CARE PROGRAMME APPROACH (CPA)
 
Health Service Circular/Local Authority Circular
HC(90)23/
LASSL(90)11
 
THE CARE PROGRAMME APPROACH
FOR PEOPLE WITH A MENTAL ILLNESS
REFERRED TO THE SPECIALIST PSYCHIATRIC SERVICES
 
 
Policy Background
 
2.          The 1975 White Paper “Better Services for the Mentally
Ill” (Cmnd 6233) first set the general policy within which care
programmes should be introduced: this general policy has been endorsed
by the Government in the 1989 White Paper “Caring for People” (Cm
849), paragraph 7.4.  Locally based hospital and community health
services, coordinated with services provided by social services
authorities, voluntary and private sectors, and carers, can provide
better care and treatment for many people with a mental illness than
traditional specialist psychiatric hospitals.
 
3.          Community based services are only an improvement when the
patients who would otherwise have been hospital inpatients get
satisfactory health care, and, where appropriate, social care. 
“Caring for People” acknowledged that providing adequate arrangements
for the community care and treatment of some patients had proved more
difficult and resource intensive than expected.  In practice adequate
arrangements have not always been achieved.
 
4.          The care programme approach is being developed to seek to
ensure that in future patients treated in the community receive the
health and social care they need, by:
 
i.              introducing more systematic arrangements for deciding
whether a patient referred to the specialist psychiatric services can,
in the light of available resources and the views of the patient and,
where appropriate, his/her carers, realistically be treated in the
community;
 
ii.             ensuring proper arrangements are then made, and
continue to be made, for the continuing health and social care of
those patients who can be treated in the community.
How the Care Programme Approach Works
5.             Individual health authorities, in discussion with
relevant social services authorities, will agree the exact form the
care programme approach will take locally.  All care programmes
should, however, include the following key elements:
 
i.              systematic arrangements for assessing the care needs
of patients who could, potentially, be treated in the community, and
for regularly reviewing the health care needs of those being treated
in the community;
 
ii.             systematic arrangements, agreed with appropriate
social services authorities, for assessing and regularly reviewing
what social care such patients need to give them the opportunity of
benefiting from treatment in the community.
 
6. It will be for relevant health and social services staff to decide
whether the resources available to them can enable acceptable
arrangements to be made for treating specific patients in the
community. If a patient’s minimum needs for treatment in the community
– both in terms of continuing health care and any necessary social
care – cannot be met, inpatient treatment should be offered or
continued, although (except for patients detained under the Mental
Health Act) it is for individual patients to decide whether to accept
treatment as an inpatient. Health authorities will need to ensure
that any reduction in the number of hospital beds does not outpace the
development of alternative community services.
 
Implementation
 
7.             Within the broad framework described it is for health
authorities, in discussion with consultant psychiatrists, nurses,
social workers and other professional staff, and social services
authorities to seek to establish suitable local arrangements and to
see that they are maintained in the context of purchaser/provider
arrangements post 1 April 1991.
 
8.             There are some specific issues which all authorities
will however need to address in determining their local arrangements. 
These relate to:
 
·         Interprofessional working;
·         Involving patients and carers;
·         Keeping in touch with patients and ensuring agreed services
are provided;
·         The role of key workers.
Interprofessional working
9.             Although all the patients concerned will be patients of
a consultant psychiatrist, modern psychiatric practice calls for
effective interprofessional collaboration between psychiatrists,
nurses, psychologists, occupational therapists and other health
service professional staff; social workers employed by social services
authorities, and general practitioners and the primary care team, and
proper consultation with patients and their carers.
 
10. Where it is clear to a consultant and professional colleagues that
continuing health and/or social care is necessary for a patient whom
they propose to treat in the community, there must be proper
arrangements for determining whether the services assessed as
necessary can, within available resources, be provided. It is
essential to obtain the agreement of all professional staff and carers
(see paragraphs 12 and 13 below) expected to contribute to a patient’s
care programme that they are able to participate as planned.
 
Involving patients
 
11.           It is important that proper opportunities are provided
for patients themselves to take part in discussions about their
proposed care programmes, so that they have the chance to discuss
different treatment possibilities and agree the programme to be
implemented.
 
