The Care Programme Approach A review for the Expert Meeting 12 November 2004

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The Care Programme Approach A review for the
Expert Meeting12 November 2004

• Mark McCarthy,
• Professor of Public Health, University College
  London
• Lesley Warner,
• Senior Researcher, Sainsbury Centre for Mental
  Health

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Structure

• I will cover
• Questions, background and sources
• Issues from CPA literature
• Implications for practice

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What we did

• Literature review - SCMH
• Academic literature
• Practice grey literature
• Views of NGOs, informants
• Discussions

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Review of Care Programme Approach

• CPA (1990, 1999) management, not therapy
• comprises
• Systematic arrangements for assessing needs
• Formulation of a care plan
• Appointment of a care coordinator
• Regular review and agreed changes to plan
• approx 300 000 people on CMHS list,
• plus 30 000 on acute/specialist teams

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Two levels of CPA
STANDARD Low support Self-management Little
danger Likely to retain contact
ENHANCED Inter-agency coordination Frequent
interventions Risk for harm - self or
others Likely to disengage
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Iceberg of Need
legal
CPA
Primary care
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Academic literature

• Implementation
• Case-management from USA community mental health
  service, with comparisons
• CPA 1990 for all those receiving specialist
  mental health care
• CPA revised 1999 two levels, with LASS
• Observational studies no policy evaluation

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Criticisms of implementation

• Implementation unstandard / incomplete
• - both for services and individuals
• Clinicians views, eg
• bureaucratic, complex, time-consuming (Simpson)
• CPA versus therapeutic relationship
• Overly risk-focused

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Standards

• National Service Framework standards
• Healthcare Commission clinical focus
• CPA Association
• a managed network collecting, analysing and
  disseminating information to members
• - core standards (2003)
• - audit tool for monitoring CPA
• good practice - SLAM

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Electronic forms

• A requirement by April 2002 (NSF)
• NHSE Mental Health Information Strategy (2001)
• NHS Information Authority Electronic Record
  Development and Implementation Programme
• Patient pathways
• CPA forms clinical record or action summary?

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Inquiries

• Review of 17 inquiry reports from 2000 onwards
• CPA practice within terms of reference
• All mention CPA, not negative, but limitations
• Evidence of risk management practice
• Inquiries and wider mental health practice
• Mechanisms for continuous improvement

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Reviewing risk

• Review of suicides and homicides
• there should be a major overhaul of CPA
• CPA should be a priority for local clinical
  governance
• National Patient Safety Authority
• National Clinical Assessment Authority
• Reliability-seeking organisations are
  preoccupied with failure learn from
  near-misses, reward staff for reporting them
  possibility of error should be evident in the
  topics and information covered in discussions and
  meetings

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National Confidential Enquiry into Suicide and
Homicide by People with Mental Illness

• 1996-2003
• 36 683 suicides
• - 24 in contact with MHS in year before death
• (1 in 6 inpatient, 1 in 3 in first two weeks
  afterwards)
• 3 645 homicides
• 15 inquiry cases
• (1 in 3 lifetime mental illness history, 1 in 6
  in contact with MHS, 1 in 2 drugs and alcohol
  abuse)

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Risk assessment

• Part of CPA
• Not standardised way
• Not standardised recording / action
• also
• crisis plan,
• contingency plan
• issue of sharing information

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CPA at the heart of practice?
Politics, Society
CPA Risk
Patient
Professional
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Improving CPA

• Full implementation
• Clearer criteria
• Evident coordinator
• Evident assessment
• Contingency plans
• Crisis plans

• Involving carers
• Full staff involvement
• Clear dates
• Multidisciplinary team
• Wide assessment
• Better recording

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Implications practice

• Clarity of purpose
• Prioritisation in culture
• Training in-service, internalised
• Audit of structures, and needs

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CPA - a performance indicator?

• Both process records and clinical record?
• Describes needs and quality
• Involves users and carers
• But coverage - CHI reported
• large numbers of users are not being placed on
  the care programme approach or allocated a care
  plan and coordinator

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Implications mental health act

• CPA includes risk assessment
• Would legislation improve implementation?
• Mental health in Healthcare Commission reviews
  is CPA practice given sufficient attention?

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Monitoring CPA - patients, carers, providers

• What is reported to the Board?
• NIMHE service guidance
• Performance -
• Healthcare Commission, LITs, SHAs
• error monitoring - an alternative to inquiries?

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Conclusions

• Good CPA good for patients and system
• CPA best approach weve got
• Full implementation requires systems thinking
• CPA monitoring / quality spiral could enhance
  care
• CPA could provide data for inquiries
• Reliability culture would regard present
  situation unacceptable