NHS England » Guidance to integrated care boards on intensive and assertive community mental health care

1. Introduction

Many people who experience psychosis are able to receive evidence-based care and treatment which enables them to recover from their psychotic episode and/or be supported to live a life that is meaningful to them alongside the management of ongoing symptoms. Some people who experience psychosis, particularly where paranoia is present, struggle to access evidenced-based care and treatment. This can be due to core services not being able to meet people’s needs, the impact of symptoms such as paranoia or a lack of understanding from the individual that they are unwell. For this group of people, it is critical that mental health services are able to meet the person’s needs by adapting the approach to engagement, providing continuity of care, and offering a range of treatment options for people experiencing a varying intensity of symptoms.

People with these needs can be very vulnerable to harm from themselves and from others; for a very small number of people relapse can also bring a risk of harm to others. Integrated care boards (ICBs) have a duty to provide care and treatment in a way that meets the needs of this group. Improving the care and treatment of individuals who require an intensive and assertive approach from health services is a priority for the NHS.

As a first step in improving care, NHS England included a requirement in the 2024/25 NHS Priorities and Operational Planning Guidance that all ICBs “review their community services by Q2 2024/25 to ensure that they have clear policies and practice in place for patients with serious mental illness, who require intensive community treatment and follow-up but where engagement is a challenge”

This document provides guidance to support ICBs to undertake these reviews. It has been developed with the support of an expert advisory group which included representatives of the Royal College of Psychiatrists and the Department of Health and Social Care. A full list of expert advisory group members is available at annex A. The guidance provides information on:

the characteristics and presentations of individuals in scope
themes and lessons for services from previous severe untoward incidents
the features of intensive and assertive community care
how ICBs should undertake local reviews

As part of these reviews, ICBs are asked to report any gaps and barriers to delivering good care that they have identified (e.g. resourcing and workforce implications of delivering this care) to regional NHS England teams. Chapter 5 provides more information on how ICBs should undertake local reviews and a reporting template is available with this guidance to further support ICBs.

Intensive community care and wider community mental health provision

While this guidance and the local reviews being conducted by ICBs necessarily have a specific focus on intensive and assertive community treatment, this is intrinsically linked to the need for high quality and safe care across community mental health services. ICBs will need to take a whole population view to determine how to meet the needs of the small group of individuals who require intensive and assertive community care described in this guidance, while also ensuring that they can provide the best possible care to all people with severe mental illness (SMI), stepping up and down intensity in response to people’s fluctuating needs.

Recognising the importance of improving the quality and safety of care across all community mental health services, NHS England will continue to work with the expert advisory group to develop further guidance for ICBs that is broader in scope. Phase 2 of this work will provide guidance across a range of issues relating to the provision of high quality and safe care in community mental health services. This will include specific focus on care coordination and the role of key workers, personalised care and support planning, access to NICE recommended treatments and other interventions, and the management of interfaces with other mental health services. This work will begin in Q3 2024/25 with a focus on care coordination.

Human rights considerations

Assertive outreach teams are often tasked with minimising potential harms including harms to the individual, their friends and families and to others in the community. Clinical decision making requires balancing each of these to find an optimal solution. Knowledge of the Human Rights Act and its application can support this, ensuring that decisions go beyond merely considering a person’s absolute right to life to a balanced approach considering their right to be free from inhuman or degrading treatment.

Decisions should also consider the full range of non-absolute rights including the person’s right to liberty as well as the right to a private and family life. A good understanding of Human Rights should support decision making to ensure the rights of all concerned are considered. It should also ensure any potential restrictions that are made to non-absolute rights are applied in a lawful, legitimate and proportionate manner. Knowledge and understanding of the Mental Health Act and how it aligns to the Human Rights Act is also vital as well as proposed reforms which are aimed at facilitating a patient-centred therapeutic approach.

Key messages

Services have a duty to engage with people with SMI and their families/carers

Lack of engagement may be a result of the service offer not being what they want or need; reflective of previous poor treatment; a lack of cultural relevance/understanding; the individual not recognising that they are unwell and need treatment.

