Refocusing the Care Programme Approach - Policy and Positive Practice Guidance - March 2008

Refocusing the Care
Programme Approach
Policy and Positive Practice Guidance

March 2008

Policy                                    Estates
HR/Workforce                              Commissioning
Management                                IM & T
Planning / Performance                    Finance
Clinical                                  Social Care/Partnership Working

Document Purpose      Best Practice Guidance
Gateway Reference     9148
Title                 Refocusing the Care Programme Approach
Author                Department of Health
Publication Date      19 Mar 2008
Target Audience       PCT CEs, NHS Trust CEs, Care Trust CEs, Foundation Trust CEs,
                      Medical Directors, Directors of Nursing, Local Authority CEs, Directors
                      of Adult SSs, GPs
Circulation List

Description           Following the national consultation, Reviewing the Care programme Approach
                      (CPA), and having considered the issues identified, this guidance updates
                      policy and sets out positive practice guidance for trusts and commissioners to
                      review local practice to refocus CPA within mental health services.
Cross Ref             Reviewing the Care programme Approach 2006

Superseded Docs       N/A
Action Required       N/A
Timing                N/A
Contact Details       Janet Davies
                      Department of Health
                      Wellington House
                      133 Waterloo Road
                      London, SE1 8UG

For Recipient’s Use

© Crown copyright 2008
First published March 2008
Produced by COI for the Department of Health
The text of this document may be reproduced without
formal permission or charge for personal or in-house use.
Refocusing the Care
Programme Approach
Policy and Positive Practice Guidance

March 2008

Foreword                                                          1

Executive summary                                                2

Section 1: Introduction                                          3

Section 2: Personalised Mental Health Care                       6

Section 3: Refocusing The Care Programme Approach               11

Section 4: Assessment and Care Planning                         18

Section 5: Whole Systems Approach                               27

Section 6: Supporting the Workforce                             33

Section 7: Measuring and Improving Quality                      39

Annex A: CPA and Other Assessment And Planning Frameworks       43

Annex B: CPA and Child and Adolescent Mental Health Services    47

Annex C: CPA and Older Adults                                   50

Annex D: Glossary                                               53
Foreword by Louis Appleby
Our NHS, Our Future interim report sets out         sound values and principles across the country.
the vision for the NHS to deliver services which    There is much good practice, but more needs
are fair, personalised, effective and safe. In      to be done so that individuals directly feel
many ways mental health services can claim to       the impact of policy advances in their daily
lead the way in delivering such an approach         interactions with services, and can recognise
across health and social care.                      and realise the tangible benefits and outcomes
                                                    from receiving them.
Since the publication of the Mental Health
National Service Framework in 1999 mental           This document Refocusing The Care Programme
health policies have increasingly focused on        Approach updates guidance and highlights
personalisation through an emphasis on              good practice. It emphasises the need for a
meeting the wider needs of those with mental        focus on delivering person-centred mental health
illness, addressing equalities, tackling the        care and also repeats that crisis, contingency
problems of social inclusion, and promoting         and risk management are an integral part of
positive risk management. The setting of Public     assessment and planning processes.
Service Agreement (PSA) indicators to improve
                                                    I urge everyone working in mental health
housing and employment opportunities for
                                                    services to critically examine current policies and
people with severe mental illness will provide a
                                                    practice against this guidance so that progress
welcome additional lever.
                                                    can continue to be made.
The Care Programme Approach (CPA) is at the
centre of this personalisation focus, supporting
individuals with severe mental illness to ensure
that their needs and choices remain central in
what are often complex systems of care. It
provides an excellent framework, the principles
of which are supported by all.

But it is clear from the recent review that there   Louis Appleby
needs to be more consistency in applying these      National Director for Mental Health

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Executive summary

The Care Programme Approach has been                      Whole systems approaches should support CPA.
reviewed to ensure that national policy is more           Services and organisations should work together
consistently and clearly applied and unnecessary          to: adopt integrated care pathway approaches
bureaucracy removed.                                      to service delivery; improve information sharing;
                                                          establish local protocols for joint working
All individuals receiving treatment, care and
                                                          between different planning systems and
support from secondary mental health services
                                                          provider agencies. The role of commissioners is
are entitled to receive high quality care based on
                                                          key in ensuring a range of services to meet
an individual assessment of the range of their
                                                          service users’ needs and choices. Joint planning
needs and choices. The needs and involvement
                                                          across agencies through Local Strategic
of people receiving services (service users) and
                                                          Partnerships and Local Area Agreements are
their carers should be central to service delivery.
                                                          also critical.
An underpinning set of values and principles
of person-centred care which apply to all is              To ensure that services are person-centred and
essential, and is described.                              values and evidence based an appropriately
                                                          trained and committed workforce is needed.
Individuals with a wide range of needs from a
                                                          For individuals requiring the support of CPA the
number of services, or who are at most risk,
                                                          role of the care co-ordinator is vital. National
should receive a higher level of care co-
                                                          competences for the care co-ordinator are
ordination support. From October 2008 the
                                                          outlined and the development of national
system of co-ordination and support for this
                                                          training for care co-ordination, risk and safety
group only will be called the Care Programme
                                                          has been commissioned. Guidance is given on
Approach (CPA). The revised characteristics of
                                                          measuring and improving capacity and
this group is set out and trusts should review
policies against this.
                                                          The quality of assessment and care planning
Assessments and care plans should address the
                                                          should be focused on improving outcomes for
range of service users’ needs. Risk management
                                                          service users and their families across their life
and crisis and contingency planning is integral
                                                          domains. Attention to local audit; performance
to the process. A number of critical issues are
                                                          management; national regulation; and issues
highlighted, including assessing the needs of
                                                          of equalities is needed to ensure equitable
parents; dual diagnosis; physical health; housing;
                                                          outcomes for all.
employment; personality disorder; history of
violence and abuse; carers; and medication.

