Commissioning guides
Published 01 November 2011

Commissioning stepped care for people with common mental health disorders

This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg41

3 A stepped-care approach to commissioning high-quality integrated care for people with common mental health disorders

NICE recommends that a stepped-care model is used to organise the provision of services and to help people with common mental health disorders, their families, carers and healthcare professionals to choose the most effective interventions. In stepped care the least intensive intervention that is appropriate for a person is typically provided first, and people can step up or down the pathway according to changing needs and in response to treatment.

Commissioning services using the stepped-care model is likely to be cost effective because people receive the least intensive intervention for their need. If a less intensive intervention is able to deliver the desired positive service-user outcome, this limits the burden of disease and costs associated with more intensive treatment.

Service users may begin their journey at any step of the pathway, in accordance with their needs. Timely referral to higher or lower steps may be appropriate and cost effective for some people. A study of psychological intervention services shows that services that comply with NICE guidance and provide stepped care have better service-user outcomes and improved recovery rates[4].

Commissioners and their partners should develop integrated care pathways that promote stepped care. Figure 3 shows a stepped-care model for common mental health disorders, covering steps 1 to 4. When commissioning services using the stepped care model, commissioners should ensure that local systems allow for some flexibility in how interventions are provided, with the crucial factors being the patterns of local need and whether a service provider is competent to provide a particular psychological and/or pharmacological intervention.

Figure 3 Stepped-care model showing steps 1 to 4 for people with common mental health disorders

3.1 Working collaboratively

'Common mental health disorders: identification and pathways to care' (NICE clinical guideline 123) recommends that primary and secondary care clinicians, managers and commissioners collaborate to develop local care pathways that promote access to services for people with common mental health disorders. It states that responsibility for the development, management and evaluation of local care pathways should lie with a designated leadership team, which should include primary and secondary care clinicians, managers and commissioners.

Commissioners should develop, or enhance existing, multiagency partnerships to lead on developing and monitoring local care pathways for people with common mental health disorders. Partnerships may include representatives from a range of professional groups and from a variety of statutory, voluntary and private providers. Examples are included in box 1.

Box 1 Possible members of a multiagency common mental health disorder partnership

Primary care representatives including:

  • GPs, including clinical commissioning group leads and/or GPs with a special interest in mental health

  • Practice nurses

  • Practice-based counsellors, mental health or wellbeing workers

Community-based services representatives from:

  • Local psychological intervention and counselling services (primary care psychology services/improving access to psychological therapy [IAPT] services, which typically provide services at steps 2 and 3)

  • Community mental health team (typically provide more specialist care to people at step 4 and above)

  • Social care

  • Local employment and education services

  • Local drug and alcohol services

  • Local debt, welfare or citizens advice or victim support services

  • Local relationship counselling services

  • Physical activity services

  • Occupational therapy

  • Criminal justice

  • Refugee and asylum seeking services

Secondary care representatives including:

  • Psychiatrists, including primary care and/or community psychiatrists

  • Mental health nurses

  • Practitioner psychologists

  • Secondary care physicians and nurse specialists from a range of specialties including musculoskeletal, respiratory, dermatology, diabetes, cardiac, neurology and cancer

  • Accident and emergency staff

Support services, representatives from:

  • Local commissioning organisations

  • Data and performance

  • Finance

Figure 4 outlines a model for the development of stepped-care services using a partnership approach. Commissioners should encourage their local partnership to:

  • Use the partnership as a forum for improving communication between partners, and increasing knowledge of the range of local services for people with common mental health disorders.

  • Agree how to promote flexible, integrated and inclusive care pathways based on the stepped-care model (see section 3.2).

  • Define local service outcomes (see section 3.3).