Intensive and assertive community care requires dedicated staff

Systems have a responsibility to ensure they commission the right mix of services to support the needs of their local populations. This includes a dedicated resource to provide intensive and assertive care for those individuals wo need it.

‘No wrong door’ approach

Community mental health services should be operating a ‘no wrong door’ approach and be well joined up with other statutory services and Voluntary Community Social Enterprise (VCSE) partners to identify people who might require intensive and assertive care and who are less likely to present via standard routes.

Continuity of care is vital

An appropriately experienced and competent key worker needs to be in place for individuals; someone who knows the person well and their history to avoid missed red flags and to respond to signs of relapse.

Holistic and engaging care

Services should provide care that is holistic, engaging and trauma informed – helping people with the things that matter to them and using biopsychosocial formulation-based approaches to meet those needs and promote personal recovery (including substance use, finances, housing, etc.)

2. Scope of local reviews

The aim of local reviews (see chapter 5 for more detail on how ICBs should undertake reviews) is to ensure appropriate intensive and assertive mental health care and treatment is available to meet the needs and to support the wellbeing of a particular group of people with severe mental health illness.

The group under consideration includes individuals who:

are presenting with psychosis (but not necessarily given a diagnosis of psychotic illness)
may not respond to, want or may struggle to access and use ‘routine’ monitoring, support and treatment that would minimise harms
are vulnerable to relapse and/or deterioration with serious related harms associated (esp. but not limited to violence & aggression)
have multiple social needs (housing, finance, self-neglect, isolation etc)
likely present with co-occurring problems (e.g. drug and alcohol use/dependence)
may have had negative (e.g. harmful and/or traumatic) experiences of mental health services or other functions of the state (e.g. the criminal justice systems)
concerns may have been raised by family/carers

This list is not exhaustive and it is to be expected that many of the individuals described above will not be in contact with services currently or will be on the caseload of a service that cannot adequately meet their needs. This group of people are often marginalised, very vulnerable, at high risk of accommodation instability or homelessness, and not accessing services for multiple reasons. They are at risk of suicide and physical ill health. These are individuals who have serious mental illness and are often experiencing command hallucinations telling them to harm others which they feel unable to ignore, or experiencing high levels of threat due to paranoid beliefs. Not only are they feeling unsafe, but those around them including staff members often report feeling worried or scared about their actions. When they are not receiving appropriate services this may be because they are in the wrong service, or because the service is struggling to engage with them, or they are unknown to the system.

ICB and provider boards will need to ensure that they have appropriate governance, partnership working arrangements and monitoring systems in place to identify individuals in their communities that require intensive and assertive community care to meet their needs and to keep them and others safe. Identifying individuals who require intensive and assertive community care requires proactive identification across all services, recognising that people with the needs described above may be on caseloads of services that cannot adequately meet their needs.

According to the National Confidential Inquiry into Suicide and Safety in Mental Health in 2018:

11% of people convicted of homicide were mental health patients
6% had a delusional mental illness such as schizophrenia or psychosis
4% had an alcohol dependence
3% had a drug dependence

3. Key themes and lessons from serious untoward incidents (SUIs)

While it is more likely that someone with severe mental illness will harm themselves rather than other people, serious untoward incidents (SUIs) such as the tragic events in Nottingham in 2023 serve to highlight the need for services to seek to engage and treat individuals that pose a risk of harm to others when unwell.

Previous SUIs contain a number of themes that demonstrate the importance of high quality and safe care within ‘core’ community mental health services. ICBs should consider the ability of core community mental health services to provide care against these themes as described below, alongside the need for a specific service offer for the individuals in scope.

