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The Commissioning Friend for Mental Health Services

A guide for health and social care commissioners

Commissioning Support
for London

The Commissioning Friend

for Mental Health Services.
A guide for health and social care commissioners
Revised December 2009

The Commissioning Friend for Mental Health Services
2 A guide for health and social care commissioners
Mental Health World Class Commissioning.
A quick guide for mental health professionals

The National Mental Health Development Unit

(NMHDU) has been commissioned to support
the achievement of World Class Commissioning
(WCC) in mental health. The programme is jointly
owned and supported by the Department of Health
Commissioning Directorate and the Director General
of Social Care and works in partnership with ADASS,
the NHS Confederation and others. The programme is
aligned with and complementary to achieving World
Class Commissioning for mental health services.

This updated and revised version of the Commissioning

Friend for Mental Health Services has been developed
by the Commissioning Support for London (CSL)
Mental Health Commissioning Programme in
collaboration with NMHDU.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Welcome to The Commissioning Friend for Mental Health Services.

On behalf of the National Mental Health Development Unit (NMHDU)

and Commissioning Support for London (CSL), we are pleased to
introduce this revised and updated version of The Commissioning
Friend for Mental Health Services.

This guide is written mainly for commissioners in primary care trusts

and local authorities to assist them in developing their mental health
commissioning practice, but it may also be a useful resource for others
involved in commissioning and the provision of mental health services.

It provides commissioners with a framework to navigate the changing

legislation and policy landscape as well as guidance to ensure mental
health commissioners contribute to their organisations’ achievement of
the World Class Commissioning competencies.

Our aim, with this guide, is to provide a tool to help commissioners

to navigate the complexities of modern mental health commissioning
and provide a resource that is informative and reliable – a “friend”
for commissioners of mental health services.

We hope you will find this guide useful.

Kieron Murphy
Programme Director
National Mental Health Commissioning Programme,
National Mental Health Development Unit

Sean Farran
Programme Director
London Mental Health Commissioning Programme
Commissioning Support for London

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Introduction and purpose 06
1. Key challenges for commissioners 09

2. Understanding the policy and legislative framework 11

2.1 Policy and guidance 11
2.1.1 World Class Commissioning 11
2.1.2 New Horizons 11
2.1.3 The Next Stage Review 12
2.1.4 Personalisation 12
2.2 National Service Frameworks and strategies 13
2.2.1 The National Service Framework for Mental Health (NSF) 13
2.2.2 The National Service Framework for Older People 13
2.2.3 The National Dementia Strategy 13
2.2.4 The National Service Framework for Children, Young People & Maternity Services 14
2.2.5 Child & Adolescent Mental Health Service (CAMHS) National Review 14
2.2.6 Our Choices in Mental Health Framework 14
2.2.7 Transforming Adult Social Care 15
2.2.8 Joint Strategic Needs Assessment (JSNA) 15
2.3 Legislation 16
2.3.1 The Mental Health Act 1983 16
2.3.2 The Mental Capacity Act 2005 16
2.3.3 The Mental Capacity Act 2005 – Deprivation of Liberty Safeguards (MCA DOLS) 16
2.3.4 The National Health Service Act 2006 - Section 75 17
2.3.5 Social Care Green Paper 17
2.3.6 The Sex Discrimination Act 1975 and the Gender Equality Duty 18
2.3.7 The Race Relation (Amendment) Act 2000 18
2.3.8 The Disability Discrimination Act 2005 18
2.3.9 Single Equality Bill 2009 18
2.3.10 Equality Impact Assessment 18
2.4 Relevant Reviews, Reports and Policy 19
2.4.1 The Bradley Report 19
2.4.2 Delivering Race Equality in Mental Healthcare Programme (DRE)
– A Framework for Action 20
2.4.3 Tacking Health Inequality 20

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

3. Personalisation 21
3.1 Personalisation 21
3.1.1 Personal health budgets 21
3.2 The impact of personalisation 22
4. The Commissioning Context 24
4.1 Introduction 24
4.2 Financing mental health services and the resource challenge 25
4.3 Practice Based Commissioning (PBC) 25
4.4 Payment by Results (PbR) 25
4.5 Commissioning for Quality and Innovation (CQUIN) 26
4.6 Standard contract for mental health (and learning disability) 27
4.7 The performance imperatives 28
4.8 Combating stigma and discrimination 28
4.9 Developing a skilled workforce 29
5. Co-production, partnership and integration 30
5.1 Co-production and the role of service users in commissioning 30
5.2 Partnership working 32
5.3 Formal partnership arrangements 33
5.4 The role of the provider 34
5.5 Working with stakeholders 34
5.6 Communication 35
6. Effective mental health commissioning 37
6.1 World Class Commissioning (WCC) 37
6.2 The Operating Framework for the NHS 41
6.3 Understanding local need 42
6.4 The commissioning cycle 42
6.4.1 Development of local commissioning strategies for mental health 43
6.4.2 The commissioning cycle 44
6.5 Commissioning Specialised Mental Health Services 45
6.6 Practical tips 45

7. Measuring effectiveness 48
Conclusion 49
Appendix 1: NHS Targets in 2009/2010 50
Appendix 2: National Mental Health Workforce Strategy 51
Appendix 3: The Ten Essential Shared Capabilties 52
Appendix 4: Useful Links: Meeting the needs of particular groups 54
Appendix 5: Useful Links: The Commissioning Process 56
Appendix 6: Useful Links 60

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Introduction and purpose

The Commissioning Friend for Mental “...a state of well-being in which the
Health Services was first published in 2005 individual realises his or her own abilities,
as part of a range of guidance documents can cope with the normal stresses of life,
produced by the National Primary and can work productively and fruitfully and
Care Trust Development Programme is able to make a contribution to his or
(NatPaCT). The guide was developed in her community”.1
partnership with the National Institute for World Health Organisation (WHO)
Mental Health in England (NIMHE) and was
intended to assist Primary Care Trusts (PCTs) This guide provides a route map for
and Local Authorities (LAs) to develop their commissioners rather than being a
skills, expertise and knowledge in relation detailed encyclopaedia of all research and
to commissioning mental health services. practice relevant to mental health services.
Since its publication there have been a Specifically it provides commissioners
number of legislative, policy, guidance and with a framework for thinking about
organisational changes, both in the NHS commissioning issues.
and social care system.
It covers a range of mental health and
The role of the Commissioning Friend has related priorities and takes account of
not changed: it is still there to support existing and emerging policy and guidance.
commissioners; but the landscape in which It does not include detailed reference to
commissioners are operating has altered specialist services such as eating disorders
significantly since The Commissioning or forensic services.
Friend for Mental Health Services was first
published and consequently this guide The guide assumes a level of knowledge
aims to provide commissioners with an of mental health and commissioning and
overview of recent legislative and policy is intended to provide an up to date
developments and some tools to help reference on some of the key issues as
navigate them. well as information that should assist
commissioners in carrying out their day
The focus of commissioning has to day functions. It has been designed
broadened, reflecting the need to view to support PCTs and Local Authorities in
mental health as a whole population issue. understanding how to use policy levers
This includes moving towards a more and their commissioning activities
holistic approach to service delivery and as a key part of improving the mental
through such an approach enabling service health of the communities they serve.
users to experience positive mental health
and well-being.