Section 1: Introduction

The consultation document Reviewing the Care                   were becoming increasingly responsive to the
Programme Approach 2006 set out the reasons                    needs and wishes of services users, yet urged
and aims of the current review of the Care                     that continued effort needed to be made. Other
Programme Approach (CPA). It made clear that                   major Department of Health (DH) publications
the ultimate aim was to ensure that there is a                 emphasise, at their core, the need for services to
renewed focus on delivering a service with the                 empower individuals to achieve greater
individual using the services at its heart – in                independence and improve their lives through
which national policy is more consistently and                 more personalised care, more choice, and their
clearly applied and where bureaucracy does not                 active engagement in service development 4, 5, 6, 7.
get in the way of the relationship between the
                                                               However, the review also found that, although
service user and practitioner.
                                                               much positive practice exists, there still remain
A clear response from everyone contributing to                 variations around the country in applying these
the review of CPA was support for the principles               sound principles. In particular improvements
underpinning a system of care assessment,                      still need to be made in service user and
planning and review in secondary mental health                 carer engagement and involvement, and in
services. These principles are set out in the Mental           consistency in the identification and support of
Health National Service Framework (MHNSF)                      individuals most in need of engagement who
(Standard Four)1 and Effective Care Co-ordination              are at risk.
in Mental Health Services: Modernising the Care
                                                               This document Refocusing the Care Programme
Programme Approach: A Policy Booklet2. More
                                                               Approach: Policy and Positive Practice Guidance
recent documents about mental health and
                                                               aims to build on the strong foundation of the
wider have echoed these principles.
                                                               MHNSF1 Effective Care Co-ordination in Mental
The National Service Framework for Mental                      Health Services3, and other DH policy guidance
Health 5 Years On3 recognised that services                    and to reinforce them by:

  Department of Health, National Service Framework for Mental Health: modern standards and service models. 1999.
  Department of Health, Effective care co-ordination in mental health services: modernising the care programme approach –
  A policy booklet. 1999.
  Department of Health, National Service Framework for Mental Health, Five Years On. 2004
  Department of Health, The NHS Improvement Plan: Putting people at the heart of public services. 2004
  Department of Health, Independence, Well-being and Choice: Our Vision for the Future of Social Care for Adults. 2005
  Department of Health, Our Health, our care, our say: a new direction for community services. 2006
  CSIP, Our Choices in Mental Health: a framework for improving choice for people who use mental health services and their
  carers. 2006

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

> setting out an underpinning statement of                Services are reminded that the Mental Health
  values and principles that all in secondary             Act 2007 establishes a new, simplified single
  mental health services should aim for;                  definition of mental disorder which does not
                                                          distinguish between different categories of
> highlighting positive practice around service
                                                          mental disorder, so the same criteria apply
  user and carer involvement and engagement;
                                                          to all individuals. In particular, people with a
> providing a clearer definition of individuals           personality disorder should be able to benefit
  and groups who may need a higher level of               from treatment and support, and this guidance
  engagement and co-ordination support;                   applies to them just like anyone else.

> focusing on areas of assessment and care
  planning that should be strengthened;                   Consultation
> presenting an overview of the systems that
                                                          Around 300 responses were received from
  can support multi-agency delivery to meet the
                                                          individuals, groups and organisations as part of
  range of an individual’s needs;
                                                          the formal consultation. This was supplemented
> strengthening workforce capabilities by                 by discussion with service users and carers at
  describing the core competences needed                  a number of events. We are grateful for the
  by a care co-ordinator and commissioning                time, consideration and expertise put into the
  national training for CPA and risk and safety           replies. A summary of these responses is at
  management; and                               
> announcing a review of local CPA audits to
  enable a renewed focus on service user and              Using the Guidance
  carer satisfaction and engagement.
                                                          Each section of the guidance aims to give a brief
                                                          summary of current policy, evidence and
                                                          positive practice. Where it is silent on an issue
                                                          readers should refer to existing policy guidance
This guidance is focused on the support needed
                                                          on CPA as this will still be relevant. A summary
for individuals receiving secondary mental health
                                                          of critical points made is set out at the end of
services. This will mainly include adults of
                                                          each Section to provide an overview of issues
working age but the principles should be
                                                          that services should address when reviewing
applied to any individual receiving these services
                                                          policy and practice in light of this guidance.
regardless of their age. Annex B provides
guidance on applying CPA principles in CAMHS.             For ease of reference many of the policy
Annex C provides guidance on CPA and older                documents, briefing papers, publications and
people and CPA and the Single Assessment                  good practice examples cited in this guidance
Process (SAP).                                            can be accessed by clicking the hyperlinks in the
Section 1: Introduction