Service failure identified	Why is this important	What should happen
Lack of continuity of care and failure to join-up presentation history. Missed ‘red flags’ of earlier minor offending / not reflected in risk assessments	Knowledge of an individual’s care history is vital to ensure services understand that person’s needs and how to meet them.	Effective care coordination is essential to the provision of high quality and safe care for all people with severe mental illness; it allows for a longitudinal view of an individual’s care history, as well as providing a point of contact at the point of relapse, when a stepping up of care is required. A key aim of the Community Mental Health Framework was to ‘maximise continuity of care and ensure no “cliff-edge” of lost care and support by moving away from a system based on referrals, arbitrary thresholds, unsupported transitions and discharge to little or no support. Instead, move towards a flexible system that proactively responds to ongoing care needs.’ As the Framework states, all service users should have a suitably experienced and competent named key worker as part of an MDT approach to meeting their needs, alongside high quality and dynamic co-produced personalised care plans. Access to the most important information is vital, particularly given the likely staff changes within services over the longer term. Information gathering and collection should be multi agency and not just health focused. Electronic Patient Records (EPRs) should make the most important information easily accessible and immediately obvious to clinicians/key workers. For all people with severe mental illness, it is important that staff are able to quickly identify a person’s individual signs of relapse and are able to support a rapid ‘stepping up’ of care. decisions to discharge people who have been discharged from community mental health services should be documented, noting any personal relapse indicators and known harms/risks if these are not responded to promptly. routes back into community mental health services should be clearly identified and communicated at discharge and there should be a low threshold for readmittance. For people identified in chapter 2, important information may include risk and offending history alongside access to past psychiatric history. A good risk assessment is not predictive but seeks to understand the types of situations where the person has been risky in the past. E.g. environmental factors like access to drugs.In line with NICE guidance, services should avoid using risk assessment tools as a predictor of future risk (NICE, 2020). Instead, assessments should ‘focus on the person’s needs and how to support their immediate and long-term psychological and physical safety. Mental health professionals should undertake a risk formulation as part of every psychosocial assessment’ (NICE, 2020).NHS England recognises there is more to do to support services in establishing robust approaches to care coordination and information sharing and will prioritise this in the development of further guidance for ICBs on high quality and safe care in community mental health services.
Lack of, or poor involvement of carers or family members	Carers and/or family members can provide vital context and information on an individual’s wellbeing, adherence to treatment, etc. that may not be forthcoming from someone not engaged in standard service offer	For all people with severe mental illness in need of care within community mental health services, engagement with families, carers and close friends who are involved should be seen as standard practice, not limited to times of relapse. If families are asking for help, this should be viewed as a potential red flag – services must listen and get involved. A lack of understanding about the limits of confidentiality is often a barrier to listening to the views of families and carers. Although it is important to respect an individual’s wishes about sharing information with family and friends, this should not preclude services from gathering information and listening to their concerns. Clinicians and services need to be clear about the limits of confidentiality and what this means in in practice when talking to and listening to relatives, friends and carers (RCPSYCH, 2017). Local confidentiality guidance should be available to support staff to engage appropriately with family members, friends and carers. Organisational charters and frameworks for involvement of families and carers are helpful, as are use of outcome measures completed by families and carers. Accessibility considerations should also be accommodated for, for example the provision of interpreters, sign language, etc. for both service users, families and carers.
No long-term planning of care	Some people experience long-term severe mental illness with periods of relapse and remission. A long-term view of an individual’s care is therefore vital	Coproduced personalised care and support plans should be needs focused and take a long-term view of an individual’s care. Decisions to discharge people from core community mental health services should be taken with a personalised understanding of the long-term nature of a person’s presenting problems. This should consider both the positive, protective factors that support someone’s improved mental health, as well as potential triggers/causes of relapse in future. For all people with severe mental illness, it is important that staff are able to quickly identify their individual signs of relapse and are able to support a rapid ‘stepping up’ of care. decisions to discharge people from core community mental health services should be documented noting any relapse indicators and known harms/risks if relapse is not responded to promptly. routes back into core community mental health services should be identified and communicated to all relevant parties at discharge and there should be a low threshold for readmittance. Failure to engage with services should not be a reason for discharge in those with known severe and enduring relapsing remitting mental illness.
Poorly planned, precipitous discharges from hospital	A significant change in circumstances is related to an enhanced risk of harm. This is especially true of discharge from hospital, as patients may be going back to less than ideal community circumstances – e.g. ready access to recreational drugs, lack of structured support or activity, etc and unstable accommodation with a risk of homelessness	Detailed guidance on proactively planned and effective discharge from acute inpatient mental health services for adults and older adults is available on the NHS England website: NHS England » Acute inpatient mental health care for adults and older adults A person’s accommodation stability and potential risk of homelessness should be assessed and addressed as part of discharge planning, with social care staff involved as part of a multi-disciplinary care package when necessary.
Failure to review treatment/medication	People with severe mental illness should have access to a full range of evidence-based treatments, including medication and psychological therapies.	Individuals should have access to staff with appropriate experience and competence within Community Mental Health settings to support assessment, monitoring and delivery of treatment , monitoring and review of medication. Clinicians need access to clinical supervision. Clinicians should have an understanding of how to make judgments on the use of oral medication vs depot medication in community settings (see below). Continuity of care (see above) is important in identifying any signs of deterioration that might prompt a medication review. Engagement with family, carers and close friends who are involved can support identification of early warning signs of deterioration or relapse that might prompt a medication review. Access to NICE recommended psychological therapies for severe mental health problems should be provided, as should access to include social and occupational interventions.