  • Agree methods to destigmatise common mental health disorder services. This may include using service user feedback to understand barriers to accessing services, exploring language use, public education or local media initiatives, and encouraging services to allow self-referral. A study of psychological intervention services shows that self-referred service-users present with symptoms as severe as those of GP-referred service-users but recover with fewer sessions of treatment, suggesting that services should seek to expand self-referral to improve efficiency, and promote better access for different sectors of the community[4].

Figure 4 A partnership approach to commissioning common mental health disorder services

Commissioners should work with their partnership to develop shared governance procedures for their integrated common mental health disorders service, which support the delivery of the whole pathway of care. Commissioners should ensure that they have the policies and procedures in place for:

  • data protection, information sharing and confidentiality

  • referral, assessment, treatment and discharge processes

  • safeguarding vulnerable children, young people and adults (including adults with common mental health disorders who care for children and young people)

  • serious untoward incident reporting

  • workforce development, including recruitment, training programmes, induction, appraisal, supervision and continuing professional development

  • communications, promotion of services and marketing

  • service user, carer and public engagement and involvement.

3.2 Developing local common mental health disorder pathways

NICE clinical guideline 123 makes recommendations for commissioners and their partners who are developing care pathways for people with common mental health disorders, underpinned by the stepped care model. Table 1 has a summary of these recommendations.

Table 1 Designing a local care pathway for common mental health disorders[5]

Promoting the principles of good care

Ensure local care pathways are:

  • negotiable, workable and understandable for all involved

  • accessible and acceptable to all people in need of the services

  • responsive to the needs of people with common mental health disorders and their families and carers

  • integrated, with no barriers to movement between different levels of the pathway

  • outcomes focused (including measures of quality, service-user experience and harm).

Promoting access to services

Ensure local care pathways:

  • support integrated delivery of services across primary and secondary care

  • include clear and explicit criteria for entry to the service and focus on these rather than exclusion criteria

  • have multiple means to access the service (including self-referral)

  • provide multiple points of access that facilitate links with the wider healthcare system and community

  • promote access to services for people from a range of socially excluded groups including:

    • black and minority ethnic groups

    • older people

    • people in prison or in contact with the criminal justice system

    • ex-service personnel.

Promoting a stepped-care model of service delivery

Ensure local care pathways:

  • provide the least intrusive, most effective intervention first

  • have clear and explicit criteria for the thresholds determining access to and movement between the different levels of the pathway

  • do not use single criteria (such as symptom severity) to determine movement between steps

  • monitor progress and outcomes to ensure the most effective interventions are delivered and the person moves to a higher step if needed

  • promote a range of evidence-based interventions at each step in the pathway

  • support people in their choice of interventions.

Promoting active engagement of all populations

Ensure local care pathways:

  • offer prompt assessments and interventions that are appropriately adapted to the cultural, gender, age and communication needs of the person

  • keep to a minimum the number of assessments needed to access interventions.

Responding promptly and effectively to changing needs

Ensure local care pathways have in place:

  • clear and agreed goals for the services offered to a person

  • robust and effective ways to measure and evaluate the outcomes associated with the agreed goals

  • clear and agreed mechanisms for responding promptly to identified changes to the person's needs.

Providing an integrated programme of care

Ensure local care pathways:

  • minimise the need for transition between different services or providers

  • allow services to be built around the pathway (and not the pathway around the services)

  • establish clear links (including access and entry points) to other care pathways (including those for physical healthcare needs)

  • have designated staff who are responsible for the coordination of people's engagement with the pathway.

Having robust systems for outcome measurement

Ensure local care pathways provide:

  • individual routine outcome measurement systems

  • effective electronic systems for the routine reporting and aggregation of outcome measures

  • effective systems to audit and review the overall clinical and cost-effectiveness of the care pathway.

To facilitate service-user choice from a range of local, evidence-based interventions a variety of interventions should be commissioned at each step. Commissioners should specify that their providers offer people information resources that enable them to make an informed choice about the most cost-effective, evidence-based intervention for them. An example is the WHICH talking therapy for depression? produced by the Department of Health. Commissioners should ensure that pathways enable people to receive the least intensive intervention that is appropriate to their needs.

