GPs to access ‘personalised care plans’ for people with severe mental health problems
People with severe mental health problems should be given a ‘personalised care and support plan’, which should be accessible to GPs, NHS England has said.
The commissioner has published a new framework setting out what core elements of care that mental health services must provide to everyone with severe mental health problems.
It said that ‘care and support plans’ and ‘safety management plans’ should be available to the person and staff who may need to access them, including the person’s GP.
It comes as ICBs have been tasked with reducing variation in GP practices’ QOF performance as part of a new NHS-wide quality strategy.
As part of the quality improvement work, NHS England is developing a series of modern services framework – aimed at reducing unwarranted variation – starting with a cardiovascular framework, a second one on sepsis, with the mental health one being the latest to be published.
The framework added that where a person is being discharged to primary care, a ‘care planning meeting’ should take place and include the person.
At the point of discharge, the person and their GP should be provided with:
- reason for change in care
- a discharge plan that details how the person can re-access support from the community mental health service – including a working hours telephone number and email address
- information about other available community support that may be helpful to the person
- a copy of the person’s updated care and support plan and other relevant plans developed as part of their care and treatment
- medicines reconciliation
The framework said that there should be a ‘single shared personalised care and support plan’ to which all health and care professionals can contribute.
The aim is to ‘avoid separate care plans created by different professionals’ which are not widely visible, don’t join up, and ‘don’t promote a holistic approach to meeting a person’s care needs’.
The document said: ‘High quality care and support plans are central to the effective delivery of care and treatment for people with severe mental health problems. They are “owned” by the person and should follow them when they move between services.
‘Effective communication is critical in building trust between people and the service and establishing a shared understanding of why the person needs support from that service.
‘Services need to communicate their offer clearly: what they provide, what help they can give and over what timeframes.
‘When people move between services, care should remain consistent and connected. Services should work together, share relevant information and carry forward relationships, knowledge of the person and agreed care plans so that continuity is preserved and care does not feel fragmented.’
Severe mental health conditions within the scope of the framework include (but are not limited to):
- severe mental illnesses, such as schizophrenia, other psychosis or bipolar disorder
- complex post traumatic stress disorder and severe mental health difficulties from complex trauma
- eating disorders
- severe manifestations of common mental health problems, such as anxiety or depression
- co-existence of frailty (likely in older adults) alongside a severe mental health problem
- co-existence of neurodevelopmental conditions alongside a severe mental health problem
- people given a diagnosis of ‘personality disorder’
- co-occurrence of drug, alcohol or other addiction problems, including gambling, with a severe mental health problem
- dementia (with or without mental health co-morbidity) where needs or risks require the intervention of secondary mental health services or integrated primary care mental health neighbourhood services
The new Quality Strategy for NHS-funded care in England said ICBs will be required to ‘put in place action plans’ to ‘improve contract oversight, commissioning and transformation for primary care and tackle unwarranted variation.’
These plans, which should be put in place this financial year, should improve QOF standards for several conditions including mental health.
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