The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Using this guide

This guide has also highlighted key points
of information in text boxes throughout the
chapters. The key for these is below:

Key points for commissioners

Case examples or quotations

World Class Commissioning competencies

World Class Commissioning

competencies that relate to
this aspect of commissioning.

Navigating your way around

the electronic PDF
If you are viewing this guide electronically,
all text displayed as: See Section 3.2 is a
hyperlink to that place in the document.

The header The Commissioning Friend for

Mental Health is a hyperlink back to the
contents page.

The guide is available on disc and to

download from

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners


The revised guide has been structured to reflect the key areas commissioners need to focus
on when considering mental health services.

Section 1 highlights the key challenges Section 6 provides detail about the factors
facing commissioners. that contribute to effective mental health
commissioning, within the context of the World
Section 2 provides a summary of Class Commissioning (WCC) commissioning
the relevant policy and legislative competency framework, and provides
framework that sets the context practical guidance for commissioners.
for mental health commissioning.
Section 7 examines how to measure the
Section 3 highlights the impact of effectiveness of mental health commissioning.
personalisation on future commissioning
processes. With clear drivers in both These sections are supported by appendices
heath and social care policy, the impact providing links to relevant resources and
of personalisation will involve a shift publications. Sections three, four and five
in commissioning. also identify how implementing the specific
polices, imperatives or actions outlined may
Section 4 explores in more detail the support the evidence of achievement of
commissioning context including the WCC competencies.
financial and resource challenges
in the commissioning process.

Section 5 explores the role of partnership

in mental health commissioning, including
the importance of co-production.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 1 1
Key challenges for commissioners

Key challenges for mental health commissioners

This section provides a broad overview a need to ensure appropriate recognition
of the challenges commissioners face to and representation of mental health issues
place mental health at the heart of their within the Joint Strategic Needs Assessment
commissioning priorities and align it with (JSNA), Local Area Agreements, Local
other strategic priorities. Subsequent Strategic Partnerships, Joint Commissioning
chapters will explore key legislative and Boards and Practice Based Commissioning
policy drivers in detail. (PBC) consortia.

One of the most significant challenges for The wide ranging policy framework
commissioners is achieving the balance of requires commissioners to have a clear
efficiency and effectiveness while focusing understanding of a range of different
on improvements in quality. The range policy and legislative drivers and how
of targets and deliverables for PCTs and these relate to each other to inform the
local authorities remain considerable. commissioning process.
Keeping mental health at the centre of the
commissioning agenda, linking it to wider The broader challenge to commissioners
public health initiatives, and embracing the is set out in the Next Stage Review and
WHO’s vision of “no health without mental the local strategies for health services that
health” requires commissioners to think are now being implemented as a result.
both strategically and pragmatically. The review has clearly signalled the
direction of travel for health care services
Mental health commissioning is a joint in broad terms.
activity for heath and social services and
this brings together differing organisational More detail can be found at:
cultures and presents particular challenges uk/en/Publicationsandstatistics/Publications/
for commissioners. This includes the extent PublicationsPolicyAndGuidance/DH_085825
to which each has recognised how to work
effectively with the other’s cultures and Health inequality remains a challenge
established ways of working.2 Overcoming for commissioners. The Government
the different priorities and competing has recognised that addressing health
targets that sometimes conspire to create inequalities must be a major part of local
boundaries to effective partnership at commissioning strategies.
a commissioning level remains high on
the agenda. More detail can be found at:
The range of partnership agreements, PublicationsPolicyAndGuidance/DH_085307
targets and policy imperatives creates an
extensive and sometimes complex map The emergence of the personalisation
for commissioners to navigate. There is agenda in health and social care also

2 The Commissioning Friend for Mental Health Services, NatPACT/NIMHE 2005

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

1 Commercial Support Units (CSUs) to provide

commercial support to local commissioners
and help to stimulate and manage local
Key challenges for mental health commissioners

markets.4 The principle factor in managing

the local market will be for commissioners
to commission services from providers
who are best placed to deliver the needs
of patients.5

Reduced budget allocations, the focus

on savings and the need to prioritise
investment all remain high on the agenda
brings challenges for commissioners. of all commissioners. The requirement to
Personalisation requires commissioners to commission the most clinically effective
think about care and support services in a and cost effective services will be greatly
different way. It means starting with the intensified. New developments will be
person as an individual with strengths, scrutinised even more closely to ensure
preferences and aspirations. It is about that they are evidence based and will be
putting people at the centre of the process of direct benefit to users of services and
of identifying their needs and making the wider community.
choices about what, who, how and when
they are supported to live their lives. It In addition, there are a number of areas
requires a significant transformation of of policy and guidance that are related to
health and social care so that all systems, the financial elements of commissioning
processes, staff and services are geared including:
up to put people first.3 s 0RACTICE"ASED#OMMISSIONING0"#
(see section 4.3)
The need to improve the quality of services
will require commissioners to make use
(see section 4.4)
of a number of levers for change. Among
these will be plurality in provision and s #OMMISSIONINGFOR1UALITYAND
greater choice. The importance of a diverse Innovation (CQUIN) (see section 4.5)
range of providers, more effective market
management and the stimulation of The challenge of achieving effective,
competition has also grown in recent years. meaningful and productive engagement
As part of this process, commissioners with service users and the wider public
will need to develop specifications for is significant. Commissioners will need
contracts around care pathways and to employ new approaches and create
place greater emphasis on effective opportunities to engage experts by
contract management. experience. Co-production will provide
a means by which commissioners can
Commissioners will require a range of develop ways of involving service users in
commercial skills to enable them to the planning, design, commissioning and
make the best use of those levers. The evaluation of services. (Co-production is
Department of Health is establishing covered in more detail in section 5.1)

3 Personalisation briefing for commissioners, Social Care Institute for Excellence, June 2009 | 4 Necessity not nicety – A new commercial
operating model for the NHS, DH, May 2009 | 5 Market Operating Guidance – NHS South Central 2009

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 2
Understanding the policy and legislative framework 2

