Introduction

This quality standard covers the treatment and management of psychosis and schizophrenia (including related psychotic disorders such as schizoaffective disorder, schizophreniform disorder and delusional disorder) in adults (18 years and older) with onset before the age of 60 years in primary, secondary and community care. It will not cover adults with transient psychotic symptoms. For more information see the psychosis and schizophrenia in adults topic overview.

Why this quality standard is needed

Psychosis and the specific diagnosis of schizophrenia represent a major psychiatric disorder (or cluster of disorders) in which a person's perception, thoughts, mood and behaviour are significantly altered. The symptoms of psychosis and schizophrenia are usually divided into 'positive symptoms', including hallucinations (perception in the absence of any stimulus) and delusions (fixed or falsely held beliefs), and 'negative symptoms' (such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self‑neglect). Each person will have a unique combination of symptoms and experiences.

A 2012 review of the incidence of schizophrenia and psychosis found a pooled incidence of 31.7 per 100,000 person‑years for psychosis and 15 per 100,000 person‑years for schizophrenia in England between 1950 and 2009[1]. Rates varied according to gender and age, generally decreasing with age (although with a second peak in women starting in the mid to late 40s). Men aged under 45 years had a schizophrenia rate twice as high as that for women, but there was no difference in incidence over this age. The rate of schizophrenia was significantly higher in people of African–Caribbean and African family origin than in the baseline population.

In both hospital and community settings, antipsychotic drugs are the primary treatment for psychosis and schizophrenia. There is well‑established evidence for their efficacy in both treating acute psychotic episodes and preventing relapse over time in conjunction with psychological interventions. However, despite this, considerable problems remain. A significant proportion of service users (up to 40%) have a poor response to conventional antipsychotic drugs and continue to show moderate to severe psychotic symptoms (both positive and negative).

Psychological and psychosocial interventions in psychosis and schizophrenia include interventions to improve symptoms and to address vulnerability, dependent on the person's needs.

In the past decade, there has been a new emphasis on services for early detection and intervention, and a focus on long‑term recovery and promoting people's choices about managing their condition.

There is evidence that people can recover, although some will have persisting difficulties or remain vulnerable to future episodes. Most people with persisting difficulties receive their care from both primary and specialist mental health care. However, about 30% of people will be well enough to be cared for solely by primary care[2]. There will also be a small number of people who may not accept help from statutory services.

The quality standard is expected to contribute to improvements in the following outcomes:

  • severe mental illness premature mortality

  • employment and vocational rates

  • hospital admissions

  • referral to crisis resolution and home treatment teams

  • service user experience of mental health services

  • detention rates under the Mental Health Act.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements in a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Overarching indicator

1a Potential years of life lost (PYLL) from causes considered amenable to healthcare

i Adults

Improvement areas

Reducing premature death in people with mental illness

1.5 i Excess under 75 mortality rate in adults with serious mental illness* (PHOF 4.9)

iii Suicide and mortality from injury of undetermined intent among people with recent contact from NHS services** (PHOF 4.10)

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions** (ASCOF 1A)

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Enhancing quality of life for carers

2.4 Health‑related quality of life for carers** (ASCOF 1D)

Enhancing quality of life for people with mental illness

2.5 i Employment of people with mental illness** (ASCOF 1F and PHOF 1.8)

ii Health‑related quality of life for people with mental illness

4 Ensuring that people have a positive experience of care

Overarching indicator

4a Patient experience of primary care

i GP services

4b Patient experience of hospital care

Improvement areas

Improving people's experience of outpatient care

4.1 Patient experience of outpatient services

Improving access to primary care services

4.4 Access to i GP services

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving people's experience of integrated care

4.9 People's experience of integrated care** (ASCOF 3E)

Alignment across the health and social care system

* Indicator shared

** Indicator complementary

Indicators are in development

Table 2 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life** (NHSOF 2)

Outcome measures

People manage their own support as much as they wish, so that are in control of what, how and when support is delivered to match their needs

1B Proportion of people who use services who have control over their daily life

1C Proportion of people using social care who receive self‑directed support, and those receiving direct payments

Carers can balance their caring roles and maintain their desired quality of life

1D Carer‑reported quality of life** (NHSOF 2.4)

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation

1F Proportion of adults in contact with secondary mental health services in paid employment** (PHOF 1.8, NHSOF 2.5)

1H Proportion of adults in contact with secondary mental health services living independently, with or without support* (PHOF 1.6)

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care and their carers are satisfied with their experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carer with social services

Placeholder 3E Effectiveness of integrated care** (NHSOF 4.9)

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

Aligning across the health and care system

* Indicator shared

** Indicator complementary

Table 3 Public health outcomes framework for England, 2013–2016

Domain

Objectives and indicators

1 Improving the wider determinants of health

Objective

Improvements against wider factors which affect health and wellbeing and health inequalities

Indicators

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are on contact with secondary mental health services** (NHSOF 2.5 and ASCOF 1F)

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.3 Mortality rate from causes considered preventable** (NHSOF 1a)

4.4 Under 75 mortality rate from all cardiovascular disease (including heart disease and stroke)* (NHSOF 1.1)

4.9 Excess under 75 mortality rate in adults with serious mental illness* (NHSOF 1.5)

4.10 Suicide rate

Alignment across the health and social care system

* Indicator shared

** Indicator complementary

Service user experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to psychosis and schizophrenia in adults.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that impact on service user experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for psychosis and schizophrenia in adults specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole psychosis and schizophrenia care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with psychosis and schizophrenia.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality psychosis and schizophrenia services are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating adults with psychosis and schizophrenia should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with psychosis and schizophrenia. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.



[1] Kirkbride JB, Errazuriz A, Croudace TJ et al. Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and meta‑analyses. PLoS ONE 7(3): e31660

[2] Reilly S, Planner C, Hann M, Reeves D, Nazareth I et al. (2012) The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom. PLoS ONE 7(5): e36468. doi:10.1371/journal.pone.0036468