Specifying services

Commissioners can use content from this section to review local or regional service specifications depending on service needs and local arrangements. To help with this, the specifying services section is structured to reflect Schedule 2a – The Services in the 'Particulars' section of the NHS standard contract 2014/15. This information can be used to review your local service specification but it should not be used as an 'off‑the‑shelf' service specification.

Population needs

Outcomes

The quality standard for psychosis and schizophrenia in adults describes how the quality standard supports the delivery of the NHS and Social care Outcomes Frameworks.

Local defined outcomes

CCGs should agree local outcomes based on the specific needs of their population and the quality and accessibility of current service provision.

Table 2 offers commissioners suggestions for data collection.

Commissioners can refer to the outcomes and quality measures in table 2 and add any reporting requirements to Schedule 6C of the 'Particulars' of the NHS standard contract.

Table 2 Outcomes and process measures from the quality standard for psychosis and schizophrenia in adults

Quality statement 1: Referral to early intervention in psychosis services

Structure: Evidence of local arrangements to ensure that early intervention in psychosis services are in place and local referral pathways are available for adults with a first episode of psychosis.

Local data collection

Process: Proportion of adults with a first episode of psychosis who are referred to early intervention in psychosis services.

Local data collection

Outcome: Acute hospital admission rates.

Health and Social Care Information Centre Mental health and learning disabilities data set

Outcome: Duration of untreated psychosis.

Health and Social Care Information Centre Mental health and learning disabilities data set

Quality statement 2: Cognitive behavioural therapy

Structure: Evidence of local arrangements to ensure that CBTp is available to adults with psychosis or schizophrenia.

Local data collection

Process: Proportion of adults with psychosis or schizophrenia who receive CBTp.

Local data collection

Data can be collected using the Royal College of Psychiatrists' National audit of schizophrenia Audit of practice tool, questions 42 and 44

Outcome: Symptoms of psychosis and schizophrenia.

Local data collection

Quality statement 3: Family interventions

Structure: Evidence of local arrangements to ensure that family interventions are available to family members of adults with psychosis or schizophrenia.

Local data collection

Process: Proportion of adults with psychosis or schizophrenia whose family members receive family interventions.

Local data collection

Outcome: Relapse rates of psychosis and schizophrenia in adults.

Local data collection

Quality statement 4: Use of clozapine

Structure: Evidence of local arrangements to ensure that adults with schizophrenia that has not responded adequately to at least 2 antipsychotic drugs (at least 1 of which should be a non‑clozapine second‑generation antipsychotic) are offered clozapine.

Local data collection

Process: Proportion of adults with schizophrenia that has not responded adequately to at least 2 antipsychotic drugs who receive clozapine.

Local data collection

Outcome: Rates of remission.

Local data collection

Quality statement 5: Supported employment programmes

Structure: Evidence of local arrangements to ensure that adults with psychosis or schizophrenia who wish to find or return to work are offered supported employment programmes.

Local data collection

Process: Proportion of adults with psychosis or schizophrenia who wish to find or return to work who receive supported employment programmes.

Local data collection

Outcome: Employment rates for adults with psychosis or schizophrenia.

Local data collection

Quality statement 6: Monitoring physical health

Structure: Evidence of local arrangements to ensure that adults with psychosis or schizophrenia receive a comprehensive physical health assessment.

Local data collection

Process:

a) Proportion of adults having treatment for a first episode of psychosis who have their blood pressure, fasting blood glucose, HbA1c and blood lipid levels monitored and recorded at 12 weeks and then annually.

b) Proportion of adults having treatment for a first episode of psychosis who have their weight monitored and recorded weekly for the first 6 weeks, then at 12 weeks and then annually.

c) Proportion of adults having treatment for a first episode of psychosis who have their waist circumference plotted annually.

d) Proportion of adults with psychosis and schizophrenia transferred from secondary care to primary care whose physical health is monitored at the point of transfer and then at least annually.

Local data collection

Outcome: Premature mortality of adults with psychosis or schizophrenia.

Local data collection

Quality statement 7: Promoting healthy eating, physical activity and smoking cessation

Structure:

a) Evidence of local arrangements to ensure that adults with psychosis or schizophrenia are offered combined healthy eating and physical activity programmes.

b) Evidence of local arrangements to ensure that adults with psychosis or schizophrenia who smoke are offered help to stop smoking.

Local data collection

Process:

a) Proportion of adults with psychosis or schizophrenia who received combined healthy eating and physical activity programmes within the past 12 months.

b) Proportion of adults with psychosis or schizophrenia who smoke who received help to stop smoking within the past 12 months.