Understanding the policy and legislative framework

The range of legislation, policies and guidance of services which shift the focus of care
that impact on both commissioning and from diagnosis and reactive intervention to
service delivery continues to widen. This prevention and the promotion of well-being
section summarises the key relevant legislation and to improve the quality of commissioning.
and policy guidance that informs or impacts
on mental health commissioning, in both More detail can be found at:
NHS and local authorities. It is not intended
to be exhaustive, but provides a resource for Commissioning/Worldclasscommissioning/index.htm
commissioners to refer to when considering
their priorities. Commissioners will need to
2.1.2 New Horizons
understand the relationship between these The Department of Health, under the title
different legislative and policy drivers and how New Horizons7, has been developing plans
they influence the commissioning agenda. for the future of mental health, building
on the progress made through the National
Those commissioners with a background Service Framework in the last ten years. It
in mental health will find much that is is expected that this new phase of reform
familiar. Those without such a background, will bring together key areas of policy,
or who want to have a useful summary of increasingly addressing the mental well-
relevant policy and guidance in one place, being of communities as a whole and
will find this section of particular use. strengthening the progress made to date
across all age groups, and to more marginal
ones, such as offenders. Broader priorities
will also help shape services, with themes
2.1 Policy and guidance such as health inequalities, the value of
carers and dignity in care all contributing to
2.1.1 World Class Commissioning an ever improving service.
World Class Commissioning (WCC)6 is a
Department of Health led programme New Horizons8 will enable commissioners
designed to improve the standard of
to be creative in the development and
commissioning of NHS services. It sets out
design of services, encouraging them to look
an assurance framework, supported by a
beyond traditional mental health services. It
number of competencies that are intended
will challenge commissioners and providers
to create a shift in the culture and standard
to work in different settings to deliver
of commissioning. The key philosophy of the
services that focus not only on secondary
approach is the intention to ‘add life to years
care, but also primary care and the voluntary
and years to life’ by taking a more strategic
sector. Services will need to be more based
and long term approach to commissioning.
around models of recovery and seek to
In common with the Next Stage Review, WCC
promote positive mental health and well-
emphasises the need for the commissioning
being in a broader public health context.

6 World Class Commissioning: vision, DH, December 2007 | 7 New Horizons: towards a shared vision for mental health, DH, July 2009
8 New Horizons: towards a shared vision for mental health, a consultation, DH July 2009

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

The final document is expected to

be published before the end of 2009.

2 More detail can be found at:
Understanding the policy and legislative framework

2.1.3 The Next Stage Review

Published to coincide with the 60th
anniversary of the NHS, High Quality Care
for All 9 describes how healthcare will be
personalised and fair, will include the most
2.1.4 Personalisation
effective treatments within a safe system,
and will help patients to stay healthy.10 The emergence of the personalisation
agenda in health and social care brings
The review has set out the direction of travel challenges for commissioners. Putting
for health care services in broad terms and can People First11 requires local authorities to
be characterised by a renewed focus on primary transform their adult social care systems
care and prevention rather than just curative by March 2011. Much of the focus is on
and reactive interventions. It states that for the personalisation; giving more choice over
NHS to be sustainable it must concentrate on services and control over decision making
improving health as well as treating sickness. to individual service users.12 Through
It recognises that this will involve working in Putting People First, councils and joint
partnership with other agencies. commissioning teams must ensure:
Every PCT will commission comprehensive to users on the basis of need, from which
well-being and prevention services in they will fund care services
partnership with local authorities and services s ASTRATEGICSHIFTFROMREACTIONTO
will be personalised to meet the needs of the prevention, promoting independence
local population. The review urges NHS bodies for older and vulnerable people
to focus their efforts on a range of areas s ANINFORMATIONANDADVICESERVICE
including the improvement of mental health. available to all users and carers,
including those who self fund
Commissioners will need to take s GREATERSELF ASSESSMENTBYUSERS
account of their regional Next
Stage Review vision documents and Many recent health policies mirror these
understand their relevance and impact themes, giving a clear indication that
on local strategies and priorities. personalisation is a key feature of both
health and social care commissioning.
Commissioners based in the NHS can
More detail can be found at:
learn much from their colleagues in
local authorities about the challenges of
implementing this approach and the ways
of overcoming them.

9 High Quality Care for All – The report of the NHS Next Stage Review DH 2008 | 10 ibid
11 Putting People First – a shared vision & commitment to the transformation of adult social care Dept. Health December 2007 | 12 ibid

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

More detail can be found at: and social care services. It is a ten year programme of reform which seeks to
Personalisation/index.htm promote social inclusion and control for
older people of their lives, ensuring respect
and choice. It aims to help older people to
2.2 National Service live independently for as long as possible,

Understanding the policy and legislative framework

benefit from tailored care and support, and
Frameworks and Strategies experience an enhanced quality of life. It
contains eight standards, the seventh of
2.2.1 The National Service which relates specifically to older people’s
Framework for Mental Health (NSF) mental health.
The National Service Framework for Mental
Health was published in October 1999 as Standard 7
a ten year plan for the modernisation of Older people who have mental health
mental health services. It covers mental problems have access to integrated
health services for adults of working age. mental health services, provided by the
Local Implementation Teams (LITs) have NHS and councils to ensure effective
been working to implement the seven diagnosis, treatment and support, for
standards set out in the NSF. them and for their carers.

Although it may be argued that subsequent

legislation and guidance has reduced the More detail can be found at:
central role of the NSF, it still represents
the key guidance that has influenced those Deliveringadultsocialcare/Olderpeople/
delivering mental health services at a local NSFforOlderPeopleandsystemreform/index.htm
level, and is the basis upon which their
work has been evaluated. 2.2.3 The National Dementia Strategy
Living Well with Dementia: A National
The implementation period of the NSF
Dementia Strategy13 was published in
ends in 2009 and a new phase of mental
February 2009. It sets out 17 objectives that
health development will begin with the
are designed to make the lives of people
publication of New Horizons. (see 2.1.2)
with dementia, their carers and families
better and more fulfilled. The strategy
More detail can be found at:
is also intended to increase awareness
of dementia, ensure early diagnosis and
intervention and radically improve the
quality of care that people with the
condition receive. The strategy is supported
2.2.2 The National Service by a national implementation plan and
Framework for Older People a National Dementia Strategy joint
The National Service Framework for Older commissioning framework.14 This provides
People was published in March 2001 and best practice guidance for commissioning
set new national standards and service dementia services. It includes a Joint
models of care across older people’s health Strategic Needs Assessment template,

13 Living Well with Dementia: A National Dementia Strategy, DH, February 2009
14 Joint Commissioning Framework for Dementia, DH, June 2009

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

summary of NICE and SCIE evidence for challenging needs to ensure that they
dementia services and commissioning levers are delivered in a more integrated way.
against each of the strategy’s objectives. It has considered how to deliver better
2 outcomes for children with mental health
More detail can be found at: problems and identified practical solutions to how those delivering, managing and
Understanding the policy and legislative framework

Deliveringadultsocialcare/Olderpeople/ commissioning services can address the

NationalDementiaStrategy/DH_083362 challenges they face.