The use of community treatment orders and depot medication

In cases where there is a history of poor engagement, consideration should be given to the use of supervised treatment within the framework of a community treatment order for eligible individuals (usually those subject to section 3).

A decision to use a community treatment order should be based on individual circumstances, however there may be shared factors which may be of relevance to this decision, including:

the presence of severe mental illness including psychotic presentations, in which an individual shows a poor awareness of their illness (including the need for treatment and their risks associated with relapse)
evidence of previous positive response to treatment
previous poor compliance with the treatment plan (including discontinuation of medication)
previous hospital detentions due to the risks they pose during relapse to their own health and safety and to others
disorganised behaviour/avoidance of contact resulting in being lost to follow up
unsuccessful prior attempts to engage the individual with a less restrictive approach

The authority to recall the individual to hospital in the event of failure to adhere to the treatment plan or in the event of deterioration must be necessary rather than simply desirable. The purpose of any conditions stipulated in the community treatment order should be to ensure psychiatric treatment (including monitoring of the individual’s mental health) and to mitigate against the identified risks associated with relapse. As outlined in the Mental Health Act Code of Practice (Tiihonen et al. 2017), the least restrictive and maximising independence principles should be considered and, wherever possible, there should be consultation with family and carers. The longer-term intention should be to facilitate engagement and the formation of a therapeutic alliance and to aid holistic support and continuing recovery.

A related issue is the consideration of depot antipsychotic medication for those with psychotic illnesses, with or without the use of a community treatment order. For individuals with a pattern of poor engagement as described above, there may be a history of inconsistent treatment due to disorganisation and/or a refusal of treatment. While this subject has proved challenging to study, a large real-world observational study concluded that depot antipsychotic injections were substantially more effective than oral antipsychotics (excluding Clozapine) in reducing the risk of rehospitalisation or any treatment failure (defined as discontinuation or switch of antipsychotic medication). Therefore, in this specific patient cohort, the administration of a regular depot injection may be the only way to ensure individuals are getting the medication they need, it also provides more frequent opportunities for clinical monitoring.

4. Features of intensive and assertive community care

This guidance uses the term ‘intensive and assertive community care’ to describe service provision that is designed to meet the needs of the group of people described in chapter 2. This care involves high frequencies of contact with individuals (intensive) alongside an assertiveness of approach to ensuring people get the right treatment and care.

This includes ‘assertive outreach’ which is a distinct, evidence-based service model for people with psychosis who for various reasons are not engaged with secondary psychiatric services. The features of this service described in the table below, closely follows the Dartmouth assertive community treatment scale (DACTS). Annex B has more information on this model.

Over the past three years, ICBs have been implementing new models of care, as set out in the Community mental health framework, based upon the needs of their local populations and maximising their community assets. People with complex needs such as those described in chapter 2 are in scope for transformed community mental health services, with the framework committing that ‘people with the highest levels of need and complexity will have a coordinated and assertive community response.’