Local data collection

Data can be collected using the Royal College of Psychiatrists' National audit of schizophrenia Audit of practice tool, question 40

Outcome:

a) Type 2 diabetes rates in adults with psychosis or schizophrenia.

b) Obesity rates in adults with psychosis or schizophrenia.

c) Smoking rates in adults with psychosis or schizophrenia.

Local data collection

Data can be collected using the Royal College of Psychiatrists' National audit of schizophrenia Audit of practice tool, question 31

Quality statement 8: Carer-focused education and support

Structure: Evidence of local arrangements to ensure that carers of adults with psychosis or schizophrenia are offered a carer‑focused education and support programme at the earliest appropriate opportunity.

Local data collection

Process: Proportion of adults with psychosis or schizophrenia whose carers receive a carer‑focused education and support programme at the earliest appropriate opportunity.

Local data collection

Outcome: Carer of adults with psychosis or schizophrenia quality of life.

Local data collection

Scope

Aims and objectives of service

When considering the aims and objectives of the service, commissioners should work with service providers and service users and their families and carers.

Commissioners and providers seeking to address quality improvement areas may wish to refer to the NICE Into practice guide, which is a source of practical support for health professionals and managers. It suggests ways to improve partnership working and signposts tools that can help identify where change may be needed to meet the NICE quality standard for psychosis and schizophrenia in adults.

When considering objectives for psychosis and schizophrenia services, commissioners may wish to note that achieving the quality standard for psychosis and schizophrenia should result in:

  • reduced severe mental illness

  • reduced premature mortality

  • reduced duration of untreated psychosis

  • increased employment and vocational rates amongst people with severe mental illness

  • reduced hospital admissions to both acute trusts for physical illness and to mental health hospitals for people with severe mental illness

  • increased referrals to early intervention in psychosis, cognitive behavioural therapy and family intervention services

  • improved service user experience of mental health services

  • reduced detention rates under the mental health act.

To achieve these objectives services should include the following components:

  • effective therapies

  • prescribing

  • education and support

  • physical health.

Service description/care pathway

Effective therapies

Quality statement 1: Referral to early intervention in psychosis services

Early intervention can improve outcomes for people with psychosis. When people with a first episode of psychosis have early intervention the severity of the psychosis and likelihood of hospitalisation are reduced and relapse is less likely. If all people diagnosed with schizophrenia received early intervention, the potential healthcare savings are estimated at £44 million for 2010, rising to £65 million by 2026 (Paying the price: the cost of mental health care in England to 2026, King's Fund, 2008).

Early intervention in psychosis services should be delivered by early intervention teams, composed of a variety of professionals such as psychiatrists, psychologists, occupational therapists and social workers. Mental health care providers should have sufficient staff resources to provide early intervention within 2 weeks of referral. Providers should be required to report waiting times to commissioners, and give details of plans to improve waiting times if they exceed 2 weeks at regular contract monitoring meetings.

Referrals should be accepted from a range of sources such as GPs, social workers, accident and emergency departments and self‑referral. Commissioners should work closely with GPs, social workers and local healthcare providers to ensure that they are aware of the referral criteria for early intervention in psychosis, the availability of the service and the pathway for people to receive treatment.

Quality statement 2: Cognitive behavioural therapy

Cognitive behavioural therapy for psychosis (CBTp) should be offered to all people with psychosis or schizophrenia, as a first‑line treatment. CBTp should be delivered one‑to‑one with the service user and their therapist. A programme of CBTp should include at least 16 sessions, and commitment from the service user to take part in regular sessions over a prolonged period should be obtained. An initial assessment costs £250–300, and follow‑up attendances around £100 (National schedule of reference costs 2013/14, Department of Health, 2013) so a course of 16 sessions costs approximately £1750–1800.

Further information about CBTp can be found in the NICE guideline on psychosis and schizophrenia in adults, section 1.3.7.1.

Mental health providers should be required to report to commissioners on the proportion of service users who start a programme of CBTp and complete 16 sessions. CCGs should use this as a quality measure for the providers who they commission from and this should be reviewed at regular contract monitoring meetings.

CBTp can be adapted for people from black and ethnic minority groups to help reduce drop‑out rates and improve outcomes. For an example, see the shared learning example from Southern Health NHS Foundation Trust.

Quality statement 3: Family intervention

Family intervention should be delivered as a course of at least 10 sessions over a period of 3 months to 1 year. The cost of a course of 10 family intervention sessions is dependent on the services offered, but the approximate cost was estimated as £1150–1200 in the costing statement for the NICE guideline on psychosis and schizophrenia in adults.The intervention should include the person with psychosis or schizophrenia if practical, and should take account of the whole family's preference for a single‑family intervention or multi‑family group intervention.