The Topic Advisory Group suggests that in many areas there is disharmony in the defined thresholds for treatment between steps. This means that many people who are referred up to higher steps for treatment, and particularly those with more complex diagnoses or social needs, do not meet the threshold for stepping up and therefore cannot access treatment at the appropriate step. This is thought to be a particular issue between steps 2 and 3 and between steps 3 and 4. The Topic Advisory Group also noted that there is a tendency for more people to be referred upwards through the stepped-care model than for people to be referred back down to lower intensity interventions. Therefore commissioners should:

  • Ensure that pathways and service specifications clearly define the characteristics of people who will use each step, including thresholds for the severity of a person's common mental health disorder at each step. Commissioners should ensure that this does not generate gaps in which people in need of interventions may not be eligible for services.

  • Define and monitor referral to assessment, and assessment to treatment start times.

  • Monitor the numbers of people who are referred to services and the numbers who do and do not take up the offer of interventions. Commissioners and providers should discuss the relative advantages and disadvantages of different referral systems including opt-in, partial booking or set appointment times, and consider supplementing these with reminder systems, including letters, text messages, recorded phone messages and/or personal phone calls, especially before the first appointment for a new intervention.

  • Monitor the numbers of people who are referred up or down the local stepped-care pathway, and specify that providers record the reasons for steps up or down.

  • Use contract monitoring meetings and multiagency partnership meetings to discuss, understand and agree actions to overcome problems, such as lower than expected uptake of services, lack of service capacity, rejected or 'bouncing' referrals, lower or higher than expected levels of people stepping up or down.

  • Consider specifying that the service has a service user experience lead, agreeing what information about service users' experience should be collected and reported at contract management meetings, and how this information will be used to contribute to service improvement.

The National Audit of Psychological Therapies for Anxiety and Depression: National Report 2011 found that 70% of service-users who had high intensity therapy received less than the minimum number of treatment sessions that NICE recommends[6]. About half of these service-users had not recovered by the time their therapy was discontinued. Commissioners should ensure that they commission sufficient capacity to enable all people referred for treatment to receive the number of sessions of psychological interventions recommended by NICE.

Longer and more intensive interventions are needed for patients with complex needs, which can affect service capacity, therefore commissioners should work with providers to assess the level of need for this group.

When commissioning psychological interventions, commissioners should consider how to optimise funding available as part of the Department of Health's Improving Access to Psychological Therapies (IAPT) programme. Most PCTs have started implementing IAPT, although there is considerable national variation in the maturity and reach of these services. The local implementation and availability of IAPT services is likely to have a considerable impact on the resources needed to meet NICE guidance and achieve the NICE quality standards[7].

From April 2011 funding for existing IAPT services and future expansion has been included within the baselines of participating primary care trusts (PCTs). Therefore commissioners may wish to work with finance leads to maintain existing funding and seek additional investment to expand access to psychological interventions if necessary.

3.3 Measuring the outcomes, quality and performance of the stepped care pathway

NICE clinical guideline 123 recommends that local care pathways should have robust systems for outcome measurement in place, which should be used to inform all involved in a pathway about its effectiveness. Measuring outcomes, progress, recovery and relapse is vital to ensure that people's treatment is reviewed, and where appropriate stopped, in line with the stepped-care model, if there are signs of deterioration or no indications of improvement.

