Service user experience in
adult mental health
Implementing NICE guidance
December 2011
NICE clinical guidance 136
What this presentation covers
Epidemiology of mental health problems
Costs and savings
NICE pathway & NHS Evidence
Find out more
Quality standard
• Several documents and initiatives have highlighted the
importance of the service user's experience and the
need to focus on improving these experiences where
• Despite these initiatives further work is needed to
deliver the best possible experience for users of NHS
• High-quality care should be clinically effective, safe and
be provided in a way that ensures the service user
has the best possible experience of care.
Epidemiology of mental
health problems
Mental ill health represents around 23% of the total
burden of ill health in the UK and is the single largest
cause of disability.
One in six adults in England will have a mental health
problem at any one time.
Demand for mental health services is increasing. In
2009/10 more than 1.25 million people (2700 per
100,000 population) used NHS specialist mental health
This guidance makes recommendations on the
appropriate treatment and care of people within the
NHS. The accompanying quality standard is based on
the guidance recommendations.
The guidance and quality standard cover people who
use adult NHS mental health services in community and
inpatient mental health settings.
The guidance does not cover those using mental health
services for physical health problems or carers’
experiences of services.
The key recommendations are those from which the quality
statements were developed. These cover :
Relationships and communication
Avoiding stigma and promoting social inclusion
Decisions, capacity and safeguarding
Engaging service users in improving care
Access to care
Community care
Assessment and referral in crisis
Hospital care
Assessment under the Mental Health Act (1983; amended
1995 and 2007)
• Control and restraint, and compulsory treatment.
Relationships and
When working with people using mental health services
and their families and carers:
• work in partnership
• offer care in an atmosphere of hope and optimism
• take time to build trusting, supportive, empathic and
non-judgemental relationships
• promote active participation in treatment decisions and
• maintain continuity of therapeutic relationships
• offer access to a trained advocate.
Avoiding stigma and
promoting social inclusion
When working with people using mental health services
ensure that you:
• take into account stigma and discrimination
• are respectful of and sensitive to service users’ gender,
sexual orientation, socioeconomic status, age,
background and any disability
• work with local authorities and health/social care
Advance statements and
advance decisions
Develop advance statements and advance decisions
with the service user if they wish to do so. Document
these in their care plans and ensure copies are held by
the service user and in primary and secondary care
When a service user has impaired capacity, check their
care record for advance statements and advance
decisions before offering or starting treatment.
Engaging service users in
improving care
Service providers should consider employing service
users to be involved in the training and support of health
and social care professionals.
Such training should be tailored to the needs of people
who attend mental health services and should be
evaluated using experience of care as an outcome.
Engaging service users in
monitoring experience
Consider employing service users to monitor the
experience of using mental health services. Offer
service users training to do this.
Reports on experience of care
Service managers should commission reports on the
experience of care. These reports should:
• include data that allow direct comparisons of the
experience of care according to gender, sexual
orientation, socioeconomic status, age, background
(including cultural, ethnic and religious background)
and disability
• include analyses of data from multiple sources
• be routinely communicated to the health and
social care providers’ board.
Access to care: referral
When people are referred to mental health services,
ensure that:
• they are given/sent a copy of the referral letter
• they are offered a face-to-face appointment within 3
weeks of referral
• they are informed that they can change the
date/time of the appointment
• any change in appointment does not result in a
delay of more than 2 weeks.
Access to care: working
Mental health services should establish close working
relationships with primary care services and third sector
organisations to ensure:
• agreed processes for referral are in place
• primary care can provide information about mental
health and social care services
• that all people have equal access to services based on
clinical need
• services are culturally appropriate.
When carrying out an assessment:
• ensure there is enough time for the description and
discussion of problems and for summarising
• explain the use/meaning of any clinical terms
• explain and give information in an accessible format
about any diagnosis given
• give information about different treatment options
• offer support after the assessment, particularly if
sensitive issues have been discussed
• ensure the wait before an assessment is no
longer than 20 minutes after the agreed
appointment time.