text in the electronic version. A glossary of some   Equality Impact Assessment
of the words and phrases used in this guidance
is at Annex D.                                       As part of its statutory obligations, the
                                                     Department of Health (DH) is required to assess
                                                     the impact of any policy proposals on different
                                                     groups in the community in terms of equality of
                                                     access and impact on the rights and needs of
The Care Services Improvement Partnership
                                                     those groups. It is also DH’s policy to extend
(CSIP) will be supporting a number of
                                                     such an assessment to consideration of impact
workshops around the country in 2008 to
                                                     on equality in terms of religion or belief and
enable discussion on this guidance to aid
                                                     sexual orientation. In producing this guidance
implementation. Further details will be available
                                                     we have undertaken a Single Equality Impact
early in 2008 on
                                                     Assessment (SEIA) to help ensure that this
                                                     guidance takes account of the diverse individual
Information for Service Users and Carers             needs of the service user, paying proper
                                                     attention to issues of age, disability, gender,
This guidance is mainly aimed at professionals.      sexual orientation, race and ethnicity and religious
So that service users and carers can understand      beliefs. A report of the SEIA and action plan is
the principles and application of good practice      available on
around CPA a separate leaflet, booklet and DVD       Issues for services to address, and the guidance
has been produced. The intention is that these       and support available, have been threaded
resources can be used to provide accessible          through this document.
information to individual service users and
carers; as a focus in service user and/or carer
                                                     Values and Principles
group discussions; and for discussions and
training between service users, carers and
                                                     CPA review respondents agreed that setting out
professionals. Hard copies are available from:
                                                     an underpinning statement of values and
Write to:                                            principles would help secondary mental health
DH Publications Orderline                            services check that their assessment and care
PO Box 777                                           planning systems are focused on personalised
London SE1 6XH                                       care with an ethos of recovery. This statement
Telephone: 0870 155 54 55                            is set out in Table 1.
(8 am to 6 pm Monday to Friday )
                                                     There was much consensus on the broad issues
Fax: 0162 372 45 24
                                                     and approach in developing this statement, but
                                                     getting the language right so that everybody

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Section 2:
Personalised Mental Health Care
receiving or providing services understands and               Services may wish to use the statement below
owns it was more of a challenge. For example                  as a basis of local discussion with staff and
“recovery” will mean different things to                      service users as part of reviewing their
different people and the concept of “person-                  approaches to care planning and delivery for all.
centred” or “personalised” services can change                Certainly at an individual level an exploration of
depending on an individual’s perspective, client              values is critical so that service responses can be
group and service setting.                                    tailored to individual need and choices.

What is clear, however, is the importance of                  The following statement draws on the Ten
open discussions on values and principles                     Essential Shared Capabilities framework8,
between individuals and professionals, and                    Human Rights in Healthcare – A Framework for
between professionals in and beyond mental                    Local Action,9 and person-centred approaches
health services. Open discussions will help                   to healthcare.
ensure that issues of meaning and the values
underpinning service delivery can be
understood, acknowledged and addressed.

  Department of Health. Ten Essential Shared Capabilities – A framework for the whole of the Mental Health Workforce.
  Department of Health. Human Rights in Healthcare – A Framework for Local Action. 2007

Section 2: Personalised Mental Health Care

Statement of Values and Principles                                                            Table 1

The approach to individuals’ care and support puts them at the centre and promotes social
inclusion and recovery. It is respectful – building confidence in individuals with an understanding of
their strengths, goals and aspirations as well as their needs and difficulties. It recognises the
individual as a person first and patient/service user second.

Care assessment and planning views a person ‘in the round’ seeing and supporting them in their
individual diverse roles and the needs they have, including: family; parenting; relationships;
housing; employment; leisure; education; creativity; spirituality; self-management and self-nurture;
with the aim of optimising mental and physical health and well-being.

Self-care is promoted and supported wherever possible. Action is taken to encourage independence
and self determination to help people maintain control over their own support and care.

Carers form a vital part of the support required to aid a person’s recovery. Their own needs should
also be recognised and supported.

Services should be organised and delivered in ways that promote and co-ordinate helpful and
purposeful mental health practice based on fulfilling therapeutic relationships and partnerships
between the people involved. These relationships involve shared listening, communicating,
understanding, clarification, and organisation of diverse opinion to deliver valued, appropriate,
equitable and co-ordinated care. The quality of the relationship between service user and the care
co-ordinator is one of the most important determinants of success.

Care planning is underpinned by long-term engagement, requiring trust, team work and
commitment. It is the daily work of mental health services and supporting partner agencies,
not just the planned occasions where people meet for reviews.

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Understanding Mental Health:                              the care planning process is meaningful to them,
A Shared Vision                                           and their input is genuinely recognised, so that
                                                          their choices are respected.
To develop discussion on values in mental health
                                                          The CPA review consultation process helped to
further DH has commissioned CSIP to develop
                                                          identify a number of areas of good practice.
draft guidance for consultation on Finding a
                                                          These are summarised in a Briefing Paper and
shared vision of how people’s mental health
                                                          Annex B addresses some issues for involving
problems should be understood. The draft
                                                          young people. However, most of what is set
guidance aims to:
                                                          out will not be new to services. What is needed
> identify a shared vision of how people’s                is a renewed attention by all to the evidence,
  mental health problems should be understood             principles and good practice to ensure that
  that is recognised equally by different provider        activity takes place through governance
  groups and by service users and their carers;           systems, training and audit to ensure service
                                                          user and carer involvement and effect
> raise awareness of the wide variety of different
                                                          real change.
  approaches to assessing mental health
  problems and wellbeing; and                                      Positive practice (available at
> build mutual understanding of these different
  approaches as resources for drawing together,
                                                            2 Positive practice (available at
  through a shared process between service                   ✓
  users, carers and service providers, ways of
  understanding a mental health problem that
  reflect the particular and often very different         Advocacy
  strengths and needs of individual service users.
                                                          Commissioners and services should recognise
                                                          the positive role that advocacy can play in
Service User Engagement and
                                                          enabling effective service user involvement in
                                                          the development and management of their care
                                                          and the benefits that a skilled advocate can
To make sure that service users and their carers
                                                          bring in helping service users engage with what
are partners in the planning, development and
                                                          can often feel like an overwhelmingly
delivery of their care, they need to be fully
                                                          complicated and intimidating system.
involved in the process from the start. Processes
should be transparent, consistent and flexible            Section 30 of the Mental Health Act 2007 gives
enough to meet expectations of service users              certain patients access to independent advocacy
and carers without over promising or under                services to be delivered by Independent Mental
delivering. Service users will only be engaged if         Health Advocates (IMHAs). Local commissioners

