Commissioning a service for the treatment and management of schizophrenia in adults

Schizophrenia is a major psychiatric disorder, or cluster of disorders, and is characterised by psychotic symptoms that alter a person's perception, thoughts and behaviour. The nature of the condition varies from person to person but the main symptoms are psychotic experiences, for example hearing voices and other hallucinations or having fixed beliefs that are false but which the person believes in completely (delusions). Typically there is a prodromal period characterised by deterioration in personal functioning including memory and concentration problems, unusual behaviour and ideas, disturbed communication and affect, and social withdrawal.

Recently, there has been a new emphasis in services on early detection and intervention, and a focus on long-term recovery and promoting people's choices about the management of their condition. There is evidence that most people will recover, although some have persisting difficulties or remain vulnerable to future episodes. Carers, relatives and friends of people with schizophrenia are important both in the process of assessment and engagement, and in the long-term successful delivery of effective treatments.

The difficulties experienced by people with schizophrenia are not solely the result of recurrent episodes or continuing symptoms. Unpleasant side effects of treatment, social adversity and isolation, poverty and homelessness also play a part. These difficulties are not made any easier by the continuing prejudice, stigma and social exclusion associated with the diagnosis, which can lead to reduced opportunities to get back to work or study, and problems forming new relationships[1][2].

Social functioning and reduced isolation can be improved through social interventions that strive to promote recovery such as access to work, education and recreation. Social support and services looking at independent accommodation/housing, fighting stigma, improving access to meaningful activities, and promoting health in the wider communities, are all important considerations for health and social care commissioners when planning services[3].

Over a lifetime, about 1% of the population will develop schizophrenia. The prevalence of schizophrenia and related disorders is estimated to be 5 per 1000; estimates vary widely and are known to be affected by several factors including social deprivation and ethnicity[4]. Mortality among people with schizophrenia is approximately 50% above that of the general population, partly as a result of an increased incidence of suicide (about 10% die by suicide) and violent death, and partly as a result of an increased risk of a wide range of physical health problems, including those induced by cigarette smoking, obesity and diabetes.

The estimated total societal cost of schizophrenia in England is £6.7 billion (in 2004/05 prices). Of this, around £2 billion (about 30% of the total cost) comprises direct costs of treatment and care, while the rest £4.7 billion (70% of the total cost) constitutes indirect costs to society[5].


The potential benefits of robustly commissioning an effective comprehensive schizophrenia service across all phases of the condition include:

  • reducing self-harm and deaths from suicide
  • improving clinical and social outcomes through early detection, intervention, treatment and structured day-time activity
  • improving support for carers and families
  • promoting recovery and increasing independence and self-management
  • reducing the frequency of relapse and subsequent hospital admissions
  • increasing earlier discharge from inpatient wards
  • improving general physical healthcare, for example increasing the number of people with schizophrenia who undergo a cardiovascular disease risk assessment as described in Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (NICE clinical guideline 67)
  • improving access to high quality evidenced based care across all phases of the condition
  • reducing inequalities and improving access to primary and secondary care services, particularly for people from deprived areas and different ethnic groups
  • increasing patient choice about the management of their condition and improving partnership working, service user experience, engagement and retention with treatment
  • better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians and social care professionals to undertake local service redesign to meet local requirements in novel ways.

Key clinical issues

Key clinical issues in providing an effective schizophrenia service are:

  • improving access to and engagement with a range of services for all people affected by schizophrenia
  • providing effective and efficient clinical care in line with NICE clinical guideline CG82 on schizophrenia, and ensuring appropriate treatment of comorbid disorders
  • ensuring the service is integrated with other services that address health and social care needs
  • providing a quality assured service.

National drivers

National priorities and initiatives relevant to commissioning a schizophrenia service include:

Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.


1. Sartorius N (2002) Iatrogenic stigma of mental illness. British Medical Journal 324: 1470-1

2. Thornicroft G (2006) Shunned: discrimination against people with mental illness. Oxford: Oxford University Press

3. National Collaborating Centre for Mental Health (2008) Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care (update). London: Royal College of Psychiatrists

4. McCrone P, Dhanasiri S, Patel A et al. (2008 ) Paying the price: the cost of mental health care in England to 2026. London: The King's Fund

5. Mangalore R, Knapp M (2007) Cost of schizophrenia in England. The Journal of Mental Health Policy and Economics 10: 23-41

This page was last updated: 02 March 2012

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Selected, reliable information for health and social care in one place

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.