While some ICBs may already commission ‘assertive outreach’ teams or similar, others may not currently commission a specific team or service that is focused on intensive and assertive approaches. A key message of this guidance is that while ICBs are not required to commission assertive outreach teams, meeting the needs of individuals described in chapter 2 requires dedicated resource. Outlined below are the features of a ‘dedicated function within community mental health services’ this describes the core elements of intensive and assertive community care that need to be in place to meet the needs of these individuals. This has been developed based on the advice of the expert advisory group supporting NHS England with the development of this guidance (see annex A). Both approaches should be well integrated with wider community mental health services to ensure that individuals can step up or step down care as appropriate to their needs.

In undertaking local reviews, ICBs should consider the needs of their local populations and geography. This should include reviewing local data on who is currently accessing services and identifying population groups who are not. To support this, ICBs should also consult with people with lived experience who have used their local services. ICBs should also consider their existing model of integrated primary and community mental health services and use the table below to identify whether they are commissioning services that have the right mix of staff with dedicated time, competences and experience to meet the needs of these individuals. In particular, people from racialised and ethnic minority backgrounds experience systemic barriers to accessing care and receiving the support that meets their needs. ICBs should continue to embed the changes outlined in the Patient and carer race equality framework (PCREF) across all aspects of policy, procedure and practice.