Section 2: Personalised Mental Health Care

are expected to contract for these service in                   A number of frameworks, guidance documents
their areas and DH is currently considering how                 and implementation support programmes is
best this can be achieved. The provision of                     available to help mental health services identify
IMHAs is subject to secondary legislation on                    and address issues of equality, including:
which there is current consultation.
                                                                > National Service Framework for Older People
                                                                  (DH 2001)10 which includes a standard on
Ensuring Quality: Tackling Inequalities                           mental health

                                                                > National Service Framework for children,
To help ensure that quality mental health
                                                                  young people and maternity services11 (and
services are provided to all, appropriate to their
                                                                  also see Annex B)
needs, services must also pay attention to the
potential for inequalities in outcomes of                       > Mainstreaming gender and women’s mental
individual care assessment and planning, and                      health: implementation guidance (DH 200312)
the service they provide. Public services have                    and CSIP/NIMHE implementation programme
clear legal requirements under Race, Gender
                                                                > Delivering race equality in mental health
and Disability legislation. DH would also urge
                                                                  care: An action plan for reform inside and
services to adopt good practice when addressing
                                                                  outside services and the Government’s
any adverse impact due to inequalities in terms
                                                                  response to the Independent inquiry into the
of age, religion or belief and sexual orientation
                                                                  death of David Bennett (DH 2005) and
of the service user and carers.
                                                                  CSIP/NIMHE DRE programme.13,14

                                                                > Inspiring Hope: Recognising the Importance
                                                                  of Spirituality in a Whole Person Approach to
                                                                  Mental Health (NIMHE/Mental Health
                                                                  Foundation 2003).15

   Department of Health, National Service Framework for Older People 2001
   Department of Health, National Service Framework for Children, Young People and Maternity Services. 2004
   Department of Health, Mainstreaming gender and women’s mental health: implementation guidance 2003
   Department of Health, Delivering race equality in mental health care: An action plan for reform inside and outside services
   and the Government’s response to the Independent inquiry into the death of David Bennett. 2005
   NIMHE/CSIP Delivery Race Equality Programme
   .html (accessed on 25 Feb 2008)
   NIMHE/Mental Health Foundation. Inspiring Hope: Recognising the Importance of Spirituality in a Whole Person
   Approach to Mental Health. 2003

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

> Everybody’s Business: Integrating mental
  health services for older adults (2005)16                   Summary In reviewing policies and practice in
                                                              light of this guidance mental health trusts
> Green Light for Mental Health; how good
  are your services for people with learning
  disabilities? (Valuing People Support Team,                 > use the statement of values and principles
  DH 2004)17                                                    as a basis for discussion with staff and
                                                                service users and carers
> Mental Health and Deafness: Towards Equity
  and Access (DH 2005)18                                      > understand and implement good practice
                                                                in service user and carer involvement and
          Positive practice (available at
                                                                engagement, including the value of
                                                                advocacy support
     4 Positive practice (available at
      ✓                          > note draft guidance for consultation on
                                                                Finding a shared vision of how people’s
     5 Positive practice (available at                          mental health problems should be
      ✓                            understood

                                                              > ensure that equalities are addressed for
                                                                individuals and by organisations by
                                                                implementing relevant legislation and

   CSIP. Everybody’s Business: Integrating mental health services for older adults (2005)
   Department of Health, Valuing People Support Team, Green Light for Mental Health; how good are your services for
   people with learning disabilities? 2004
   Department of Health. Mental Health and Deafness: Towards Equity and Access. 2005

Section 3: Refocusing the
Care Programme Approach
The term Care Programme Approach (CPA)                Where a service user has straightforward
has been used since 1990 to describe the              needs and has contact with only one agency
framework that supports and co-ordinates              then an appropriate professional in that agency
effective mental health care for people with          will be the person responsible for facilitating
severe mental health problems in secondary            their care. Formal designated paperwork for
mental health services. Two levels of support         care planning and the review process for these
and co-ordination are currently determined:           service users is not required. However a
                                                      statement of care agreed with the service user
> standard support for individuals receiving care
                                                      should be recorded. This could be done in any
  from one agency, who are able to self-manage
                                                      clinical or practice notes, or in a letter, and this
  their mental health problems and maintain
                                                      documentation will constitute the care plan. It is
  contact with services;
                                                      not necessary to engage in further bureaucracy
> enhanced support for individuals with multiple      for these individuals.
  care needs from a range of agencies, likely to be
                                                      However, as a minimum, service providers
  at higher risk and to disengage from services.
                                                      must continue to maintain a short central
It is clear that all service users should have        record of essential information is maintained
access to high quality, evidence-based mental         on all individuals receiving secondary mental
health services. For those requiring standard         health services and that reviews take place
CPA it has never been the intention that              regularly.
complicated systems of support should surround
this as they are unnecessary. The rights that
                                                      Refocusing CPA
service users have to an assessment of their
needs, the development of a care plan and a
                                                      The term Care Programme Approach in future
review of that care by a professional involved,
                                                      (from October 2008) will describe the approach
will continue to be good practice for all.
                                                      used in secondary mental health care to assess,
However, using the term CPA to describe the           plan, review and co-ordinate the range of
system of care provided to those with less            treatment, care and support needs for people in
complex, more straightforward support needs           contact with secondary mental health services
has often led to more attention being paid to         who have complex characteristics (as outlined
the system (with ensuing needless bureaucracy)        below). It is called an “approach”, rather than
rather than a focus on good professional care.        just a system, because the way that these
So, from October 2008 the term CPA will no            elements are carried out is as important as the
longer be used to describe the usual system of        actual tasks themselves. Active service user
provision of mental health services to those with     involvement and engagement will continue to
more straightforward needs in secondary mental
health services (formerly standard).