More detail can be found at:

2.2.4 The National Service
Framework for Children, Young
People & Maternity Services DH_090399
The Children’s National Service Framework
(NSF) is a ten year programme intended to 2.2.6 Our Choices in Mental
drive forward improvement in children’s
Health Framework
health. Published in 2004 it sets out eleven
Patient choice is a central part of the
standards for health and social services
Government’s reform of health and social
for children, young people and pregnant
care services. It aims to reduce inequalities
women. It aims to ensure fair, high quality
in access and improve outcomes.
and integrated health and social care.
Standard nine focuses on the mental health
Our Choices in Mental Health Framework16
and psychological well-being of children
was published by the DH in November 2006.
and young people.
It describes four “choice points”, i.e. areas
in which people said that they wanted
More detail can be found at:
more choice. They are:
NationalServiceFrameworkdocuments/index.htm 1. promoting and supporting life choices
2. choice in relation to accessing
2.2.5 Child & Adolescent and engaging with services
Mental Health Service 3. choice in assessment
(CAMHS) National Review 4. choice of care pathway
The independent CAMHS review, and treatment options.
Children and young people in mind15
was commissioned to look at how These areas remain relevant as domains
mainstream and universal services are within which opportunities for choice in
meeting the educational, care and support mental health may be evaluated, promoted
of children and young people at risk of and extended.17 The Government has
and experiencing emerging emotional, committed to extend free choice to mental
behavioural, psychological and mental health18, but currently mental health along
health problems. with maternity services are not subject
to this requirement. A new right to
The review examined how CAMHS are choice is included in revisions to the NHS
meeting the needs of some of the most Constitution and covers rights to choose
vulnerable children with complex and treatment and providers and to receive

15 Children and young people in mind: the final report of the National CAMHS Review, DH, November 2008
14 18 Departmental Review, Dept. of Health May 2007
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

information on quality. This builds on the
work done to date on the choice agenda. Achieving this shift requires partners
to develop commissioning strategies
which include incentives to stimulate
Commissioners should be open to the development of high quality services.20
opportunities presented within the
choice and personalisation agenda as

Understanding the policy and legislative framework

well as the associated transformational 2.2.8 Joint Strategic Needs
change within social care services.19 Assessment (JSNA)
Since 1 April 2008, local authorities
and PCTs have been under a statutory
More detail can be found at: duty to produce a Joint Strategic Needs Assessment (JSNA).21
Social Care Sustainable Communities Strategy
Outlined in the Local Authority Circular LAC s INFORMSTHE0#4/PERATIONAL0LANS
The challenge of transforming adult social Class Commissioning competencies in
care is to provide services that will treat people particular: working collaboratively with
with dignity and implement strategies to community partners and engaging with
support them to make informed choices. the public and patients
These choices should help them employ the
most beneficial help and support to meet
their specific needs.This might include a s CONTRIBUTESTOTHEPRIORITISATIONOFTHE
focus on specific outcomes such as hospital top 30 of the 198 indicators that all
discharge, transition to adulthood and local areas must deliver on. One specific
co-location of services. example is PSA 16 (Socially Excluded
Adults)22 and National Indicator 150
An integrated approach to working with the on employment for people who have
NHS and wider local government partners been in contact with secondary mental
will require the gathering of resources from health services.
across the whole system, with a strategic
shift from reactive intervention at the point The process of conducting and updating a
of crisis to a preventative model centred on JSNA will establish the current and future
improved well-being. health and well-being needs of a population,
leading to improved outcomes and reductions
More detail can be found at: in health inequalities. This is a partnership duty which involves a range of statutory
Lettersandcirculars/LocalAuthorityCirculars/ and non-statutory partners, informing
DH_095719 commissioning and the development of
appropriate, sustainable and effective services.

22 15
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

2.3.2 The Mental Capacity Act 2005

Note: The Mental Capacity Act 2005 (MCA 2005)
NMHDU has produced guidance about was implemented on 1 October 2007. It
2 conducting JSNAs for mental health, provides the legal framework for acting and
entitled Joint Strategic Needs Assessment making decisions on behalf of adults who
and Mental Health Commissioning lack the capacity to make particular decisions
Toolkit - A practical guide. It can be
Understanding the policy and legislative framework

for themselves. The main provisions of the

found at: MCA 2005 apply to individuals aged 16 or
over. Section One of the MCA 2005
Further detail about JSNA can also incorporates five principles.
be found at
Publicationsandstatistics/Publications/ More detail can be found at:
PublicationsPolicyAndGuidance/DH_081097 uk/en/SocialCare/Deliveringadultsocialcare/

2.3 Legislation 2.3.3 The Mental Capacity Act 2005

Deprivation of Liberty Safeguards
2.3.1 The Mental Health Act 1983 (MCA DOLS)
The Mental Health Act is largely concerned MCA DOLS legislation came into force on
with the circumstances in which a person 1 April 2009. It provides for the lawful
with a mental disorder can be detained deprivation of liberty of those people who
for treatment for that disorder without lack capacity to consent to arrangements
his or her consent. It also sets out the made for their care or treatment in either
processes that must be followed and the hospitals or care homes, but who need to
safeguards for patients, to ensure that be deprived of liberty in their own best
they are not inappropriately detained interests, to protect them from harm.
or treated without their consent. The main
purpose of the legislation is to ensure that PCTs and local authorities (known as
people with serious mental disorders which ‘supervisory bodies’) have a statutory
threaten their health or safety or the safety responsibility for operating and overseeing
of the public can be treated irrespective of the MCA DOLS. Hospitals and care homes
their consent where it is necessary to prevent (known as ‘managing authorities’) have
them from harming themselves or others. responsibility for applying to the relevant PCT
or local authority for a DOLs authorisation.
The Mental Health Act 1983 was amended
in the Mental Health Act 2007, which PCT and local authority commissioners
introduced a number of key changes. need to:
• establish and maintain robust
More detail can be found at: contractual arrangements to ensure
en/Healthcare/Mentalhealth/DH_089882 compliance with the legislation
from managing authorities

