Introduction
Citizens Advice Bureaux have been delivering services in an increasing number of health and social care setting for many years. By 2005 these included 773 GP surgeries and health centres, 158 mental health community facilities, 80 psychiatric hospitals and 62 general hospitals. Citizens Advice is therefore able to draw on a wide experience of advising people with mental health problems, as exemplified by our 2004 report Out of the picture: CAB evidence on mental health and social exclusion. The role of advice in mental health settings is also illustrated in Prescribing advice: improving health through CAB advice services.
Question 1: Overall approach.
a. The paper acknowledges (p5) that it takes a fairly conservative approach. It states that where there are no explicit models, it focuses on resource requirements for provision of accepted treatments and services based on current examples of good practice (p9).
There is a risk that this approach, by focussing on treatments and services as a basis for a model for a good mental health service, will not take sufficient account of other ways of achieving the outcomes of sustaining health, aiding recovery and combating social exclusion. It is likely to give less emphasis to innovative or non-medical services that can also contribute to those outcomes.
There is also a danger that the paper’s conclusions, which point to severe staffing shortages across a range of services, may be challenged on the grounds that alternative models of service delivery may not been explored.
If the aim is to achieve a broad consensus of opinion on a model, there is a strong case for exploring other approaches. For example, the IPPR paper Mental Health in the Mainstream: a good choice for mental health outlined an alternative model for example (walk-in community mental health centres for physical and mental health needs from which clients 'chose' the services they wanted, which would include 'trained counsellors who can direct people to specialist health services, as well as leisure, transport, housing, financial advice...etc').
b. Local examples of good practice could be broadened to include services, such as advice services, often provided within mental health service settings and delivered in partnership with statutory mental health services and usually funded from NHS and local authority budgets. Advice for service users, particularly on welfare benefits, debt and housing, helps to maintain income and security, which is likely to be beneficial to sustaining health. Conversely, low incomes and insecurity are likely to undermine health and frustrate recovery. The role of support for service users on benefits and employment is recognised on p20 of the paper, in the context of CMHTs, but not explicitly elsewhere.
A wide range of advice services in mental health settings is illustrated in Advice for people with mental health needs, a directory of Citizens Advice mental health projects. There are also examples on the NIMHE web site and in the SEU publication Action on Mental Health.
Question 2: Mental health promotion
a. The approach appears too conservative. The discussion of what type of service on p11 focusses on mental health promotion, but we feel that it does not really explore the combating of discrimination or the wider promotion of social inclusion. Suggested specifications, based largely on existing practice (and drawn from a relatively small number of PCTs), may well exclude important services, particularly of a non-clinical nature, from the estimation.
b. There may be a case for looking more widely at the range of programmes and associated budgets referred to on p11. Promoting social inclusion needs to take into account issues such as individuals’ financial circumstances, employment and housing status. The Citizens Advice publication Out of the picture, based on evidence about mental health and social exclusion, illustrates this point. Advice and information on welfare benefits, debt, employment and housing can be extremely useful for services user at most levels of mental health care. Ensuring that people receive entitlements and that serious debt can be managed and reduced will contribute to combating social exclusion
Question 3: NSF standards 2 & 3
a. The paper states that at present there is no clear model or consensus for mental health services at the primary care level. It then goes on to estimate need for services purely in terms of medication and CBT, being the two major forms of treatment in primary care. However, unlike the section on standards 4 and 5, this section includes no consideration of broader support needs.
We believe that definition of a good mental health service at primary care level should include provision of information and advice services, which can provide a crucial gateway to a wide range of other services.
In England and Wales there are currently 773 Citizens Advice Bureau outreach services located in primary care settings.
b. and
c. We are not currently in a position to analyse the range of mental health conditions of people using advice services in GP settings, although anecdotal evidence indicates that they are not confined to depression and anxiety and include, for example, people with obsessive-compulsive disorder.
Question 4: Community-based teams
We have no comment to make here
Question 5: Support workers
Support services as described on p24 cover a fairly wide range of services, including information and advice. Box 9 on p20 suggests 4 WTE support workers per CMHT, assuming that one per team will be a specialist in employment and benefits for users. It is not clear, however, whether this would include, for example, finding employment. We are not currently in a position to estimate the scale of service that would be required to meet users’ generalist advice needs in the context of community-based teams see answer to question 11).
CABx provide services in 158 community mental health settings. It is important to have advice services physically co-located with mental health services. For many service users this is the only way in which they are likely to be comfortable accessing services, at least until they have had the opportunity to develop a relationship of trust with the advice agency. “High street” advice services are often over-subscribed; on-the-spot access via referral to appointments avoids the stress of going to unfamiliar venue, queuing in crowded waiting rooms and having to explain difficult issues to unknown advisers.
Question 6: Inpatient and residential services
a. No comment
b. Here again no specific attention is paid to advice and information; the main focus seems to be on nursing levels, except for other hostel accommodation. Estimates of social workers and occupational therapists are included in Box 14, though without specific discussion. Both these groups are significant sources of referrals to advice workers. CABx provide advice in 80 psychiatric hospitals or units.
Question 7: Day care and employment schemes
Many Citizens Advice Bureaux operate in day centres. It could be worth exploring how far advice services might fulfil some aspects of the bridge building role, but in any case there is a specific role for advice services in this context.
Question 8: Forensic services
We have no comment to make on this.
Question 9: Prison services
A Citizens Advice service is provided at Broadmoor (previously also at Ashworth) and also in 46 other prison venues.
Question 10: Sub-speciality services
We have no comment to make on this.
Q11: Coverage
Our overall view is that effective delivery needs a wider interpretation of the services required for the implementation of the NSF and possibly a broader social model for services. From our own viewpoint that means advice and information, though it might also include support workers who seem to have been omitted from Box 26 summarising staff increases required.
Advice and information – not just about health and care services - should be an integral part of mental health care across a wide range of groups. However, it is difficult to quantify the levels required. Existing Citizens Advice services for mental health service users often cover both hospital and community facilities, and to conform to the paper’s approach it might be necessary to disaggregate these. Few if any of these services are currently able to meet all demands. Research would be needed to quantify desirable levels of provision.
We would be pleased to have the opportunity to discuss these comments further.
National Development contact: Ian Thomas
ian.thomas@citizensadvice.org.uk
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