Involving carers
 
12. Relatives and other carers often know a great deal about the
patient’s earlier life, previous interests, abilities and contacts and
may have personal experience of the course of his/her illness spanning
many years. Wherever consistent with the patient’s wishes,
professional should seek to involve them in the planning and
subsequent oversight of community care and treatment.
 
13. Carers often make a major and valued contribution to the support
received by many people with a mental illness being treated in the
community. Where a care programme depends on such a contribution, it
should be agreed in advance with the carer who should be properly
advised both about such aspects of the patient’s condition as is
necessary for the support to be given, and how to secure professional
advice and support, both in emergencies and on a daytoday basis. In
addition, professional staff may be able to offer the carer help in
coming to terms with his/her role visàvis the patient.
 
Arrangements for keeping in touch with patients and making sure the
services agreed as part of the programme are provided
 
14. Once an assessment has been made of the continuing health and
social care needs to be met if a patient is to be treated in the
community, and all the professional staff expected to contribute to
its implementation have agreed that it is realistic for them to make
the required contributions, it is necessary to have effective
arrangements both for monitoring that the agreed services are, indeed,
provided, and for keeping in contact with the patient and drawing
attention to changes in his or her condition. This is a narrower
concept than that of case management as envisaged in the White Paper
“Caring for People” and upon which specific guidance will shortly be
given to local authorities. In the Department’s view the most
effective means of undertaking this work is through named individuals,
often called key workers, identified to carry the responsibilities
outlined above in respect of individual patients.
 
15.           Key workers.  Where this can be agreed between a health
authority and the relevant social services authority, the ideal is for
one named person to be appointed as key worker to keep in close touch
with the patient and to monitor that the agreed health and social care
is given.  The key worker can come from any discipline but should be
sufficiently experienced to command the confidence of colleagues from
other disciplines.  When the key worker is unavailable, proper
arrangements should be made for an alternative point of contact for
the patient and any carer(s).
 
16            A particular responsibility of the key worker is to
maintain sufficient contact with the patient to advise professional
colleagues of changes in circumstances which might require review and
modification of the care programme.
 
17.           In additional to key worker arrangements, professional
staff implementing a care programme may decide that they need a
suitable information system as a means of keeping in touch and
prompting action.  Systems using a microcomputer are available and
some relevant information about them is available from Research and
Development for Psychiatry, 134 Borough High Street, London SE1 1LB. 
Tel: 02074038790.  (Note from Rosemary: Research and Development for
Psychiatry is now the Sainsbury Centre for Mental Health at the same
address and phone number.) When establishing such a system, those
concerned have a duty to consider how to ensure the proper
confidentiality of information about individual patients.
 
18.           Sometimes patients being treated in the community will
decline to cooperate with the agreed care programmes, for example by
missing outpatient appointments.  An informal patient is free to
discharge himself/herself from patient status at any time, but often
treatment may be missed due to the effects of the illness itself, and
with limited understanding of the likely consequence.
 
19. Every reasonable effort should be made to maintain contact with
the patient and, where appropriate his/her carers, to find out what is
happening, to seek to sustain the therapeutic relationship and, if
this is not possible, to try to ensure that the patient and carer
knows how to make contact with his/her key worker or the other
professional staff involved. It is particularly important that the
patient’s general practitioner is kept fully informed of a patient’s
situation and especially of his or her withdrawal (partial or
complete, see paragraph 20 below) from a care programme. The general
practitioner will continue to have responsibility for the patient’s
general medical care if she/he withdraws from the care programme.
 
20.           Often patients only wish to withdraw from part of a care
programme and the programme should be sufficiently flexible to accept
such a partial rather than a complete withdrawal.  It is important
that, within proper limits of confidentiality, social services day
care, residential and domiciliary staff (including those from the
voluntary and private sectors) are given sufficient information about
the situation to enable them to fulfil completely their responsibility
of care to the patient.  Similarly, relatives and carers should also
be kept properly informed.
 
 
Care Programme Approach
Health Service Circular / Local Authority Circular
HC(90)23/