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

DOCUMENT The Case for Change THE

Future of Care TogetherSUGGESTSWAYS
s Prevention services 4HERIGHTSUPPORT
s National assessment 7HEREVER
MentalCapacityActDeprivationof s Joined-up services !LLTHESERVICES
s Information and advice 0EOPLESHOULD
s Personalised care and support 4HE
-OREDETAILCANBEFOUNDAT Publications/PublicationsPolicyAndGuidance/
HealthAct1999partnershiparrangements/index.htm DH_102338

support-system.pdf | 25 Shaping the Future of Care Together Green Paper, The Stationery Office July 2009
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

2.3.6 The Sex Discrimination Act 2.3.8 The Disability

1975 and the Gender Equality Duty Discrimination Act 2005
The Sex Discrimination Act 1975 prohibits This Act makes substantial amendments to
2 sex discrimination against individuals in the Disability Discrimination Act 1995. The
employment, education, and the provision 2005 Act places a general duty on public
of goods, facilities and services. The gender authorities, which include NHS bodies to:
Understanding the policy and legislative framework

equality duty came into force in April 2007. s PROMOTEEQUALITYOFOPPORTUNITYBETWEEN

It is an amendment to the 1975 Act by disabled people and other people
the Equality Act 2006. It places a statutory
general duty on public authorities (which
under DDA
include NHS bodies) that when carrying out
their functions, to have due regard to the s ELIMINATEHARASSMENTOFDISABLED
need to: people that relates to their disability

and harassment disabled people

between men and women people in public life
(the legislation also includes s TAKESTEPSTOMEETDISABLEDPEOPLES
transgender people). need, even if it requires more
favourable treatment.
Specified public organisations, which
include NHS bodies, have specific duties 2.3.9 Single Equality Bill 2009
including to develop and publish a Gender The Government published the Single
Equality Scheme which identifies gender Equality Bill in 2009, the creation of
equality goals and proposed actions to a new Equality Act will see a modern,
achieve the goals, in consultation with single legal framework, providing clearer,
employees and stakeholders. streamlined law that is more effective in
tackling disadvantage and discrimination.
2.3.7 The Race Relation
(Amendment) Act 2000 2.3.10 Equality Impact
This amendment placed a general statutory Assessment (EqIA)
duty on a wide range of public authorities All public bodies have a legal duty
which includes NHS bodies to promote race to promote equality and eliminate
equality. This means that listed bodies must discrimination. Equality Impact Assessment
have due regard to the need to: (EqIA) is the process by which organisations
s ELIMINATEUNLAWFULRACIALDISCRIMINATION examine their activities in order to minimise
the potential for discrimination and identify
possible and real inequalities that people may
s PROMOTEGOODRELATIONSBETWEENPEOPLE experience. Assessing the positive or adverse
of different racial groups. impact of policies, practices and services is a
core component of several pieces of Equalities
Legislation including Statutory Public
Duties in the Race Relations (Amendment)

26 ibid, pp.47

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Act 2000, the Disability Discrimination Act 2.4 Relevant reviews,
(2005) and the Gender Equality Duty (2006),
which requires all public bodies to monitor reports and policy
the impact of their functions, policies
2.4.1 The Bradley Report30 2
and procedures by carrying out impact
assessments and publishing these.27 This independent review was commissioned
by the Secretary of State for Justice in

Understanding the policy and legislative framework

EqIAs must be carried out for all new December 2007. It examines the extent
policies, functions and procedures to ensure to which offenders with mental health
that there is no risk of direct or indirect problems or learning disabilities could,
discrimination, and wherever possible, in appropriate cases, be diverted from
to include positive action measures28 prison to other services and the barriers
to such diversion. The recommendations
To meet legal requirements in conjunction include the establishment of criminal
with their Single Equality Schemes, justice mental health teams in every
commissioners must ensure that those locality and improvements in the delivery
they commission services from screen and effectiveness of court diversion for
all new (and eventually, all existing) offenders with mental health problems.
policies, practices and services for their
impact on people from a range More detail can be found at:
of groups including:
s PEOPLEFROMDIFFERENTETHNICBACKGROUNDS Publications/PublicationsPolicyAndGuidance/
transgendered people) Note:
Health has produced Commissioning
mental health services for offenders:
guidance and advice on how to
More detail about EqIAs and a toolkit respond to some of the commissioning
developed by the Department of Health challenges posed by The Bradley Report.
can be found at: The document is available to download
Publicationsandstatistics/Publications/ from:

27 | 28 ibid
30 Lord Bradley’s review of people with mental illness or learning disabilities in the criminal justice system, DH, 2009
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

The programme is based on three ‘building

blocks’, first proposed in the consultation
version of DRE:
2 1. More appropriate and responsive services
- achieved through action to develop
organisations and the workforce, to
Understanding the policy and legislative framework

improve clinical services and to improve

services for specific groups, such as older
people, asylum seekers and refugees,
and children.
2. Community engagement – delivered
through healthier communities and
2.4.2 Delivering Race Equality in by action to engage communities
Mental Healthcare Programme in planning services, supported by
(DRE) – A Framework for Action recruitment of 500 new Community
There have long been concerns that people Development Workers.
from black and ethnic minority communities 3. Better information - from improved
are over represented in mental services and monitoring of ethnicity, better
that those services do not always adequately dissemination of information and good
or appropriately meet their needs. This practice, and improved knowledge about
framework sets out what those planning, effective services. This will include a new
delivering and monitoring local primary care regular census of mental health patients.
and mental health services need to do to
improve access, experience and outcomes
2.4.3 Tacking Health Inequality
for users, relatives and carers from black and
minority ethnic communities. It applies to Commissioning is increasingly focused
both health and social care organisations. in trying to address health inequalities.
Health inequalities: progress and next steps
In 2005 the Government launched a five year outlines the Government’s approach to
action plan for achieving equality and tackling tacking health inequalities through Public
discrimination in mental health services in Service Agreement (PSA) targets, and
England to support the Government’s 2010 setting the direction of travel.
targets of measurable services. It draws on
three other publications: The Marmot Review will help to shape
future actions across health and social care.
s Inside Outside: Improving Mental Health
Services for Black and Minority Ethnic
Communities in England
s Delivering Race Equality: A Framework for DH_085307
Action: A Consultation Document -Oct 2003
s The Independent Inquiry into the death
of David Bennett -Dec 2003 (although
DRE itself is not a direct response to the
inquiry’s report).