Single‑family intervention takes place between the person with psychosis or schizophrenia, their family and a therapist. Multi‑family interventions involve multiple people with psychosis or schizophrenia, their families and a therapist. Multi‑family interventions seek to combine the power of group process with the systems focus of family therapy.

Over the course of the therapy, both multi‑ and single‑family interventions can be used.

Further information about family intervention can be found in the NICE guideline on psychosis and schizophrenia in adults, section 1.3.7.2.

Providers of family intervention should be required by commissioners to report on the number of courses started by the families of adults with psychosis or schizophrenia and the proportion who complete at least 10 sessions. When granting the contract to the provider, this should be recorded as a local requirement reported locally, under schedule 6 part B of the NHS standard contract.

Prescribing

Quality statement 4: Use of clozapine

Adults with a confirmed diagnosis of psychosis or schizophrenia should be offered antipsychotic drugs to complement any psychological therapies.

The first time antipsychotic drugs are prescribed should be in consultation with a consultant psychologist. The choice of antipsychotic drug prescribed should be made by the service user and their healthcare professional. Prescribing healthcare professionals should make the service user aware of any side effects they can expect.

The response to antipsychotic drugs in adults with psychosis or schizophrenia should be monitored routinely both to measure the effectiveness of the treatment and to monitor any side effects. Antipsychotic drugs can have severe metabolic and cardiovascular side effects so monitoring the physical health of adults who have been prescribed antipsychotic drugs as detailed in the physical health section of this resource is vital.

Adults with schizophrenia that does not respond adequately to at least 2 different antipsychotic drugs should be offered clozapine. For a typical dose and unit cost, the drug cost is approximately £510 per annum for treating schizophrenia, but this will be partially offset by savings when people would otherwise be receiving another antipsychotic option.

More detailed information on the use of antipsychotic drugs can be found in the NICE guideline on psychosis and schizophrenia in adults, section 1.3.6.

Education and support

Quality statement 5: Supported employment programmes

Adults with psychosis or schizophrenia who wish to find or return to work should be offered supported employment programmes. These programmes should follow a 'place then train' model using the Individual Placement and Support method (IPS).

A 'place then train' supported employment programme using the IPS method should:

  • aim to get people into competitive employment

  • be open to all those who want to work

  • try to find jobs consistent with the service user's preferences

  • work quickly

  • bring employment specialists into clinical teams

  • develop relationships between employment specialists and employers based on the service user's work preferences

  • provide unlimited, individualised support for the service user and their employer

  • include benefits counselling.

Mental health providers should work with employers, and training and education providers (such as Jobcentre Plus, schools and colleges, and private sector training providers), and should co‑ordinate their efforts with commissioners and government bodies such as the Department for Work and Pensions.

Supporting adults with psychosis or schizophrenia in employment has cost benefits to the NHS through better mental and physical health outcomes and to the Department for Work and Pensions through reduced benefits claims such as jobseekers allowance. Raising healthcare professionals' awareness of referral pathways for employment support is likely to be done through current communication channels, and is not likely to lead to a direct cost impact.

When monitoring the service and measuring the effectiveness of supported employment programmes, commissioners should require providers to report on the proportion of service users who have found competitive employment after joining the programme and the average length of time taken for people to find employment. When granting the contract to the provider, this should be recorded as a local requirement reported locally, under schedule 6 part B of the NHS standard contract.

See the Centre for Mental Health for more information on supported employment programmes.

Quality statement 8: Carer-focused education and support

Carers for adults with psychosis or schizophrenia should be offered education and support to help them support the person and to reduce the burden of being a carer. The cost of carer‑focused education and support was estimated at approximately £1150–1200 per carer in the costing statement for the NICE guideline on psychosis and schizophrenia in adults.

Physical health

Quality statements 6 and 7: Monitoring physical health and promoting healthy eating, physical activity and smoking cessation

The physical health of adults with psychosis or schizophrenia (including those cared for solely in primary care) should be monitored regularly. Responsibilities for monitoring should be clear with effective systems in place to share findings between mental health providers and primary care.

Antipsychotic drugs may have serious adverse effects on physical health, and there are particular concerns about premature morbidity and mortality from cardiovascular disease, diabetes and obesity. The National Audit of Schizophrenia has produced the Lester toolkit to help improve monitoring of physical health in people with severe mental illness.

To improve physical health and address health inequalities, adults with psychosis or schizophrenia should be offered combined healthy eating and physical activity programmes and help to stop smoking where appropriate.

