Quality standard

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 (Kirkbride JB, Errazuriz A, Croudace TJ et al. (2012) Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and meta\u2011\analyses). 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 (Reilly S, Planner C, Hann M et al. (2012) The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom). 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:

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 NICE 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.