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 3


3.1 Personalisation Within the framework of personalisation, 3

in local authorities, the implementation
As outlined in section 1, the Putting of direct payments and individual budgets

People First programme requires the creates greater flexibility in the use of social
transformation of adult social care systems care budgets (see below), giving greater
by March 2011. Much of the focus is on control to people who use services. This
personalisation; giving more choice over enables them to determine the nature and
services and control over decision making provision of their care. For NHS services,
to individual service users.31 work is currently underway to pilot
Individual health budgets.
Personalisation is implemented in local
authorities and this supports the impetus 3.1.1 Personal health budgets
to redesign services in a more personalised Plans to implement the use of personal health
way. Recent health policies have also budgets in the NHS were set out in High
stressed the need for this approach and for Quality Care for All. The implementation
commissioners in mental health this will be will build on the experience of individual
an important agenda going forward. budgets in social care, and test personal
health budgets as a way of giving people
Personalisation is about giving people greater control over the services they use.
much more choice and control over their
lives and goes well beyond simply giving More detail can be found at:
personal budgets to people eligible for
council funding. Personalisation means Highqualitycareforall/DH_090018
addressing the needs and aspirations of
whole communities to ensure everyone
has access to the right information, advice Individual budgets
and advocacy to make good decisions Individual budgets are an alternative
about the support they need. It means way of paying for social care. Instead
ensuring that people have wider choice in of local authorities buying services on
how their needs are met and are able to behalf of individuals, they are given
access universal services such as transport, control of their own budget and can
leisure and education, housing, health and direct how it is spent, allowing the care
opportunities for employment, regardless package to be self tailored.
of age or disability.32

31 Putting People First - a shared vision & commitment to the transformation of adult social care Dept. Health December 2007
32 Personalisation briefing for commissioners, Social Care Institute for Excellence, June 2009

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

The Social Care Institute for Excellence (SCIE)

Direct payments has developed a personalisation briefing for

Direct payments are intended to create commissioners. It draws particular attention

greater flexibility in the use of social to the need to find ways of working in
care budgets, giving greater control to partnership with providers to ensure a good
people who use services and enabling range of choices and the right types of
3 them to determine the nature and
provision of their care. Direct payments
support for personal budget holders and self-
funders. As larger proportions of investments
are cash payments to people who have are given to individuals to make their own
been assessed as needing services. purchasing decisions, commissioners will

need to ensure that a range of innovative

services is in place which can better respond
Commissioners will need to respond to to individuals’ purchasing decisions.33
the challenge of authentic partnership,
working across a wide range of SCIE have highlighted key implications
stakeholders as the traditional balance that commissioners should be aware of
of power shifts towards users of services to respond effectively to personalisation.
to determine their own care. These include:
between different services
World Class Commissioning competencies


Engage with public and patients flexible and responsive services are
WCC competency 7 available for personal budget holders
Stimulate the market and self-funders
Manage the local health system information and advice to make good
decisions about their care and support
More detail can be found at: support and actively engage people in the design, delivery and evaluation
Personalisation/index.htm of services
a range of services for people to
3.2 The impact choose from
inclusion and community development.34
Previous sections of this document have
outlined the nature of the personalisation Personalisation will facilitate a move away
agenda. In order to commission to improve from traditional models of social care and
mental health services, a shift in approach embed a set of values that enable the
will be needed to take account of the empowerment of individuals. It provides
implications of personalisation. the chance for commissioners to reshape
their approach to both the commissioning
and delivery of care services.

33 Personalisation briefing for commissioners, Social Care Institute for Excellence, June 2009
34 ibid

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners


One impact of personalisation for
commissioners may be a disaggregation
of resources, so that they no longer control
the entirety of local finances. Additionally,
it will require them to develop ways of
influencing and informing providers about
the kind of services that will be needed.

Commissioners will need to manage

arrangements both within and across
local authorities and PCTs to deliver
long-term and sustained changes in their
relationships with individuals managing
their own support.35

35 Commissioning and personalisation – Briefing Paper, CSIP/ADASS South West Commissioning Network

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 4
The Commissioning Context

4.1 Introduction Ensuring that an appropriate range of

services and treatment options are in place
Given the finite resources to meet local or are being developed will be central to
4 needs, it is in the interests of commissioners improving mental health and well-being
to invest in early interventions to support across localities.
people experiencing mental health problems.
The Commissioning Context

It is therefore important for commissioners to The aims of commissioning are simple

take a broad view on mental health issues. ones: to identify the needs of the local
population, commission a range of effective
It is a view that must go beyond the high services within defined financial parameters
profile specialist and acute services that and monitor the effectiveness of those
are traditionally labelled ‘mental health’ services to ensure improvements in health
and commissioned primarily from mental and well-being are achieved. Beneath those
health trusts. Commissioners in the NHS and words lies a more complex agenda that is
local authorities need to give increasing influenced by a range of factors. Among
attention to the well-being agenda that can those factors are:
enable prevention and earlier intervention. s THE7ORLD#LASS#OMMISSIONINGFRAMEWORK
The clear message for commissioners is that
investment in improving the life chances
and circumstances for all the communities s THEPERFORMANCEREQUIREMENTSFORLOCAL
they serve (including vulnerable individuals) authorities and NHS organisations
will enable them to successfully meet a s THEDEVELOPMENTOFASKILLEDWORKFORCE
(as outlined in Section 3)
It is important that commissioners align s THENEEDTOTACKLESTIGMA
their inputs with broader strategies for and discrimination
community well-being, devised and delivered
through local partnership activity. Investment
in supporting community outreach and s THEIMPORTANCEOFSERVICE
voluntary sector groups with a prevention user and carer involvement.
and promotion focus will enable the overall
needs of vulnerable people to be addressed This section sets out the impact of those factors
and may thereby reduce the likelihood and describes some of the tools that may help
of their needing support from specialist commissioners to meet the challenges.
mental health services.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

4.2 Financing mental together in PBC consortia to maximise their

commissioning expertise. This will help them
health services and develop an efficient and effective approach,
the resource challenge providing greater opportunities to develop
locally based and responsive services.

Mental health services must compete for
their share of the resources available at local World Class Commissioning competencies
level. When financial resources are limited 4 – Collaborate with clinicians
and must be prioritised to maximise efficiency 6 – Prioritise investment
and productivity, commissioners will need to
find new ways of creating innovative services
10 – Manage the local health system 4
11 – Make sound financial investments
that can harness the opportunities created by
new financial models.

The Commissioning Context

The central challenge for all commissioners, 4.4 Payment by Results (PbR)
whether in PCTs or social care, remains
the balancing of effective and efficient Payment by Results (PbR) was first
service delivery, improved outcomes introduced in the NHS in 2003/04 to improve
for users of services, higher quality and the fairness and transparency of hospital
cost effectiveness. payments and to stimulate provider activity
and efficiency. PbR means that providers are
World Class Commissioning competencies
paid for the number and type of patients
6 – Prioritise investment treated, in accordance with a set of national
11 – Make sound financial investments rules and a national tariff for acute services.

