5 Organisation and delivery of psychiatric services5.1 Providing care in mental health services
5.1 Multidisciplinary management and coordination of psychiatric care
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Written by Resident Doctor Committee · Published
Care Programme Approach
The Care Programme Approach began in England in 1991, requiring a written care plan, a named coordinator and scheduled multidisciplinary reviews.
It arose from the Spokes Inquiry into the after-care of Sharon Campbell, who killed her former social worker.
It had two levels, allocated by need and risk: standard, and enhanced for people with complex, multi-agency, higher-risk needs.
The modernised approach (from 1999) calls the single professional coordinating health and social care the care coordinator, the title that replaced key worker.
Jurisdiction | Current framework |
|---|---|
England | Community Mental Health Framework 2019 and 2022 position statement: a named coordinator, a co-produced care plan, reviews whenever circumstances change |
Wales | Care and Treatment Plan, a legal entitlement under the Mental Health (Wales) Measure 2010 |
Scotland and Northern Ireland | Their own frameworks |
Assertive outreach and case management
Backing off is an assertive outreach engagement technique: the team lowers the intensity of contact with a reluctant patient but keeps the case open.
Intensive case management and assertive community treatment help mainly when baseline hospital use is high, not because caseloads are small.
In the UK700 trial, reducing caseload size did not reduce hospital use.
Early intervention in psychosis
Early intervention services treat people at ultra-high risk and people with a first episode.
Randomised trials support psychological, vocational, nutritional and service-level interventions in these services.
Dialectical behaviour therapy, developed for recurrent self-harm in borderline personality disorder, has no randomised trial evidence in early psychosis.
Team roles
Profession | Distinctive contribution |
|---|---|
Mental health nursing | Regular contact, monitoring mental state and side effects, often care coordination |
Clinical psychology | Formulation, therapy, neuropsychological assessment |
Occupational therapy | Daily living skills, graded activity |
Social work | Safeguarding, housing, welfare; may be the Approved Mental Health Professional |
Pharmacy | Medicines reconciliation, switching, deprescribing |
Psychiatry | Diagnosis, risk, prescribing, electroconvulsive therapy, statutory duties as responsible clinician |
In England and Wales, the responsible clinician can be an approved clinician from another eligible profession.
Medication adherence
When an acutely psychotic inpatient declines medication, first discuss it collaboratively: listen to the reasons, respect the person and explain the benefits, before considering any coercive or covert route.
Comorbid substance misuse is a risk factor for non-adherence to psychotropic medication in major psychiatric disorders.
Pattern of non-adherence | Best response | Why |
|---|---|---|
Covert, with repeated relapse, in someone who denies missing doses but attends clinic reliably | Long-acting injectable antipsychotic | NICE advises it where avoiding covert non-adherence is a clinical priority |
Unintentional, from forgetting | Monitored dosage system, filled by a pharmacist with each dose in a labelled compartment | An empty slot shows the dose was taken |
Deliberate, anxiety-driven erratic dosing | Supervised administration: a relative keeps the supply and hands over one tablet daily | Needs a willing partner at home every day |
Adverse effect, such as raised prolactin | Switch to a better-tolerated drug, such as prolactin-sparing aripiprazole | A depot keeps the same side effect |
Information sharing and consent
Disclosure | Basis |
|---|---|
Within the direct care team | Usually implied consent; share only what is needed |
To family, employers or unconnected professionals | Usually explicit consent; disclose the minimum |
Risk of serious harm to the patient or an identifiable other | May justify disclosure without consent; if only the patient is at risk, usually respect a capacitous refusal |
Document decisions, reasons and the legal basis for any disclosure, and hand over risks and actions explicitly.
Shared decision making lets the patient's values choose between reasonable options.
Cultural humility means asking about the individual's experience rather than assuming beliefs from group membership.
Carers' own assessment needs are separate from access to the patient's information.