The Topic Advisory Group agreed that commissioning high quality services for people with common mental health disorders could contribute to delivering the following outcomes:

Box 2 Service level outcomes for common mental health disorder services[a]

  • Reducing the stigma and discrimination associated with a diagnosis of, or treatment for, common mental health disorders

  • Increasing the proportion of people with common mental health disorders who are identified, assessed and receive treatment in accordance with NICE guidance

  • Improving the proportion of people with common mental health disorders who make a clinically significant improvement or recover

  • Reducing the proportion of people with common mental health disorders who relapse

  • Identifying risk and preventing avoidable harm

  • Improving emotional wellbeing, quality of life and functional ability in people with common mental health disorders

  • Preventing sick leave and helping people stay in education, employment or meaningful activities

  • Reducing long-term unemployment, homelessness and family breakdown

  • Improving service-user choice and experience of mental health services

  • Improving the interface between services for people with common mental health disorders

A stepped-care approach to commissioning high-quality services for people with common mental health disorders may also contribute to the following outcomes in the NHS outcomes framework 2011/12:

Domain 2 enhancing quality of life for people with long-term conditions:

  • Enhancing quality of life for carers

  • Enhancing quality of life for people with mental illness

Domain 4 ensuring that people have a positive experience of care:

  • Improving experience of healthcare for people with mental illness

[a] Adapted from: Department of Health (2011) No health without mental health: a cross-government mental health outcomes strategy for people of all ages. London: Department of Health; Department of Health (2010) NHS Outcomes Framework 2011/12. London: Department of Health and Department of Health (2011) Talking therapies: a 4 year plan of action. London: Department of Health

Commissioners should work with their partners to agree local outcome measurement tools and ensure that the tools are appropriate to the intervention and setting. The Topic Advisory Group agreed that the IAPT data standard (see box 3) is a comprehensive outcomes-focused measurement tool that would be suitable for all providers in the pathway to monitor service-user and aggregated outcomes, clinical improvement and performance.

Box 3 The IAPT data standard

The IAPT data standard forms the basis of national data collection for IAPT services and is a clinical management tool that is used to record service-user outcomes measures. The measures include:

  • Service-user details – demographic details that can be used to demonstrate compliance with the Equality Act 2010

  • Disability details – comorbid physical or mental health disorders, learning disability, sensory impairment

  • Referral data – provisional diagnosis to inform the clinical approach, and key dates including waiting times

  • Appointment data – clinical, work and social functioning outcome scores, including disorder-specific measures, and key dates to measure recovery rates

The clinical, work and social functioning outcome measures are:

  • Patient health questionnaire (PHQ-9) for depression

  • Generalised anxiety disorder assessment (GAD-7)

  • IAPT phobia scales

  • A range of anxiety disorder specific measures (ADSMs)

  • Work and social adjustment scale (WSAS)

  • IAPT employment status questions

  • IAPT patient choice and experience questionnaire

Appropriate measures should be taken at every service-user contact.

Further information can be found in the IAPT data handbook: guidance on recording and monitoring outcomes to support local evidence-based practice and the data collection in IAPT training presentation.

Commissioners should:

  • Ask primary care and contracted services to demonstrate that service-user outcomes are measured at assessment, and routinely monitored before or during every service-user contact throughout treatment. If outcomes are not routinely monitored, there is a risk that people continue with unnecessary or inappropriate treatment, which may compromise recovery, service-user outcomes and cost effectiveness. There is evidence that routinely discussing therapeutic scores with service-users can help them understand their condition and assist the therapeutic relationship[8].

  • Specify when and for how long outcomes should continue to be measured after the completion of treatment, to monitor levels of relapse.

  • Specify that relevant staff are competent in using the agreed outcomes measurement tools.

  • Specify that information on service users' progress and outcomes, and treatment completion, are fed back to the agency that made the initial referral and other services working with the service users (for example, the GP or the case managers of people with comorbid chronic physical health conditions).

In addition to outcomes measurement, commissioners and their partners may wish to define locally-agreed performance measures and waiting times. They should ensure that they have measures for:

  • how many people are offered and take up the offer of interventions

  • how many people are assessed, start and complete treatment programmes.

Commissioners should specify that outcomes measurements are collected using secure electronic systems, to ease data collection, collation and analysis.