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

be at the heart of the approach, as will a focus          and a new list set out in Table 2. This list was
on reducing distress and promoting social                 reached by looking at the current description
inclusion and recovery.                                   of characteristics for enhanced CPA, combined
                                                          with issues of complexity highlighted in
In the remainder of this guidance we use
                                                          the CPA review consultation document and
the term (new) CPA to describe this refocus.
                                                          in consultation responses. The list was validated
However, in future publications the term CPA
                                                          by working with a range of multi-professional
will be used to describe the revised description
                                                          clinical teams in a number of trusts who tested
of support and co-ordination for people with
                                                          and developed the list against their case loads
more complex needs.
                                                          (not including CAMHS).

                                                          The list is not exhaustive and there is not a
Who Will Need (new) CPA?
                                                          minimum or critical number of items on the list
                                                          that should indicate the need for (new) CPA.
In the main, the individuals needing the support
                                                          But there was clear consensus among those
of (new) CPA should not be significantly different
                                                          testing the list that it should provide the basis of
from those currently needing the support of
                                                          a reliable and useful tool. However, it is also
enhanced CPA. The current characteristics of those
                                                          critical to stress that clinical and professional
needing enhanced CPA are described as individuals
                                                          experience, training and judgement should be
who need: multi-agency support; active
                                                          used in using this list to evaluate which service
engagement; intense intervention; support with
                                                          users will need the support of (new) CPA.
dual diagnoses; and who are at higher risk.

However, we know that there are different
                                                          CPA and eligibility for services
interpretations of this locally leading to some
individuals, and some key groups (see below),
                                                          Most importantly it must be emphasised
tending to be overlooked. On the other hand,
                                                          that the list in Table 2 should not be used as
some individuals who are concordant with
                                                          indicators of eligibility for secondary mental
treatment, well supported in the community
                                                          health services. Services should continue to use
and/or have recovered from a complex episode
                                                          current local eligibility criteria to make initial
of mental illness are inappropriately identified as
                                                          decisions on an individual’s need for secondary
needing enhanced CPA.
                                                          mental health services. The list in Table 2 should
To provide clearer guidance to services so                then be employed to decide if, having been
that they can better target engagement,                   accepted as needing secondary mental health
co-ordination and risk management support                 services, further support is needed with
(new CPA) to individuals that most need it, the           engagement, co-ordination and risk
current list of characteristics has been refined          management (i.e. needing (new) CPA).

Section 3: Refocusing the Care Programme Approach

(New) CPA is a process for managing complex             Because CPA is a process and not a measure of
and serious cases – it should not be use as a           eligibility, services that currently equate CPA
“gateway” to social services or as a “badge”            levels with Fair Access to Care Services (FACS)
of entitlement to receive any other services or         eligibility levels should review their policies
benefits. Eligibility for services continues to be in   accordingly. Whether an individual needs the
accordance with statutory definitions and based         support of (new) CPA (or not) should not affect
upon assessment of individual need. Local               whether s/he is entitled to take advantage of
mental health services will want to continue            new and emerging models of service delivery
to work in an integrated and flexible way to            such as Individual Budgets.
make sure that those needs are met as
effectively as possible.

Characteristics to consider when deciding if support of (new) CPA needed                       Table 2
> Severe mental disorder (including personality disorder) with high degree of clinical complexity

> Current or potential risk(s), including:
  • Suicide, self harm, harm to others (including history of offending)
  • Relapse history requiring urgent response
  • Self neglect/non concordance with treatment plan
  • Vulnerable adult; adult/child protection e.g.
    – exploitation e.g. financial/sexual
    – financial difficulties related to mental illness
    – disinhibition
    – physical/emotional abuse
    – cognitive impairment
    – child protection issues

> Current or significant history of severe distress/instability or disengagement

> Presence of non-physical co-morbidity e.g. substance/alcohol/prescription drugs misuse,
  learning disability

> Multiple service provision from different agencies, including: housing, physical care, employment,
  criminal justice, voluntary agencies

> Currently/recently detained under Mental Health Act or referred to crisis/home treatment team

> Significant reliance on carer(s) or has own significant caring responsibilities

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Table 2 (continued)
> Experiencing disadvantage or difficulty as a result of:
     •   Parenting responsibilities
     •   Physical health problems/disability
     •   Unsettled accommodation/housing issues
     •   Employment issues when mentally ill
     •   Significant impairment of function due to mental illness
     •   Ethnicity (e.g. immigration status; race/cultural issues; language difficulties; religious practices);
         sexuality or gender issues

Key Groups                                                 The needs of individuals from these key groups
                                                           should be fully explored to make sure that the
The consultation document set out concerns                 range of their needs are examined, understood
that some key groups who should meet the                   and addressed when deciding their need for
characteristics of enhanced CPA (or new CPA)               support under (new) CPA. The default position
are not being identified consistently and that             for individuals from these groups would
services are sometimes failing to provide the              normally be under (new) CPA unless a thorough
support they need. Consultation respondents                assessment of need and risk shows otherwise.
agreed that information should be sought from              The decision and reasons not to include
individuals in these groups so that holistic               individuals from these groups should be clearly
assessments can be made on the range of their              documented in care records.
needs, and appropriate liaison and support
                                                           Services should also consider whether there are
arrangements put in place. Many respondents
                                                           any groups locally that might benefit from this
also urged that service users with significant caring
                                                           targeted approach, e.g. in some areas the needs
responsibilities should be added to the list of key
                                                           of refugee and asylum seekers might warrant a
groups. So, the key groups are service users:
                                                           similar approach.
> who have parenting responsibilities

> who have significant caring responsibilities             The Mental Health Act and (New) CPA
> with a dual diagnosis (substance misuse)
                                                           All service users subject to Supervised
> with a history of violence or self harm                  Community Treatment (SCT), or subject to
                                                           Guardianship under the MH Act (section 7)19
> who are in unsettled accommodation
                                                           status should be supported by (new) CPA.