Community care: care plans
Develop care plans jointly with the service user and:
• include activities that promote social inclusion
• provide support to help the service user realise the
• give the service user an up-to-date written copy of the
care plan, and agree a suitable time to review it.
Community care: crisis plans
For people who may be at risk, a crisis plan should be
developed and should include:
• early warning signs and coping strategies
• support to help prevent hospitalisation and where the
person would like to be admitted
• the practical needs of the service user if admitted to
• details of advance statements and advanced decisions
• whether families or carers are involved
• information about 24-hour access to services
• named contacts.
Community care: continuity of
Health and social care providers should ensure that
service users:
• can routinely receive care and treatment from a single
multidisciplinary community team
• are not passed from one team to another
• do not undergo multiple assessments unnecessarily.
Assessment and referral in
• Assessment should be undertaken by experienced
professionals competent in crisis working
• Assessment should include relationships, social and
living circumstances and level of functioning
• A service user should be seen within 4 hours of referral
• Health and social care providers should provide local
24-hour helplines
• Crisis resolution and home treatment teams should be
accessible 24 hours a day.
Hospital care
Undertake shared decision-making, including, whenever
possible, with service users who are subject to the Mental
Health Act.
Offer service users in hospital:
• daily one-to-one sessions lasting at least an hour
• regular one-to-one sessions lasting at least
20 minutes with their consultant
• an opportunity to meet with a specialist mental health
• access to a wide range of meaningful and culturally
appropriate occupations and activities.
Assessment and treatment
under the Mental Health Act
When a service user is admitted to a ‘place of safety’
• they are assessed for the Mental Health Act within 4
hours and that this assessment is carried out in a calm
and considered way
• that the reasons for the compulsory detention or
treatment are explained and understood
• that the receiving mental health service is informed so
they are expecting and are ready to welcome the service
• the service user is informed of their right to
Control, restraint and
compulsory treatment
Control, restraint and compulsory treatment including
rapid tranquillisation, should be used:
• as a last resort
• when all means of negotiation and persuasion have
been tried
• by trained healthcare professionals.
Document the reasons for such actions.
Costs and savings
There is unlikely to be significant resource impact associated with
implementing the guidance and achieving the quality standard,
although commissioners and providers may need to invest time in
activities that support improved service user experience, such as:
• implementing systems and undertaking audit to proactively measure
service user experience
• promoting a positive culture of communication and integration
• involving service users in service redesign to improve service user
In some instances this may involve an initial investment of resources,
however this may lead to a reduction in future negative service user
experiences and an associated saving in resources.
• What steps do we need to take to make sure that we
engage service users within service improvement?
• Do professionals within our service need training or
update training about providing person-centred care?
• Do we routinely develop advance statements within our
service? If not how can we do this?
• Do mental health services in our area have a good
working relationship with primary care services?
• How can we change practice to meet
NICE Pathway
The NICE service user experience pathway will be
available soon and covers recommendations on:
• care and support across all points
on the care pathway
• access to care
• assessment
• community care
• hospital care
• discharge and transfer
• assessment and referral in crisis
• assessment and treatment under
the Mental Health Act
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NICE Pathways
NHS Evidence
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evidence on all
aspects of mental
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the NHS Evidence
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Visit for:
the guidance
‘Understanding NICE guidance’
support for commissioners and others
baseline assessment tool
audit support
Quality standard
The quality standard outlines the level of service that people
using NHS mental health services in England should receive.
It describes markers of high-quality, cost-effective care that
should contribute to improving the effectiveness, safety and
experience of care for service users in the following ways:
• enhancing quality of life for people with long-term conditions
• ensuring that people have a positive experience of care
• treating and caring for people in a safe environment and
protecting them from avoidable harm.
The quality standard consists of 15 quality statements and
was developed from the guidance.
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