Commissioners will wish to ensure that there is dedicated data analyst time available to monitor aggregated outcomes, ideally provided by an analyst with an interest in mental health.

3.4 Commissioning care-planned treatment

NICE makes a range of recommendations about the coordination and planning of care for people with common mental health disorders. Recommendation 1.1.1.6 of NICE clinical guideline 123 states that care pathways should support access to services and increase the uptake of interventions by:

  • ensuring systems are in place to provide for the overall coordination and continuity of care of people with common mental health disorders

  • designating a healthcare professional to oversee the whole period of care (usually a GP in primary care settings).

NICE also recommends case management for people with obsessive-compulsive disorder and collaborative care for people with comorbid chronic physical health conditions (see also section 3.5.2). At steps 3 and 4 NICE recommends using combined interventions for depression, generalised anxiety disorder and obsessive-compulsive disorder, so good care coordination is needed.

Commissioners should ensure that all people with common mental health disorders receive care-planned treatment[9]. Together with assessment (see section 5.1.2), care-planned treatment acts as a platform for determining the intensity of support and most suitable interventions, in line with the stepped-care model (see figure 3).

Commissioners should:

  • Specify that everyone receiving psychological, pharmacological or social interventions for common mental health disorders has a care plan that is routinely monitored and includes service-user outcome measures (see also section 3.3).

  • Work with partners and providers to agree local approaches to care-planned treatment. Typically care-planned treatment will involve a case manager or care coordinator who oversees the care plan, stepped care and continuity of care. The model may vary depending on the step of care being received, and is more intense for people at higher steps or with more complex needs. This service is often provided by a GP, nurse specialist, psychological wellbeing practitioner or psychological intervention therapist, but may be provided by a range of professionals according to service-user needs.

  • Specify that people receiving treatment have a named care-coordinator or case manager who has received training on providing care-planned treatment.

  • Specify that people receiving treatment know who their care coordinator is, what their role is, how to contact them and who to contact in case of crisis outside their working hours.

Recommendation 1.4.4.1 of NICE clinical guideline 123 recommends that:

'For people with a common mental health disorder who are at significant risk of relapse or have a history of recurrent problems, discuss with the person the treatments that might reduce the risk of recurrence. The choice of treatment should be informed by the response to previous treatment, including residual symptoms, the consequences of relapse, any discontinuation symptoms when stopping medication, and the person's preference.'

Commissioners and their partners should satisfy themselves that the care planning process includes relapse prevention and is suitable for people with recurrent or chronic common mental health disorders, and should monitor practice locally.

3.5 Commissioning inclusive and accessible services

Commissioners should use their needs analysis (see section 4) and service-user feedback, to ensure that they understand local barriers to accessing common mental health disorder services, and have plans in place to improve the accessibility of services. They should pay particular attention to groups who are often excluded from services, people with comorbidities and families and carers of people with common mental health disorders.

3.5.1 Socially excluded groups

Recommendation 1.1.1.5 of NICE clinical guideline 123 states that primary and secondary care clinicians, managers and commissioners should collaborate to develop local care pathways that promote access to services for people with common mental health disorders from a range of socially excluded groups.

People from some socially excluded groups are less likely to visit their GP, receive a diagnosis of a common mental health disorder and receive treatment[10].

Commissioners and their partners should give particular attention to the needs of the following groups:

  • black and minority ethnic groups, including people who do not have English as their first language

  • older people, including people living in nursing homes or with dementia

  • younger people, especially young men

  • people in prison or in contact with the criminal justice system

  • ex-service personnel

  • people from deprived communities, including people who are on low incomes, unemployed or homeless, single-parents and carers.

Depending on local circumstances, commissioners may need to consider:

  • Commissioning services that have bilingual therapists who speak the language of local minority groups, or commissioning independent translation services. Commissioners should specify that both written communication (such as appointment letters, information leaflets and bibliotherapy) and verbal communication (such as psychological interventions) are appropriate to these groups.

