005)Department of Health, Securing better mental health for older adultsAge Concern England, Improving services and support for older adults with mental health problems Ð The second reportfrom the UK inquiry into mental health and wellbeing in later life. (August 2007)Department of Health, Human Rights in Healthcare Ð A Framework for Local Action. (March 2007) When to use (new) CPAWhen a personÕs mental health and social carepackage is complex, predominantly mentalhealth related and the characteristics in section 3of this guidance on (new) CPA are present, theircare will normally require care co-ordinationusing CPA and a mental health lead care co-ordinator should be allocated. SAP can provideCPA will provide the specialist care planning,review and health and social care provision thatis required to meet this personÕs needs.Transfer from adult to older adultÕsCurrent policy makes clear that care should beoffered on the basis of need and not age orservice configuration. Transfer of care from adultno exception. Transfer should only occur whenprofessionals working with older adults, and notjust because an individual reaches a certain age.appropriate it will necessitate a transfer of careco-ordinator and care plan. If the person hasformerly required the support of secondaryfollowing reassessment at transfer, with the SAPsupport and represent the person in particularcircumstances. It is essential that the lead co-ordinator communicates with and assists the IMCA to carry out their role.A personÕs needs change over time, and fromterms of degree of risk and complexity of need.The appropriateness (new) CPA must bereviewed in line with these changes. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance The key principles of person-centred care are:it is a continuous process not a product;it is a dynamic process of discussion, negotiation, decision making and reviewthat takes place between the individual and the professional Ð who have an the process should be led by the individual with them at the centre, basedupon their strengths, goals, aspirations and lifestyle wishes; the person should be encouraged to have an active role in their care, beoffered options to allow informed choices, and empowered to make their ownself care and self management is an essential element of good care/support Recovery is a concept that has been introduced primarily by people who haverecovered from mental health experiences and has grown considerably aroundthe developed world. Now many people are talking about and using the wordÔrecoveryÕ. However, in England, people have differing views of what recoverymeans, whilst the word is being included in common usage in mental healthservices, a clear understanding of what this means remains limited. NIMHE hasproduced a brief statement on the emerging view of mental health recovery to contribute to the development of recovery-oriented services nationwide.participate in, and contribute to, society and community as the rest of thepopulation. This includes improving access to health and social care services butalso to community services to enable people to participate. It involves increasingaspirations. Key areas are education, employment, housing, family andrelationships, financial security, leisure, arts, cultural and religious opportunities and participation in civic life. Refocusing the Care Programme Approach: Policy and Positive Practice Guidance http://www.personalitydisorder.org.uk/assets/Resources/32.pdf Statement of Statements of wishes and preferences, including written statements, are those Wishesthat are non-binding but which have to be taken into account by those makingbest interests decisions on a personÕs behalf at a time when the person lacks capacity having been made when they had capacity.The reference to people in unsettled accommodation includes: rough sleepers and people living in insecure accommodation e.g. hostels, night shelters, squats,or living with friends or in bed and breakfast accommodation; and individuals orfamilies living in temporary accommodation who are owed the main homelessness duty.Young CarerAround 3 million children in the UK have a family member with a disability. Not all take on a caring role that is inappropriate to their age. Few parents wanttheir children to be carers but it can happen for many reasons, such as families being isolated, afraid of outside interference or lack of other support. Annex D: Glossary