Whilst PbR has now been largely

mainstreamed by the NHS acute services,
4.3 Practice Based it has not yet been introduced for mental
Commissioning (PBC) health services. Work continues on
developing currencies for use in the
PBC is about engaging general practices commissioning of mental health services.
and other primary care professionals
in the commissioning of services which The ultimate goal is the creation of tariffs
is currently the sole responsibility of for these currencies. The national project
PCTs. As a consequence it devolves more team are seeking to ensure That mental
commissioning responsibility to primary health PbR work is aligned with other
care. The Department of Health intends policy developments.
that GPs, nurses and other primary care
professionals should be empowered to
become local decision makers and use their
knowledge to develop and commission
services that reflect the needs of their
local population. In many parts of the
country, general practices have joined

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

The Department of Health has published and innovation form part of commissioning
two documents: discussions and delivery.
• A Practical Guide to Preparing for Mental
Health PbR DH June 2009, which sets out CQUIN works alongside other financial
10 actions that can be taken locally levers which when used together reinforce

an overall approach to improving quality

• A Clustering Booklet for use in Mental
and encouraging innovation. CQUIN is
Health Payment by Results Evaluation
intended to encourage ambition and
work (July-Dec 2009): containing
continuous improvement beyond the
the assessment tool (currently under
4 evaluation) and the 21 clusters
minimum. It may assist improvements
in quality of care, better outcomes and
devised by the Care Pathways
innovation and fulfils a different role to the
and Packages Project.
financial penalties within contracts linked
The Commissioning Context

to failure to achieve fundamental levels of
quality and safety.
The CQUIN framework is intended
to encourage stretch and should be
about the continuous improvement
4.5 Commissioning for beyond the minimum, helping
Quality and Innovation ensure that improved quality of care,
better outcomes and innovation
(CQUIN) form part of the discussions between
commissioners and providers (using
As part of the drive for improvements in the Commissioning for Quality
quality, and the implementation of the and Innovation (CQUIN) payment
visions contained in High Quality Care for framework – DH December 2008)
All36, the NHS is to move rapidly towards
paying providers on the basis of quality
The introduction of a CQUIN scheme with
of outcomes. The new commissioning for
specific quality goals linked to a proportion
quality and innovation (CQUIN)37 scheme
of contract value will be a requirement in
aims to ensure that quality improvement
mental health for 2010/11.

36 High Quality Care for All – The report of the NHS Next Stage Review DH 2008
37 Using the Commissioning for Quality & Innovation Payment Framework, DH, December 2008

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

clear and specific outcomes. One of the

CQUIN will be a useful incentive that key benefits is that the standard contract
commissioners can use to stimulate is exactly that: it is ‘standard’, and this
improvements in quality from local provides one approach across the country.
NHS providers and many commissioners The legal sections are not negotiable and as

have already used it in mental health. such provide a fair and standard approach
They should continue to draw on its to all providers. For commissioners,
potential to drive up quality in mental having the standard legal sections reduces
health services. duplication of effort. It also provides
consistency of contract structure and clarity
about the required content, for example,
World Class Commissioning competencies service specifications, quality, finance,
6 – Prioritise investment review, performance management.

The Commissioning Context

8 – Promote improvement and innovation
11 – Make sound financial investments The standard contract provides scope for
‘collaborative commissioning’ with one PCT
leading on behalf of other PCTs; reducing
duplication and bringing together PCTs in
4.6 Standard contract potential readiness for future structures.
for mental health PCTs can also lead on behalf of their local
authority counterparts in one overarching
(and learning disability) mental health contract instead of both
partners holding separate contracts with
The NHS standard contract for mental the provider. The standard contract will
health (and learning disability) covers also help in the move towards performance
agreements between PCTs and providers management that is related to outcomes
for the delivery of NHS funded services. (both organisationally and for individuals).
All PCTs are required to use the contract,
introduced in 2009/10 with a revised For commissioners the standard contract
version in place from 2010/11 onwards. provides levers to improve the quality of
The contract will apply to agreements from data reporting which will improve long
2009/10 for: term planning.
s .(34RUSTS
s NEW&OUNDATION4RUSTSAND&4S World Class Commissioning competencies
whose existing contracts have expired
10 – Manage the local health system
and independent sector providers
third sector providers.

The aim of the standard contract is to end

the need for block contracts, introduce
greater flexibility and improve the quality
of mental health commissioning by defining

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

4.7 The performance • World Class Commissioning

assurance framework
• Public service agreement (PSA) targets
Over the past decade the performance • NHS Operating Framework and regional
planning guidance

imperatives in mental health have

concentrated on the creation of a set of • Comprehensive area assessments
community services (described in this Section) • Care Quality Commission Periodic reviews
and the monitoring of their work. Much
• Standards for Better Health.
of this information has been collected
4 through the annual assessment of progress
Details of other target areas in mental
against the targets in the mental health
health can be found in Appendix 1.
NSF. 2009 marks the end of that period of
The Commissioning Context

implementation and a new approach to the

World Class Commissioning competencies
monitoring of performance will be required.
5 – Manage knowledge and assess needs
In addition, mental health targets have 10 – Manage the local health system
become more integrated into other parts
of health and social care monitoring. From
a commissioning perspective, the need to
deliver the NHS Operating Framework has
4.8 Combating stigma
assumed a central part of local planning and and discrimination
mental health contributes to those plans.
People who use mental health services
The Comprehensive Area Assessment often identify the stigma and discrimination
(CAA) - Measuring the effectiveness of linked with their condition to be one of
partnerships was introduced in 2009/10. the most, if not the most, debilitating part
It examines how well local services are of being diagnosed with a mental health
working together to improve the quality problem. Conventionally, stigma has been
of life for local people. Led by the Audit understood as a relationship between
Commission and combining the perspectives characteristics of a person and socially
of different national inspectorates, it makes constructed negative stereotypes. The active
a joint assessment of outcomes for people discrimination that often accompanies
in an area and provides a forward look at mental health has been identified as one
prospects for sustainable improvement. part of the problem. Programmes to tackle
Local public services are held collectively mental health stigma now place a greater
to account for their impact on better emphasis on discrimination than stigma.
outcomes and increasingly expected to This approach redirects the focus of
work in partnership to tackle the challenges programmes to the people responsible
facing their communities.38 for stigmatising behaviour and away
from its victims.
The PCT targets are reflected in their Local
Area Agreements and the PCT Commissioning There are several national programmes
strategy in addition to various national including SHIFT which is a national
frameworks some of which are: Government funded five year programme,