  • Asking services to provide visually-based resources for people who do not speak English as their first language, and for people with learning disabilities.

  • Using technology to improve access for people who may struggle, or be less willing, to attend social or psychological interventions, such as young men, older people, single parents, people with caring responsibilities or people who work long hours. Commissioners should ensure that services use a range of technologies such as telephone-based psychological interventions, text messaging, video-based internet conferencing and computerised interventions.

  • Options to improve access, such as crèche facilities, subsidised public transport or taxis, and home-based assessment and interventions (for example for older people and people whose mobility is impaired by a chronic physical health condition).

  • Options for assessment and interventions to be provided in a person's home, GP practices or discreet non-traditional community settings such as job centres or children's centres.

Commissioners should also work with commissioners of child and adolescent mental health services (CAMHS) to ensure optimal transition between pathways for children aged 16 to 18 who are moving to adult services.

Commissioners should note, and satisfy themselves that providers comply with, recommendation 1.1.1.11 of NICE clinical guideline 123, which states:

'Do not significantly vary the content and structure of assessments or interventions to address specific cultural or ethnic factors (beyond language and the cultural competence of staff), except as part of a formal evaluation of such modifications to an established intervention, as there is little evidence to support significant variations to the content and structure of assessments or interventions.'

Commissioners may wish to refer to the Department of Health's publication 'Commissioning IAPT for the whole community: improving access to psychological therapies', which can help commissioners develop services that are effective and appropriate for the whole community.

3.5.2 People with comorbid chronic physical health conditions

'Depression in adults with a chronic physical health problem' (NICE clinical guideline 91) details recommendations for managing depression in people with a chronic physical health condition[11]. Commissioners should be aware an ageing population and improving medical interventions mean that larger numbers of people are living longer with multiple chronic physical health conditions. Consequently there is likely to be an increasing demand for services that can provide psychological support to people with chronic physical health conditions. There is evidence that addressing these psychological needs can reduce costs relating to their physical health conditions and improve patient experience and quality of life[12].

Recommendation 1.5.1.8 of NICE clinical guideline 123 states that common mental health disorder pathways should establish clear links, including access and entry points, to pathways for people with physical healthcare needs. Commissioners should work closely with the commissioners of clinical specialties in which chronic physical health conditions are common (see box 4), to discuss common commissioning issues and develop commissioning plans for these groups.

Box 4 Clinical specialities in which a large number of people may have chronic physical health conditions

  • Cancer services

  • Diabetes services

  • Heart disease services, for example services for chronic heart failure

  • Renal services

  • Musculoskeletal services, for example rheumatology, orthopaedics

  • Respiratory services, for example services for chronic obstructive pulmonary disease or asthma

  • Neurological services, for example services for stroke or autoimmune conditions

  • Dermatology, for example services for psoriasis

  • Chronic pain services, for example services for lower back pain

Commissioners should specify that services for people with chronic physical health conditions proactively identify common mental health disorders by incorporating measures of psychological wellbeing into assessments of functional impairment, treatment and rehabilitation[13].

Commissioners should agree with healthcare professionals and service managers the most appropriate place for people with common mental health disorders and comorbid chronic physical health conditions to be identified, assessed and managed. Commissioners and their partners may wish to consider the following:

  • For people whose depression and anxiety is directly related to their chronic physical health condition, consider commissioning psychological support within the pathway for the physical condition. An example would be anxiety that directly relates to breathing difficulties in people with chronic obstructive pulmonary disease (COPD), or needle phobia in people with diabetes. This may use the skills of nurse specialists or may need dedicated psychological therapy staff with an expertise in chronic physical health conditions.

  • For people who have an identified common mental health disorder that is not related to the chronic physical health condition, consider commissioning services within their wider pathway for people with common mental health disorders.

Commissioners and their partners may wish to consider:

  • Using the expertise of practitioner psychologists and psychiatrists with an interest in chronic physical health conditions, when developing pathways for this group.

