Introduction
The provision of advice is a fundamental need for people with mental health problems. The majority of people in this group are not in work and on very low benefit income. Only 24% with long term mental health problems areinwork, the lowestemployment rate of any disabled group (ODPM, MentalHealth and Social Exclusion, 2004).
The consequences of people being unable to manage their affairs or maximisetheir income can be extremely serious. People with mental health problems are nearly three times more likely to be in debt (ODPM ibid). Major indebtedness can lead to loss of a home, loss of services or legal action, which could seriously impede the recovery process and increase people’s need for support from mental health services.
Citizens Advice Bureaux across England run around 100 advice projects targeted at people with mental health problems, delivered mostly in hospital or community mental health settings. The service can include information, advice, practical help and representation, depending on the needs of the service user.
In providing this service, advisers take large number of referrals from health and social services staff, as well as self–referrals by patients. This results in considerable experience of the relationship between care planning and a range of social issues, including income and benefits, debt, consumer problems, housing and employment.
In our report Out of the picture: CAB evidence on mental health and social exclusion, published in 2004, Citizens Advice argued that when unwell, people with mental health problems need support to cope with their illness and advice and help to deal with the benefit system, debts, social activities and moves into work. The recommendations included developing strategies for:
- Training social workers, community psychiatric nurses, psychiatrists and GPs about the importance of advice and help on income maximisation for people with mental health problems
- Developing procedures for prompt referral of clients who need financial help to specific agencies so that, as part of their care programme, they are fully informed about benefit entitlements and have help to maximise their income and deal with debts.
Consultation questions from Section 2: Values and principles underpinning the care programme approach.
Q. Are the values and principles set out in this section the right ones?
We endorse the principle of a CPA aimed at ensuring that this group of people has access to support and services, across the provider spectrum, to meet their diverse needs, strengths, preferences and choices, promoting care activity across the individual’s life domains. We recommend that these should not be limited to care and treatment issues but explicitly include income maximization and provision of goods and services as well as housing, employment, leisure, education and other needs.
Q. cIn what ways might the current systems of operating the CPA be improved to ensure that these values are met?
Experience of CABx that provide advice in mental health settings suggests that what is taken into account in care planning varies a great deal in practice. One bureau in the South East commented “Whether service users get referred toagencies like ours depends greatly on their individual care co-ordinator or support worker and whether s/he sees us as the appropriate agency to use - some use us all the time for most of their clients, others rarely refer.”
Ensuring that this happens effectively is more likely where mental health staff have a regular working relationship with advice agencies. In Kensington and Chelsea, for example, the CAB advice workers are effectively embedded in the inter-disciplinary mental health team, attending team meetings etc. A CAB in Staffordshire reports that mental health professionals recently gave very positive feedback about the service provided by the CAB.
In many other places where advice workers operate in mental health settings, there is regular informal communication as well as more formal methods such as participation in team meetings, exchange of induction and other training etc. A CAB in the North West, that has been providing outreach services in mental health settings for many years, has found that care co-ordinators will identify a patient with debt problems, for example, and refer them to the bureau, after which advice becomes a part of the care plan.
Problems often seem to follow discharge of patients from hospital. Where this happens at short notice, where the patient lives some distance away or where continuing support is not assured by, for example, a community mental health team. Bureaux can find that they are likely to lose touch with patients when this happens, and continuity of advice is lost.
We recommend that future guidance should encourage care co-ordinators and their managers to build links with agencies, including voluntary sector agencies, providing non-treatment support for people with mental health problems.
Section 4: The care co-ordinator
Q. Is there more that needs to be done to clarify and support the role of care co-ordinator?
There may often be scope for a broader approach to the care co-ordinator role, extending beyond basic treatment issues. We recommend regular liason between care managers and advice agencies, in order to enhance the development of pathways to maximizing client income.
Turnover of health and care staff has been identified as an issue by a number of CABx. We recommend that new staff have an induction that includes awareness of money problems as a factor in mental health and options and pathways for referring patients for independent advice. This is particularly where new appointees may have little experience of the welfare benefits system.
Q. What kind of training would enhance the care co-ordinator role?
We recommend training to raise basic awareness of benefits and potential debt problems, enabling care co-ordinators (and other mental health staff) to identify more effectively the money (and related) problems of users. Some CABx, for example Sheffield Mental Health and Kensington & Chelsea, offer a benefits awareness course for health care professionals, enabling them to identify possible entitlement to benefits such as DLA and refer users as appropriate.
Section 5: Continuity of care
Q. What can services do to ensure that service users and their carers are better informed about what action to take, and who to contact, in a crisis?
Where social factors such as actual or threatened homelessness or money problems are a factor in crises, information on access to advice services would be useful. Clearly there would be benefit in minimizing the risk of crises that may threaten recovery or stability. We recommend that steps are taken to ensure that all patients’ social needs are taken into account in all aspects of care planning.
Section 7: Physical health and social outcome needs
Q. What more should be done to ensure that the physical and social outcome needs of services users are considered and met?
The experience of many CAB services working with people who have mental health problems is that much can be done to minimize the stresses on service users by means of advice and information. In some places the potential for advice services to enhance patients’ experience seems well understood; but this is certainly not universal. In other cases care co-ordinators seem to have little idea what to ask or who to refer to.
It is important to be clear that patients need not only access to service providers such as the Department for Work and Pensions/Jobcentre +, and housing providers. Advice agencies play a crucial role in identifying and explaining patient’s rights and responsibilities, providing a range of information and practical support such as form-filling, and negotiating on patients’ behalf.
We recommend that addressing income, benefits and debt should be a part of the formal care programme assessment process. This should be an integral part of the care plan, not being left to the discretion of the care co-ordinator. There is a need for clear standards and referral protocols in this area, against which performance can be measured and accounted.
Incorporating advice services more effectively into care planning will require adequate resourcing to ensure their availability for referral and consultation. The level of provision of advice services for mental health service users currently varies considerably. We recommend that this is addressed if patients are to be sure of an effective and holistic care programme that addresses social and practical issues as well as treatment.
Social Policy contact: Liz Phelps Liz Phelps
National Development contact: Ian Thomas Ian Thomas
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