Service feature	Dedicated function within CMH services	Full Assertive Outreach model
Access to dedicated and qualified staff	staff have dedicated and protected time to respond immediately when required, including: dedicated psychiatrist time dedicated registered mental health nursing staff access to CMH MDT expertise including occupational therapy, psychology, social work, housing, substance use staff working with this group of individuals have a high-level of skill in engagement and relationship building assertive engagement practised all staff have an extensive understanding of psychosis and how it can present, the treatment options (including full range of evidence based treatments that might be beneficial), harm minimisation and risk management and the use of statutory frameworks, as well as an understanding of an assertive rehabilitation approach staff have sufficient time in job plans to meet the needs of the people in scope staff have access to interpreters and know how/when to use them	team approach. Entire MDT team has a live knowledge of the patient including their treatment, care plan, progress and risks dedicated psychiatrist time dedicated registered mental health nursing staff time team structure facilitates at least daily handovers and at least weekly MDT reviews discrete team of at least 10 staff, not “integrated” into other teams assertive engagement practised principle of not “brokering out” – in house psychology, occupational therapy, social work, substance use worker, housing support all staff have an extensive understanding of psychosis and how it can present, the treatment options (including full range of evidence based treatments that might be beneficial), harm minimisation and risk management and the use of statutory frameworks, as well as an understanding of an assertive rehabilitation approach staff have sufficient time in job plans to meet the needs of the people in scope staff have access to interpreters and know how/when to use them
Extended hours operation	24/7 crisis line is aware of individuals on CMH caseload requiring intensive and assertive community support staff are available by telephone to support a crisis response out of hours	service operates extended hours, including weekends
Time unlimited	for this group of people DNA (did not attend) should never be used as a reason for discharge staff continue to proactively engage with individuals during periods where engagement is challenging if/when discharge from a core mental health service is decided to be appropriate, then a clear record of the decision making process needs to be included on the patients record	patients are actively monitored and appropriate support and treatment provided to meet their changing needs care is time-unlimited and the team operates a “no drop out” policy a discharge plan in in place, with clear arrangements for the individual to re-enter the service if appropriate discharge plan is developed and shared with other agencies
Small caseload	caseloads of staff providing dedicated function should allow for sufficient level of intensive and assertive care	small caseloads (see DACT fidelity scale for information on caseload sizes).[7]
Manages stepping up and down of care	focus on harm minimisation/risk management, including: continuity of care, comprehensive history, individual formulations, and family engagement ability to step up care to access appropriate services including crisis, acute, forensic and rehabilitation services when appropriate engagement with the individual’s friends and family takes place to determine whether care needs stepping up or down	takes responsibility to manage crisis presentations, inpatient admissions, in-reach, and discharges from hospital manages step-down to core community mental health services in partnership with CMH MDT
Identification of individuals in need of intensive community treatment	clear pathway exists within integrated CMH services offer to identify individuals in need of intensive and assertive community care an integrated community mental health rehabilitation pathway is present, and can provide advice and consultation where and identified rehabilitation need is identified engagement with the individual’s friends and family takes place where possible, to determine the right care pathway for the individual	dedicated team with explicit inclusion criteria for treating people presenting with psychosis with high risk of deterioration and relapse who are not engaged with other services alternative pathways and services exist, including mental health rehabilitation when the specific intervention is identified as beneficial for the individual
Assertive engagement of individuals	combination of core healthcare setting-based work and community outreach appointment reminders are in place, using different engagement techniques to match the persons needs i.e. not limited to written or text reminders engagement with the individual’s friends and family takes place where possible, and their views taken into account peer support workers support engagement with individuals	predominantly community-based outreach to individuals appointments can take place out of traditional settings, i.e. within a public space, or the individuals home engagement with the individual’s friends and family takes place where possible, and their views taken into account peer support workers support engagement with individuals
Collating and sharing information	assessments (including risk assessments) and care plans (including safety plans) must be co-produced whenever possible and carefully documented and accessible to the individual, their families and friends (where appropriate), and others providing care. They should be shared with receiving professionals upon transfers of care (both between services within a Trust) and when a patient moves between areas, as well as other agencies as appropriate and in line with Caldicott Principles risk of homelessness and unstable accommodation is a known concern for this group of people and should be routinely assessed and addressed when care is transferred	assessments (including risk assessments) and care plans (including safety plans, advance choice documents) must be co-produced whenever possible and carefully documented and accessible to the individual, their families and friends (where appropriate), and others those providing care. They should be shared with receiving professionals upon transfers of care (both between services within a Trust) and when a patient moves between areas, as well as other agencies as appropriate and in line with Caldicott Principles risk of homelessness and unstable accommodation is a known concern for this group of people and should be routinely assessed and addressed when care is transferred
Care and safety planning	formulation approach based upon understanding of an individual’s history use of legal frameworks as appropriate to individual need (e.g. Section 117, CTOs), including to deliver medication for those patients with serious mental illness that are known to be non-compliant with medication engagement with the individual’s friends and family takes place where possible individuals should have access to the full range of evidence based interventions (such as psychological therapies) that may address their needs (including physical health needs) not medication alone	daily planning meetings and weekly MDT reviews use of legal frameworks as appropriate to individual need (e.g. Section 117, CTOs) including to deliver medication for those patients with serious mental illness that are known to be non-compliant with medication assessments need to be completed by an appropriately trained and highly skilled professional individuals should have access to the full range of evidence based interventions (such as psychological therapies) that may address their needs (including physical health needs) not medication alone
Safety/harm management	assessments include use of legislative frameworks such as the use of S117 or community treatment orders assessments and interventions need to be completed by a trained and highly skilled professional activities of daily life assessments are conducted on a regular basis, and when appropriate, there is an ability to step up care to access appropriate services including crisis, acute, forensic and rehabilitation services where possible, engagement with the individual’s friends and family takes place, and their views taken into account key workers should be familiar with early warning signs of relapse and appropriate interventions as per the care plan discontinuation of medication against advice and disengagement should be specifically monitored multiagency frameworks (Multi agency risk assessment conference (MARAC), Multi-agency public protection arrangements (MAPPA)) to be employed as appropriate	assessments include use of legislative frameworks such as the use of S117 or community treatment orders the team should be familiar with early warning signs of relapse and appropriate interventions as per the care plan discontinuation of medication against advice and disengagement should be specifically monitored multiagency frameworks (MARAC, MAPPA) to be employed as appropriate
Coordination of care	an appropriately experienced and competent key worker is in place meaningful interventions and co-produced care plans are in place there is continuity of care, with the key worker supporting step ups & downs of care to ensure they meet the individual’s needs cover for staff members with care co-ordination role is seamless when such staff are on leave, sick or move on from the team	an appropriately experienced and competent key worker regularly engage with the individual and their family and friends as appropriate. there is active input in place from other agencies, including; social care, housing, public health, criminal justice system, and VCSE sector. meaningful interventions and co-produced care plans are in place cover for staff members with care co-ordination role is seamless when such staff are on leave, sick or move on from the team

5. How should ICBs undertake reviews of policies and practice?

All ICBs have been asked to review their local policies and practices in relation to providing intensive and assertive community care. The following provides guidance on how those reviews should be undertaken.