  • Specifying that providers of group-based physical activity or rehabilitation programmes for people with chronic physical health conditions include the management of depression and anxiety disorders as part of their programme.

  • Working with providers to identify resources and opportunities to develop the skills of nurse specialists to deliver psychological interventions, working with local psychological intervention services as appropriate.

  • Working with providers to identify resources and opportunities for psychological wellbeing practitioners and psychological therapists to develop an understanding of chronic physical health conditions and to understand the nature of comorbid depression and anxiety issues. For example, by enabling psychological intervention staff to visit or shadow nurse specialists working in local diabetes or COPD clinics.

  • Working with providers to encourage systematic coding and recording of mental health needs in people with chronic physical health conditions[13].

Quality statement 9 of the NICE quality standard on depression in adults states that:

'People with moderate to severe depression and a chronic physical health problem with associated functional impairment, whose symptoms are not responding to initial interventions, receive collaborative care.'

[Quality statement 9 includes a definition of collaborative care.]

NICE clinical guideline 91 on depression in adults with a chronic physical health problem states that collaborative care should be used at step 3 for people with chronic physical health conditions and comorbid depression, by bringing services and professionals together to provide individualised, needs-led care. Collaborative care should include a dedicated care coordinator.

Commissioners and their partners should work together to agree the local model for collaborative care for people with chronic physical health conditions and comorbid common mental health disorders. In addition to the considerations set out in section 3.4 for care-planned treatment, commissioners should specify:

  • the professionals who will provide case management for this group

  • the steps in which case management will be provided.

There is an argument that collaborative care should also be engaged at step 2 to build up the confidence of the service-user. This may lead to a smoother care-pathway or earlier discharge.

3.5.3 People with comorbid mental health conditions, substance misuse, learning disabilities or cognitive impairment

Common mental health disorders may present alongside other mental health or behavioural disorders[13].

Recommendation 1.4.1.6 of NICE clinical guideline 123 states:

'When a person presents with a common mental health disorder and harmful drinking or alcohol dependence, refer them for treatment of the alcohol misuse first as this may lead to significant improvement in depressive or anxiety symptoms.'

Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol, including psychological disorders such as depression. Alcohol dependence is associated with increased rates of mental health disorders, including common mental health disorders[13]. Commissioners may wish to refer to the NICE commissioning guide on alcohol services when commissioning services for people with common mental health disorders who are harmful drinkers or alcohol dependent. Commissioners should ensure that:

  • pathways for common mental health disorders are integrated with local alcohol and/or substance misuse pathways so that people can receive treatment in the most appropriate place for their individual needs

  • local substance-misuse services have sufficient capacity and can provide timely access to treatment

  • treatment for alcohol misuse includes psychological interventions in line with NICE guidance[14].

Commissioners should also note recommendation 1.4.1.7 of NICE clinical guideline 123, which states that when a person presents with a common mental health disorder and a mild learning disability or mild cognitive impairment, where possible provide or refer for the same interventions as for other people with the same common mental health disorder or if providing interventions, adjust the method of delivery or duration of the assessment or intervention to take account of the disability or impairment. However, recommendation 1.4.1.8 states that:

'When a person presents with a common mental health disorder and has a moderate or severe learning disability or a moderate to severe cognitive impairment, consult a specialist concerning appropriate referral and treatment options.'

Therefore commissioners should ensure that their common mental health disorder pathways identify the action that healthcare professionals should take if they suspect or have identified a common mental health disorder in a person with moderate or severe learning disability or cognitive impairment, and that pathways include links to relevant local specialist learning disability services.

Commissioners should work with providers to ensure that there are ring-fenced resources for training psychological wellbeing practitioners and therapists to work with people with comorbid mental health disorders, learning disabilities or cognitive impairment.