     Mental Health Act – Section 7
Section 3: Refocusing the Care Programme Approach

If this is not considered appropriate for any         > exchange of appropriate information with all
particular individual the reasons should be             concerned, including with carers;
clearly documented in care records.
                                                      > plans for review, support and follow-up,
                                                        as appropriate;
When (new) CPA is No Longer Needed
                                                      > a clear statement about the action to take,
                                                        and who to contact, in the event of relapse or
Services should consider at every formal review
                                                        change with a potential negative impact on
whether the support provided by (new) CPA
                                                        that person’s mental well-being.
continues to be needed. As a service user’s needs
change, or the need for co-ordination support is      Where (new) CPA is appropriate in prison or
minimised, moving towards self-directed               hospital (normal criteria will apply), the same
support will be the natural progression and the       safeguards should be continued for an appropriate
need for intensive care co-ordination support and     period when the individual is released or
(new) CPA will end. However, it is important          discharged. Automatically removing the support
that service users and their carers are reassured     of (new) CPA at this point could compromise
that when the support provided by (new) CPA           the safety and treatment of the individual at a
is no longer needed that this will not remove         vulnerable point in their care pathway.
their entitlement to receive any services for which
                                                      In reviewing a care plan as part of discharge
they continue to be eligible and need, either
                                                      planning from hospital, prison or other
from the NHS, local council, or other services.
                                                      residential settings, appropriate liaison with
Services should also be careful that the support      mental health teams in the community is
of (new) CPA is not withdrawn prematurely             essential. The period around discharge is a
because a service user is stable when a high          time of elevated risk, particularly of self-harm.
intensity of support is maintaining his/her well-     This underlines the need for thorough review
being. A thorough risk assessment, with full          and assessment prior to discharge and effective
service user and carer involvement, should be         follow up and support after discharge.
undertaken before a decisions is made that the
support of (new) CPA is no longer needed.
It is also critical that there should be a process
for changing arrangements when the need for           Table 3 summarises the main similarities and
(new) CPA or secondary mental health services         differences between service responses to service
ends. The additional support of (new) CPA             users needing the support of (new) CPA and
should not be withdrawn without:                      those that do not.
> an appropriate review and handover
  (e.g. to the lead professional or GP);

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

                                                                                                     Table 3

Service users needing (new) CPA                           Other service users
An individual’s characteristics

Complex needs; multi-agency input; higher risk.           More straightforward needs; one agency or no
See detailed definition in Table 1                        problems with access to other agencies/support;
                                                          lower risk

What the service users should expect

Support from CPA care co-ordinator                  Support from professional(s) as part of clinical/
(trained, part of job description, co-ordination    practitioner role. Lead professional identified.
support recognised as significant part of caseload) Service user self-directed care, with support.

A comprehensive multi-disciplinary, multi-agency A full assessment of need for clinical care and
assessment covering the full range of needs      treatment, including risk assessment
and risks

An assessment of social care needs against FACS           An assessment of social care needs against FACS
eligibility criteria (plus Direct Payments)               eligibility criteria (plus Direct Payments)

Comprehensive formal written care plan:                   Clear understanding of how care and treatment
including risk and safety/contingency/crisis plan         will be carried out, by whom, and when (can be
                                                          a clinician’s letter)

On-going review, formal multi-disciplinary,               On-going review as required
multi-agency review at least once a year but
likely to be needed more regularly

At review, consideration of on-going need for             On-going consideration of need for move to
(new) CPA support                                         (new) CPA if risk or circumstances change

Increased need for advocacy support                       Self-directed care, with some support if

Carers identified and informed of rights to               Carers identified and informed of rights of
own assessment                                            own assessment

Section 3: Refocusing the Care Programme Approach

 Summary In reviewing policies and practice
 in light of this guidance mental health trusts

 > consider whether the documentation
   used to record the needs and plans of
   service users not needing (new) CPA can
   be simplified
 > consider the refined definition of (new) CPA
   to ensure individuals with higher support
   needs are identified and appropriately
   supported; and that individuals not needing
   this level of support are also appropriately
   cared for

 > review key groups and consider need for
   (new) CPA

 > be clear on the links between need for CPA
   and eligibility criteria

 > ensure systems are in place for service users
   to be appropriately and safely allocated to
   and from CPA

Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Section 4:
Assessment and Care Planning
Everyone referred to secondary mental health                   and diversity issues; and social inclusion and
services should receive an assessment of their                 social contact and independence.
mental health needs. This initial assessment,
                                                               The assessment and planning process should
which aims to identify the needs and where
                                                               aim to meet the service user’s needs and choices
they may be met, may have alternative names
                                                               and not just focus on what professionals and
such as screening (assessment) or triage
                                                               services can offer. It should address a person’s
                                                               aspirations and strengths as well as their needs
The outcome of the initial assessment should be                and difficulties. Trust and honesty should
communicated to the individual (in a way that                  underpin the engagement process to allow for
they will understand) and the referrer promptly.               an equitable partnership between services users,
If it is agreed that the person’s needs are best               carers and providers of services.
met by a secondary mental health service, a
                                                               To reduce documentation and cut down on
care plan should be devised and agreed with the
                                                               duplication, services should aim to develop one
service user and, where appropriate, their carer.
                                                               assessment and care plan that will follow the
This section of the guidance refers to the
                                                               service user through a variety of care settings to
assessment and re-assessment which will then
                                                               ensure that correct and necessary information
occur as part of the CPA process. It does not
                                                               goes with them. More use of joint assessments
cover the part of the care pathway prior to the
                                                               and review, with common documentation
decision about whether secondary care is
                                                               between agencies and teams, would avoid
required, or whether CPA is required.
                                                               duplication of paperwork.
The MHNSF sets out the range of issues and
                                                                        Positive practice (available at
needs a multi-disciplinary health and social care
assessment and care plan may cover depending
on need. These including: psychiatric,
psychological and social functioning, including
                                                               Contingency and crisis planning
impact of medication; risk to the individual and
others, including contingency and crisis
                                                               Although improvements are being made
planning; needs arising from co-morbidity;
                                                               surveys20 show that almost half of service users
personal circumstances including family and
                                                               still report not being given a telephone number
carers; housing needs; financial circumstances
                                                               they could use to contact someone from NHS
and capability; employment, education and
                                                               mental health services out of hours.
training needs; physical health needs; equality