What are ICBs being asked to review?

Using the information detailed in this guidance, particularly chapter 4, ICBs are asked to review the policies and practices they have in place to identify and provide appropriate care to people with severe mental illness who might need intensive and assertive community care, as defined in section 2. ICBs should use this process to identify gaps and barriers to providing good care as set out in this guidance (e.g. resourcing and workforce challenges) and report these back to NHS England.

Who should be involved in reviews?

Reviews should seek to involve all relevant partners, including:

commissioners of community mental health services
providers of NHS community mental health services
people with lived experience of complex psychosis
families/carers of people with lived experience of complex psychosis
commissioners of inpatient mental health services and community crisis services
services managers/clinical leads from community mental health services
adult secure provider collaboratives/adults secure pathways
relevant local partners (e.g. local authorities, local safeguarding boards, VCSE partners)
ICB policy and governance leads
ICB quality and safety leads
data and business intelligence analysts

What policies and practices are in scope for reviews?

Reviews should consider all relevant policies and practices that involve delivery of care to individuals in scope (see chapter 2). This includes reviewing policies for teams delivering dedicated intensive and assertive community care as well as core community mental health services. ICBs should also review governance, partnership and monitoring arrangements that support the identification of individuals who might need intensive and assertive community care, as well as the capacity of local services to provide appropriate levels of care. Consider reviewing local data and intelligence on populations currently accessing services, as well as those who aren’t. Local reports on serious incidents, patient experience (good and poor), and patient complaints should also be reviewed.

When do reviews have to be completed?

Reviews should be completed by 30 September 2024, with the outcome of the review communicated to your Regional NHS England team.

We recognise that this is just the first step, with continued work required to improve the depth of the reviews and develop longer-term action plans to address identified gaps in provision.

It is vital that DNAs (Did Not Attends) are never used as a reason for discharge from care for this vulnerable patient group. All ICB systems are asked to rapidly check that existing service policies and practice are clear on this issue and confirm this to the NHSE Regional Mental Health Team.

How should outcomes of reviews be communicated to NHS England?

A template for reporting the outcome of reviews has been shared alongside this guidance. Templates should be returned to your Regional team by 30 September.

What happens once reviews have been completed?

Regional NHS England teams will lead the review of the returns and continue to work with ICBs where gaps in provision have been identified to ensure alignment with national guidance.

The National NHS England team will collate national trends from the reviews, and use it to inform future policy, as well as communicate the outcomes to the CQC and Department of Health and Social Care.

Annex A: National expert advisory group

Alison Brabban, Clinical Advisor to Adult Mental Health Team, NHS England
Mayura Deshpande, Consultant in forensic psychiatry and National Specialty Advisor in secure care to NHS England
Nuwan Dissanayake, Consultant Psychiatrist Assertive Outreach Service, Leeds and York Partnership Trust
Clair Hayden, Clinical Director for Mental Health Complex Care for North West England, NHS England
Rebecca Daddow, Head of Adult Secure Mental Health, NHS England
Jon Kennedy, Consultant Psychiatrist Assertive Outreach, Birmingham and Solihull Mental Health Trust
Lade Smith, President, Royal College of Psychiatrists
Liz Durrant, Deputy Director of Mental Health, Learning Disability and Autism Quality, NHS England
Andy Bell, Chief Executive, Centre for Mental Health
Esther Horner, Head of Severe Mental Illness and Offender Health, Department of Health and Social Care
Carolyn Houghton, Associate Director, Rethink Mental Illness
Geoff Heyes, Senior Programme Manager, NHS England
Emily Amess, Project Manager, NHS England
Ursula James, Associate Director of Mental Health, NHS England South East Region
Jo Kirk, Assistant Director Mental Health, NHS England Midlands Region
Chris Lynch, Expert Advisor, NHS England
Debra Moore, Deputy Head of Quality Transformation, NHS England
Emma Wadey, Deputy Director Mental Health Nursing, NHS England
Ben Walford, Expert Advisor, NHS England
Tonita Whittier, Senior Programme Manager, NHS England

Annex B: Assertive outreach teams

Assertive outreach is a clearly defined model for delivering community mental health care provided within a multidisciplinary team (MDT) approach, where all staff are involved in a person’s care package.

