Specifying a schizophrenia service
The key components of a schizophrenia service are:
- early intervention and early treatment
- treatment of the acute episode
- promoting recovery
- developing a high-quality schizophrenia services across all phases of the condition
Early intervention and early treatment
Commissioners should ensure that people with first presentation of psychotic symptoms in primary care can be urgently referred to a local community-based secondary mental health service (for example, crisis resolution and home treatment, early intervention service, community mental health team).
Referral to early intervention services may be from primary or secondary care and should be available to all people with a first episode or presentation of psychosis irrespective of the person's age or the duration of untreated psychosis. Early intervention services should aim to provide the full range of relevant pharmacological, psychological, social, occupational and educational interventions for people with psychosis, consistent with NICE clinical guideline CG82 on schizophrenia.
Treatment of the acute episode
Commissioners may wish to consider commissioning community mental health teams alongside other community-based teams as a way of providing services for people with schizophrenia during an acute episode. NICE clinical guideline CG82 on schizophrenia recommends:
- Crisis resolution and home treatment teams should be used to support people with schizophrenia during an acute episode in the community. They should also be considered for people with schizophrenia who may benefit from early discharge from hospital following a period of inpatient care.
- Acute day hospitals should be considered alongside crisis resolution and home treatment teams as an alternative to acute admission to inpatient care and to help early discharge from inpatient care.
NICE clinical guideline CG82 on schizophrenia recommends that cognitive behavioural therapy (CBT) should be offered to all people with schizophrenia, and family intervention should be offered to all families of people with schizophrenia. Cognitive behavioural therapy and family intervention should be offered either in the acute phase or later, including in inpatient settings, and delivered in line with the recommendations for the principles for providing and delivering psychological interventions within NICE clinical guideline CG82 on schizophrenia.
Commissioners should ensure that healthcare teams working with people with schizophrenia identify a lead healthcare professional within the team whose responsibility it is to monitor and review:
- access to and engagement with psychological interventions
- decisions to offer psychological interventions and equality of access across different ethnic groups.
Commissioners should also ensure that healthcare professionals providing psychological interventions:
- have an appropriate level of competence in delivering the intervention to people with schizophrenia in line with the recommendations in NICE clinical guideline CG82 on schizophrenia
- have regular supervision during psychological therapy by a competent therapist and supervisor.
Commissioners may also wish to make resources available for arts therapies. Arts therapies may be offered to all people with schizophrenia, particularly for the alleviation of negative symptoms. This can be started either in the acute phase or later, including in inpatient settings.
Commissioners may wish to note that NICE does not recommend:
Commissioners should ensure that people with schizophrenia continue to have access to the recommended treatments and interventions in the recovery phase including access to CBT, family interventions, arts therapies and pharmacological interventions in accordance with NICE clinical guideline CG82 on schizophrenia.
People with schizophrenia are at increased risk of developing cardiovascular disease and/or diabetes; therefore commissioners should make sure that mental health services work closely with primary care to ensure that the physical health needs of people with schizophrenia are monitored at least once a year and that their care is managed in accordance with the appropriate NICE guidance.
Commissioners should work in partnership with other health and social care professionals including those representing black and minority ethnic groups, to enable people with mental health problems, including schizophrenia, to access local employment and educational opportunities. Employment and educational opportunities should be sensitive to the person's needs and skill level and is likely to involve working with agencies such as Jobcentre Plus, disability employment advisers and non-statutory providers.
Commissioners may wish to consider partnership working to ensure that supported employment programmes are provided for those people with schizophrenia who wish to return to work or gain employment. However, such programmes should not be the only work-related activity offered when individuals are unable to work or are unsuccessful in their attempts to find employment.
Developing a high-quality schizophrenia service across all phases of the condition
When commissioning schizophrenia services, commissioners should ensure that services offer a comprehensive range of interventions and that all people with schizophrenia receive a comprehensive, multidisciplinary assessment including a psychiatric, psychological and physical health assessment in accordance with NICE clinical guideline CG82 on schizophrenia.
Commissioners should also consider the needs of people from black and minority ethnic groups with schizophrenia when planning services as they are more likely than people from other groups to be disadvantaged or to have impaired access to and/or engagement with mental health services.
Commissioners should be aware of the new recommendations for pharmacological interventions. NICE clinical guideline CG82 on schizophrenia recommends that people with newly diagnosed schizophrenia are offered oral antipsychotic medication and that they are provided with information and the opportunity to discuss the benefits and side-effect profile of each drug. This is a change from the recommendation in NICE guidance on the use of newer (atypical) antipsychotic drugs for the treatment of schizophrenia in NICE technology appraisal guidance 43 on schizophrenia. This is to aid adherence to medication by encouraging agreement with the service user. It is anticipated that better adherence will lead to better outcomes and savings overall. However, this may change the mix of drugs currently being prescribed and may have a cost impact locally.
Commissioners may wish to consider delivering a schizophrenia service in a number of different ways, and mixed models of provision may be appropriate across a local health economy. The NICE shared learning database offers examples of how organisations have implemented NICE guidance and developed services for people with schizophrenia locally.
Assertive outreach teams should be provided for people with serious mental disorders. This includes teams for people with schizophrenia, who make high use of inpatient services and who have a history of poor engagement with services, which can lead to frequent relapse and/or social breakdown.
Local stakeholders, including service users and carers, should be involved in determining what is needed from a schizophrenia service in order to meet local needs. The service should be client-centred and integrated with other elements of care for people with schizophrenia.
The service specification needs to consider:
- the required competencies of, and training for, staff responsible for providing the service
- the expected number of people affected by schizophrenia (this should take into account how quickly any changes in service provision are likely to take place)
- ease of access and service location; commissioners should engage with service users and other relevant individuals and organisations locally
- care and referral pathways, including potential sources of referral to enable service users to access, as soon as possible, assessment and treatment throughout all phases of care
- information and audit requirements, including IT support and infrastructure
- planned service improvement, including redesign, quality, equitable access, and referral-to-treatment times according to the 18 week patient pathway or equitable waiting times locally for those services currently outside 18 weeks
- service monitoring criteria.
Useful sources of information may include:
- The standard NHS contracts for acute hospital, mental health, community and ambulance services.
- The Map of medicine provides an information resource that visually organises the care pathway. Map of medicine -schizophrenia and chronic schizophrenia
- Costing tool and slide set for NICE clinical guideline CG82 on schizophrenia
- Guide to resources for NICE clinical guideline CG82 on schizophrenia
This page was last updated: 02 August 2013
- Commissioning a service for the treatment and management of schizophrenia in adults
- Specifying a schizophrenia service
- Determining local service levels for a service for the treatment and management of schizophrenia in adults
- Assumptions used in estimating a population benchmark
- The commissioning and benchmarking tool
- Ensuring corporate and quality assurance