3.5.4 Families and carers

All NICE clinical guidelines on common mental health disorders make recommendations for supporting families and carers. Commissioners should:

  • Ensure that providers can offer a carer's assessment appropriate to the common mental health disorder and in accordance with NICE guidance. This may include an assessment of their caring, physical, social, occupational and/or mental heath needs, as appropriate.

  • Specify that providers give families and carers written and verbal information on relevant common mental health disorders and their management, including information on how families or carers can support the person[15].

  • Specify that providers give carers and families information about local family or carer support groups, and help families and carers access these. They may also wish to request that they provide contact details for families or carers at times of crisis.

  • Review local provision of carers' support groups, and consider supporting the establishment of new groups and networks where there are identified gaps in the service. Commissioners may wish to encourage local providers to make rooms available in treatment centres or GP surgeries for carers' support group meetings during the day, evenings and/or weekends.

  • Specify that providers negotiate between the person with the common mental health disorder and their family or carer about confidentiality and sharing of information. Commissioners and their partners should have policies and agreements in place for consent, confidentiality and the sharing of information between partner services and between service users and their families or carers.

Recommendation 1.1.5.1 of 'Obsessive compulsive disorder' (OCD) (NICE clinical guideline 31) states that:

'Because OCD and body dysmorphic disorder (BDD) often have an impact on families and carers, healthcare professionals should promote a collaborative approach with people with OCD or BDD and their family or carers, wherever this is appropriate and possible.'

Therefore commissioners should specify that a family-based collaborative approach is offered by services working with people with obsessive-compulsive disorder.

Recommendation 1.5.4 of 'Post-traumatic stress disorder' (NICE clinical guideline 26) notes that:

'When a family is affected by a traumatic event, more than one family member may suffer from PTSD. If this is the case, healthcare professionals should ensure that the treatment of all family members is effectively coordinated.'

Therefore commissioners should specify that the needs of the whole family are considered and effectively coordinated when managing post-traumatic stress disorder.



[4] NHS Confederation (2011) First year study of IAPT initiative reveals key insights [online]. Available from www.nhsconfed.org/Networks/MentalHealth/LatestNews/Pages/Study-of-first-year-IAPT-initiative-reveals-key-insights.aspx [accessed 18 August 2011]

[5] Quick reference guide. Common mental health disorders: identification and pathways to care. NICE clinical guideline 123 (2011). Available from www.nice.org.uk/guidance/CG123/QuickRefGuide

[6] National Audit of Psychological Therapies and Royal College of Psychiatrists (2011) The National Audit of Psychological Therapies for Anxiety and Depression: National Report 2011 London: Royal College of Psychiatrists

[7] See Department of Health (2011) Talking therapies: a four-year plan of action. A supporting document to No health without mental health: a cross-government mental health outcomes strategy for people of all ages [online]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123766

[8] Improving Access to Psychological Therapies (2011) The IAPT data handbook: guidance on recording and monitoring outcomes to support local evidence-based practice. Version 2.0.1. London: Department of Health

[9] In this section, ensuring the coordination and continuity of care is described as 'care planned treatment'.

[10] National Collaborating Centre for Mental Health (2011) Full guideline. Common mental health disorders: identification and pathways to care. Leicester and London: The British Psychological Society and the Royal College of Psychiatrists

[11] A number of NICE clinical guidelines related to chronic physical health problems also include recommendations for identifying and managing depression and/or anxiety. Examples include, but are not limited to, NICE clinical guidelines 87 (type 2 diabetes), 101 (chronic obstructive pulmonary disease) and 108 (chronic heart failure).

[12] Imison C, Naylor C, Goodwin N et al. (2011) Transforming our health care system: ten priorities for commissioners. London: Kings Fund

[14] See 'Alcohol-use disorders' (NICE clinical guideline 115) and the NICE quality standard 'Alcohol dependence and harmful alcohol use'.

[15] For example, MIND and the Royal College of Psychiatrists produce information for carers of people with mental ill health