It is not anticipated that routinely monitoring physical health will need recruitment of additional staff. However, investment may be needed in better electronic systems to improve communication between primary and secondary care. Earlier identification of physical problems can allow for earlier intervention, and may prevent or delay disease progression, so future treatment costs could be avoided.

Avoidable treatment costs

Providing appropriate care can help to avoid a range of treatment costs over the long‑term, such as costs from admissions to secondary care. These may include:

  • Inpatient care for adults with psychosis or schizophrenia costs from £157 per bed day for an adult with ongoing recurrent psychosis with low symptoms to £376 per bed day for psychotic crisis.

  • Support for adults with psychosis and schizophrenia in the community costs from £8 to £37 per day depending on the severity of the psychosis or schizophrenia, and can help avoid expensive admissions.

Population covered

The population covered by the service is adults with psychosis or schizophrenia. Information about the incidence of psychosis and schizophrenia can be found in NICE quality standard for psychosis and schizophrenia.

The annual incidence and local population data can be used to gauge the likely demand for early intervention in psychosis services. Early intervention services cover the adult population with a first presentation of psychosis, CBT and family interventions can be accessed either through early intervention or by adults with established psychosis so the population covered for these services will be larger.

Commissioners with large urban populations should take into account that the incidence of psychosis and schizophrenia is much higher in inner cities. Similarly commissioners with large ethnic minority populations should also expect to see a higher prevalence of psychosis and schizophrenia.

Any acceptance and exclusion criteria and thresholds

The referral criteria for early intervention in psychosis are that the person is an adult and is presenting with symptoms of psychosis for the first time; no other criteria need be applied and the referral should be made immediately, even if the person has had untreated psychosis for a long time. For CBTp and family interventions, the only criterion is that the person has psychosis or schizophrenia, and referrals should be accepted from any source including GPs, hospitals, social care and self‑referral.Referral into family intervention should be offered to family members of adults with psychosis or schizophrenia.

Interdependence with other services and providers

When commissioning for psychosis and schizophrenia services, commissioners should consider the relationship with other services.

Primary care: between 30% and 40% of people with psychosis or schizophrenia are treated solely in primary care so it is important that the community and acute treatment of psychosis and schizophrenia are integrated with primary care.

Drug and alcohol misuse services: substance misuse is a very common in people with psychosis or schizophrenia. Studies suggest that the prevalence of substance misuse among people with psychosis or schizophrenia in England is around 40%, which is twice the prevalence for the general population; it may be as high as 70–80% in inner cities. This can be due to drug and alcohol misuse triggering episodes of psychosis or schizophrenia in susceptible individuals, as well as people self‑medicating their existing psychosis or schizophrenia with substance misuse.

As a result of this common comorbidity there will be a significant interdependence between drug and alcohol services and psychosis and schizophrenia services. People who attend drug and alcohol services should be assessed for comorbid mental illness and people who have psychosis or schizophrenia should be assessed for drug and alcohol misuse.

Smoking cessation services: tobacco use is another very common co‑morbidity with up to 40% of all tobacco consumption in England attributable to people with severe mental illness. Because of this, there will be a significant interdependence between smoking cessation services and psychosis and schizophrenia services.

Inpatient mental health services: inpatient services will be interdependent on community‑based care for people with psychosis or schizophrenia, because the escalation pathway for adults with an episode of psychosis or schizophrenia that is too acute to be managed in the community or primary care is for care in inpatient mental health services. Between 50% and 60% of inpatients in mental health hospitals have either a primary diagnosis of psychosis or schizophrenia or comorbid psychosis or schizophrenia.

NICE pathways are available for a range of complimentary services such as:

Applicable service standards

Applicable national standards

CCGs and NHS England area teams should work with providers to demonstrate how they are using the quality statements from the NICE quality standards for psychosis and schizophrenia in adults, patient experience in adult NHS services and service user experience in adult mental health.

Applicable standards set out in guidance and/or issued by a competent body (for example Royal Colleges)

  • None identified

Applicable local standards

Commissioners and providers should agree standards applicable for local services based on the quality and accessibility of current service provision.

Applicable quality requirements and CQUIN goals

Applicable CQUIN goals (See schedule 4, part E of the NHS standard contract)

National CQUINs:

  • Improving physical healthcare to reduce premature mortality in people with severe mental illness (SMI).

Commissioners may define local CQUINs. Examples could include:

  • Proportion of people with psychosis who start a course of CBT and complete at least 16 sessions.

  • Proportion of people with psychosis who were referred to early intervention in psychosis and seen within 2 weeks of referral.

  • Proportion of families who start a course of family interventions and complete at least 10 sessions.


This page was last updated: 12 February 2015