     Healthcare Commission, Survey: community mental health services show improvements but concerns remain over social
     inclusion and access to counselling. 2007 available from

Section 4: Assessment and Care Planning

All care plans must include explicit crisis and                 Choice
contingency plans. This will include
arrangements so that the service user or their                  Our Choices in Mental Health21 establishes
carer can contact the right person if they need                 the core principles for promoting choice in
to at any time, with clear details of who is                    acknowledging that people have the right
responsible for addressing elements of care and                 to choose their treatment, and that choice
support. Copies of the plans should be offered                  applies across the spectrum of care and settings.
to the service user and given to his or her GP                  It emphasises the increasing importance of:
and any other significant care provider, including
                                                                   Direct payments which should be a standard
carers, if appropriate. Further good practice on
                                                                   option for all those eligible to receive social
contingency and crisis planning and service user
                                                                   care services. Direct payments for people with
and carers and involvement and engagement is
                                                                   mental health problems: A guide to action
available at
                                                                   (DH, 2006)22 provides a comprehensive
                                                                   framework for implementation.

Updating Policy and Practice                                       Individual budgets (IBs) which can enable
                                                                   people to use their resources to design the
Developments in policy, practice and legislation                   type of support that works for them in
since 1999 indicate that services should pay                       meeting outcomes. DH has funded a
greater attention to issues of choice; social                      pilot of the IB system, and national roll
inclusion; and equalities. Further guidance is                     out is expected shortly.
now available on risk assessment and                     
management. The CPA review also highlighted
                                                                   Statements of wishes and advance directives
a range of critical issues within assessment and
                                                                   which are a useful way to help plan for the
care planning that would benefit from renewed
                                                                   future, and people should be supported in
consideration. Trusts should consider the range
                                                                   developing these where wanted.
of issues highlighted below and review local
policies and practice to ensure that they reflect
current national policy, legislation and good
practice in the areas outlined.

     CSIP/NIMHE, Our Choices in Mental Health, 2006
     Department of Health. Direct payments for people with mental health problems: A guide to action. 2006
Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Outcomes                                                          Risk Assessment and Management

Assessments and care plans should routinely                       Risk assessment is an essential and on-going
include arrangements for setting out, measuring                   element of good mental health practice and a
and reviewing specific outcomes. An outcomes                      critical and integral component all assessment,
focus can help to improve understanding of the                    planning and review processes. DH guidance
impact of services on the lives of people who                     Best Practice in Managing Risk 23 sets out a
use them; give assurance that treatments and                      framework of principles covering self-harm
care provided are producing results; and ensure                   and suicide, violence to others and self-neglect
that outcomes related to treatment, care and                      to underpin best practice across all adult mental
support are monitored on an on-going basis.                       health settings.
The desired outcomes should be explicitly
                                                                  The guidance provides a list of tools that
agreed with the service user and carer(s) at the
                                                                  can be used to structure the often complex
beginning of the care process so that the plan is
                                                                  risk assessment and management process.
personalised to the service user).
                                                                  The philosophy underpinning this framework is
It is expected that for people on (new) CPA,                      one that balances care needs against risk needs,
HoNOS (Health of the National Outcome                             and that emphasises: positive risk management;
Scale) ratings will be completed at significant                   collaboration with the service user and others
points of change within the care pathway and                      involved in care; the importance of recognising
at any event, at least once a year. In addition,                  and building on the service user’s strengths;
however, there is a growing number of                             and the organisation’s role in risk management
instruments available to help measure                             alongside the individual practitioner’s. It
outcomes. Different instruments cover different                   emphasises the importance of the assessment
aspects of outcomes and some are designed for                     of dynamic (changing) risk factors, as well as
a specific age group or service area. Those who                   the more well-understood static ones.
develop individual measurement tools generally
advise on usage and best practice. CSIP/DH are
commissioning a compendium of outcomes
tools to provide information about most that are
available and their use in measuring outcomes
in mental health services. It is expected that the
first release of the compendium will be available
in 2008.

