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].

Benefits

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:

• World class commissioning.
• The NHS in England: the operating framework for 2009/10. See the vital signs national requirement targets: ‘proportion of adults in contact with secondary mental health services in employment' and ‘proportion of adults (18 and over) supported directly through social care to live independently at home' and national priority for local delivery target: ‘suicide and injury of undetermined intent mortality rate'.
• National service framework for mental health: modern standards and service models.
• New Horizons in mental health.
• High quality care for all: NHS next stage review identifies the need for locally led, patient-centred and clinically driven change.
• Transforming social care.
• The NHS Plan: a plan for investment, a plan for reform.
• Choosing health: supporting the physical health needs of people with severe mental illness.
• Delivering race equality in mental health care: an action plan for reform inside and outside services.
• Mental health policy implementation guide: community development workers for black and minority ethnic communities
• The Care closer to home initiative outlined in chapter 6 of the white paper ‘Our health, our care, our say'.
• Commissioning framework for health and well-being.
• Considering the impact of patient choice.
• The Expert patients programme.
• The Personalisation programme for health and social care.
• A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
• Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with assessment processes. See also the Care Quality Commission 2009-10 periodic review indicators for mental health.

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.

References

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