The objectives of this model of care are to:

seek out people and work with them in locations where they feel comfortable, rather than requiring them to attend clinics;
maintain people within the community wherever possible and to avoid unnecessary hospital admissions; and
to provide an assertive, holistic and rehabilitative approach to care with a greater intensity of input than a standard team.

The assertive outreach model, has a strong evidence base and a fidelity scale, the Dartmouth Assertive Community Treatment Scale. The evidence suggests that the model should only be used for people with psychosis who find it difficult to engage with treatment and traditional mental health services, and may have a history of repeated relapses and admission to hospital, often under detention. Patients often have cooccurring needs, which could include homelessness, substance use, and a history of violence or other offending behaviour. Therefore, the whole assertive outreach team are involved in an individual’s care with live knowledge of the person including their treatment, care plan, progress and risks with a team structure which facilitates daily handovers and regular MDT reviews.

The team has dedicated staffing with consultant psychiatrist input to support with prescribing, formulation, physical health, legal issues and risk management. Key workers have small caseloads which allows for a minimum of one or two contacts per person per week and the teams work extended hours and weekends to ensure they can provide support when individuals need it. The service is time-unlimited and support for the individual should continue indefinitely. Continuity of care during poor engagement or inpatient admissions is vital.

Evidence

Research evidence and outcome data suggests that the assertive outreach model reduces admissions and promotes effective engagement with individuals who are the most unwell. You can find more information here:

Annex C: Service user experiences

In undertaking the development of this guidance we have benefitted from a huge range of expertise, including the advice of members of the NHS England Adult Mental Health Lived Experience Advisory Network. The members contributing to this work have lived experience of community mental health services. However we have not been able to talk directly with people with lived experience of intensive and assertive community care (or assertive outreach). We have however sought to make use of existing research where possible to support the development of this guidance.

Research that includes the direct experience of service users is limited however there are a small number of studies into staff and user engagement in assertive outreach services. More research is required that has an explicit focus on understanding the experiences of individuals from minoritised ethnic groups and NHS England would welcome further research in this area (Mental health and racial disparities report, 2020).

To support the development of this guidance, members of the NHS England Adult Mental Health Lived Experience Advisory Network undertook a ‘snapshot’ review of research literature on engagement within Assertive Outreach teams. The purpose of this review was to identify practices that the research identified as promoting positive engagement with service users, as well as those that were less engaging. The summary below summarises the key findings from this snapshot review.

Associated with more engaging assertive approaches:

staff understanding, empathy and respect
collaborative, trusting relationships with patients
maintaining non-coercive contact with patients
practitioners who listen, are caring and committed; validating patients’ thoughts and feelings
consistent relationships with individual practitioners over time
a focus on social support that addresses social isolation
support to participate in activities away from home
cultural awareness and sensitivity with effective interpreter support
patient choice and control over medication
acknowledging patients’ mental health journeys
being offered alternatives to face to face meetings and a range of means of contact
awareness of the impact of mental health stigma, from society and sometimes services, on a patient’s life
awareness of how stigma intersects with race in the lives of patients
a focus on psychotic symptoms/experiences rather than difficult emotions

Associated with less engaging assertive approaches:

support that fails to address stigma and its intersection with racism, unemployment, the impact of family breakdown
not feeling listened to or involved in care decisions
a lack of attention to patients’ life experiences of racism, discrimination, and marginalisation
a lack of recognition and understanding of the role of past negative experiences of MH services on patients’ current ‘engagement’
intrusive and controlling practices
frequent changes to the care team or support offered
a preoccupation with risk
a focus on psychotic symptoms/experiences
a lack of human connection and empathy
inflexible and rigid approaches to care
too medication focused
stigmatising attitudes from mental health services
a lack of cultural sensitivity
a lack of support with the specific impact of medication on areas of everyday life. This includes goals around work and education and the impact of medication on sex and intimacy

Publication reference: PRN01456

Cookies on the NHS England website