     Department of Health, Best Practice in Managing Risk: Principles and Evidence for Best Practice in the Assessment
     and Management of Risk to Self and Others in Mental Health Services. 2007

Section 4: Assessment and Care Planning

Where appropriate, criminal justice agencies          face difficulties and barriers in accessing services
(particularly the Offender Manager Service            and support. The assessment should take into
using the OASys system and the Multi-Agency           account the impact over time, as well as at the
Public Protection Arrangements) can provide           moment of assessment, and needs to reflect the
essential support to risk assessment in relation to   complex interplay of stressors that can occur in
some offenders and should be consulted as part        families and the cumulative impact of these.
of a holistic assessment.
                                                      Establishing whether a service user is a parent at
Risk assessment for people with a learning            the initial assessment stage is critical, and should
disability needs to be multi-agency, including        be routine. Parents who are temporarily
speech and language therapists where                  separated from their children (e.g. when in
necessary, so that a balance between risk             prison) should also be included. Assessment,
management and the individual having a                including risk assessment, should assess the
fulfilling life is achieved.                          potential or actual impact of mental health on
                                                      parenting, the parent and child relationship, the
           Positive practice (available at
      ✓                  child and the impact of parenting on the adult’s
                                                      mental health and what appropriate support
                                                      might look like and how it can be accessed.
Equality                                              It should also assess the indirect impacts of
                                                      mental illness e.g. financial problems, poor
Assessments, care plans and reviews should take       housing, stigma and discrimination.
account of the needs of individuals in respect of
                                                      It is also important to identify whether an
age, disability, gender, sexual orientation, race
                                                      individual has good relationships and support
and ethnicity and religious beliefs. Supporting
                                                      from family, friends and the community to
guidance is available – see Section 1.
                                                      establish whether there is a risk of the individual
                                                      becoming isolated.
                                                      Further information: Briefing Paper: Parents
                                                      with Mental Illness.24
Between 30% and 50% of users of mental
health services are parents with dependent
children. These parents and their children may


Refocusing the Care Programme Approach: Policy and Positive Practice Guidance

Dual Diagnosis                                                    with substance use. Certain medication may
                                                                  compound physical health risks, for example
The importance of assessing substance misuse,                     by causing weight gain or increasing the risk
having a care plan related to this and for staff                  of diabetes.
to be trained to work with people with dual
                                                                  Assessing and addressing the physical health
diagnosis, has been consistently highlighted.25,26,27
                                                                  needs of a mental health service user should be
Drug and alcohol misuse should be considered                      given a high priority. Service users should be
in all assessments undertaken by mental health                    encouraged and supported to access support for
services. Current and past substance use should                   their physical health needs and receive at least
be asked about and an assessment made of the                      a basic physical medical assessment, including
risks with an appropriate risk management plan.                   issues around smoking and obesity, through
Staff in mental health settings should routinely                  primary care if this has not already been
ask service users about recent legal and illicit                  undertaken.
drug use. The questions should include whether
                                                                  Mental health professionals should consider the
they have used drugs and if so what type and
                                                                  service users’ needs holistically and aim to
method of administration, quantity and
                                                                  improve their quality of life and their health.
                                                                  Assessments and care plans should identify and
                                                                  tackle the impact that mental illness symptoms
Physical Health                                                   and possible treatment programmes can have
                                                                  on physical health and the impact that physical
The links between mental ill health and physical                  symptoms can have on an individual’s mental
ill health are well documented. Research has                      well-being.
shown that people with mental health problems
                                                                           Positive practice (available at
have higher rates of physical illness, resulting
in increased rates of morbidity and mortality.29
There are also physical health issues associated

   Department of Health, Mental health policy implementation guide: Dual diagnosis good practice guide. 2002
   Department of Health. Dual Diagnosis In-patient guidance: Dual diagnosis in mental health inpatient and day hospital
   settings. Guidance on the assessment and management of patients in mental health inpatient and day hospital settings who
   have mental ill-health and substance use problems. 2006
   Appleby et al. Avoidable deaths; a five year report of the national confidential inquiry into suicide and homicide by people
   with mental illness. 2006. University of Manchester.
   NICE, Drug Misuse – Psychosocial Interventions. 2007
   Department of Health, Choosing Health: Supporting the physical health needs of people with severe mental illness
   (commissioning framework). 2006

Section 4: Assessment and Care Planning

Housing and Homelessness
                                                                         Positive practice (available at

People who are homeless or living in temporary
or insecure accommodation (unsettled
accommodation) have higher rates of mental                      Employment, Education and Training
illness than the general population. Generally,
rates are double and illnesses are of a more                    Only around 20% of those in contact with
severe nature. Between 30% – 50% have a                         secondary mental health services are in paid
significant mental illness.30 Functional illnesses              work. Yet only 8% of case notes of people
predominate although acute distress and                         supported by Community Health Teams address
personality disorders are also common.                          vocational needs.33 50% of service users want
                                                                help with finding paid work but have not
People who are in unsettled accommodation
                                                                received it.34
need similar care and support packages as
others with the same mental health problems.                    Assessments should explore service user’s
However, the way in which care is delivered and                 current and longer term needs for support with
the order in which problems are addressed may                   employment, education and training and agree
be different reflecting individual circumstances.               realistic outcomes. Many people with mental
                                                                health problems want to work and services need
Assessments should address the adequacy of
                                                                to be able to support them to do this. For other
housing needs and where appropriate
                                                                people with mental health problems, accessing
assessments, including risk, should be shared
                                                                education and training may be both an
with local housing agencies.
                                                                important stepping stone to employment or
The socially excluded adults Public Service                     have value in its own right. Care co-ordinators
Agreement (PSA)31 has signalled the                             should promote access to employment
Government’s priority in achieving improved                     information, advice and support, options for skill
settled accommodation outcomes for adults                       development and link with local employment
receiving secondary mental health services.                     agencies including Jobcentre plus.

Further information Briefing Paper: Understanding
Homelessness and Mental Health.32

   Department of Health, Getting Through: Access to mental health services for people who are homeless or living in temporary
   or insecure accommodation. 2007
   HM Treasury, Public Sector Service Agreements 2008 – 2011–csr/psa/pbr–csr07–psaindex.cfm
   Bertram, M. & Howard, L. Employment Status and Occupational Care Planning for People Using Mental Health Services.
   2006 Psychiatric Bulletin, 30, 48 – 61.
   Healthcare Commission, Service User Survey. 2006
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