The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

working in a number of areas to reduce 4.9 Developing a

The Commissioning Context

and remove the stigma and discrimination
directed towards people with experience skilled workforce
of mental health problems. Another
national programme ‘Time to Change’ is Building and maintaining an appropriately
England’s most ambitious programme to skilled and experienced workforce remains
end discrimination faced by people who an important part of ensuring effective
experience mental health problems. Funded and safe services. The NHS Operating
by the National Lottery and Comic Relief, it Framework places particular emphasis on
is aimed at co-ordinating public awareness the development of workforce plans. These
raising and challenging out-dated views of plans will enable commissioners to target
mental illness. resources to ensure the right numbers of
staff, with the appropriate skills, knowledge
and experience, are working in local mental
Health and social care commissioners health services.
have, with their partners, a significant
opportunity to adopt a holistic approach PCTs are required to submit a workforce
to community development and well- plan each year to their Strategic Health
being. These can create both the strategic Authorities (SHAs), which set out what
vision and operational mechanisms to changes are required to deliver local service
enhance the lives of all the people they developments. The plans are collated by
serve. This should include those who SHAs to inform the regional workforce
are suffering from long-and-short-term development and education commissioning
mental health problems. plans. Mental health commissioners need to
ensure that their local workforce plan reflects
the impact of their commissioning intentions
World Class Commissioning competencies
on the local mental health workforce.
2 – Work with community partners
3 – Engage with public and patients In 2004 NIMHE produced the National
8 – Promote improvement and innovation Mental Health Workforce Strategy which
contained six key aims – commissioners may
find these useful to help in workforce plans.
(See Appendix 2.)

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 5
Co-production, partnership and integration

Commissioners have a central role to play s Redefining work: work must include
in defining the shape of local services. whatever it takes to bring up healthy

They are also key players in negotiating children, preserve families, make
and influencing partners across health neighbourhoods safe and vibrant, care
and social care systems. Determining for the frail and vulnerable, redress
the nature of local provision through injustice and make democracy work.
5 effective provider development and s Reciprocity: wherever possible people
market management are now important must replace one-way acts with two-way
components of the commissioners’ skill transactions between individuals as well
set. WCC recognises this need to influence
Co-production, partnership and integration

as between people and institutions.

within its competency framework.
s Social networks: social networks require
ongoing investments of social capital
generated by trust, reciprocity and
5.1 Co-production and civic engagement.40
the role of service users
These core values span the health and
in commissioning social well-being agenda. They call on
commissioners and providers to work in
The emergence of co-production as a key
ways that can break down professional
component in planning and delivering
and organisational barriers. At the heart
services has gained increasing significance.
of these core values is a shift towards
Co-production is a way of working
an inclusive approach to the planning,
together to maximise the potential of
commissioning and delivery of services.
mental health services by actively engaging
service users and the local community
The concept of co-production is included
as partners in the design and delivery of
in the WCC framework. It requires
those services.39 Placing service users at the
commissioners to engage in proactive,
centre of decision making when planning,
continuous and meaningful patient
commissioning and reviewing services is
and public engagement to inform
important if commissioners and providers
commissioning decisions. This requirement
are to respond appropriately to local needs.
recognises that service users have significant
knowledge about the development and
There are four core values at the centre
delivery of services that adds value.
of co-production:
These formal imperatives are only one
s Assets: everyone can be a contributor reason why commissioners should seek to
to the mental well-being of others in engage with service users more effectively
their community. and use co-production methods in the
development of commissioning strategies.

39 Getting Real: co-production, time banking and mental health, 2007

40 Hidden Work: co-production by people outside paid employment, New Economics Foundation/Joseph Rowntree Foundation, 2006

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

and co-production that go beyond

Systematically and rigorously finding traditional consultation meetings.
out what people want and need from
their services is a fundamental duty Some suggested alternatives on how to
of both the commissioners and the approach this are:
providers of services. It is particularly
important to reach out to those whose
full and clear information about the
needs are greatest but whose voices
processes used to identify and develop

are often least heard.41
services and how these work.


limitations faced (resource/capacity/
finance, etc)
The more important imperative is the
benefit that co-production will bring at
if they can easily locate timely and
a local level for both commissioners and
accessible information.
service users.

Co-production, partnership and integration

It can help to develop and strengthen some service users face in becoming
partnerships and provides a framework involved in the commissioning process.
for two-way engagement that will help to s $EVISEWAYSOFCOMMUNICATINGTHAT
create more appropriate and responsive enable reasonable involvement of
services. For service users it can also help service users.43
build and extend their social networks and s 4HEREISANEEDTOPROVIDESUPPORT
increase their confidence. It enables them possibly in the form of ‘training’,
to make a full and meaningful contribution to strengthen and facilitate mental
to their own health and social well-being health service users’ contribution to
as well as that of the wider community in shaping future services and involvement
which they live. in meetings. This should include
familiarisation with organisational
The Picker Institute report, Patient and processes and systems and should
public engagement: the early impact of promote confidence building to support
World Class Commissioning published in individuals in their involvement44
June 2009 stated that PCTs have reported
significant changes to the way they
organise patient and public engagement
in commissioning, amounting to the
beginnings of a cultural shift.42 The shift will
need to be accelerated and maintained to
embed co-production as a way of working.

The challenges for commissioners are

varied. They include how to ensure an
effective representation of the local
service user population and utilising
different approaches to engagement

41 Department of Health (2006). Our Health, Our Care, Our Say | 42 Patient and public engagement: the early impact of World Class Commissioning, Picker
Institute, June 2009 | 43 Commissioning eBook, Chapter Three, Involving people who use services in the commissioning process, Walker, N Integrated Care
Network/DH 2008 | 44
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

An example of the issues raised in developing co-production approaches








World Class Commissioning competencies 5.2 Partnership working


46 Getting Real: co-production, time banking and mental health, 2007

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

delivery of services. Additionally, the role of engagement with the membership, the
the third sector as an increasingly important wider public and those who use services
partner in the planning and delivery of mean that decision making and planning
services creates a powerful triumvirate for are likely to become increasingly rigorous.
local health and social care economies.
Local authorities have a significant part 5.3 Formal partnership
to play and should be regarded as both
stakeholder and partner. Creating Strong, arrangements

Safe and Prosperous Communities47 states that
local authorities will generally be better able The National Health Service Act 2006
to meet their best value duty by adopting provides an enabling framework so that
a commissioning role where they seek to money can be pooled between health
secure the best outcomes for their local bodies and health-related local authority
communities by making use of all available services. Functions can be delegated and 5
resources, without regard for whether services resources and management structures can
are provided in-house, externally or through be integrated49:

Co-production, partnership and integration

various forms of partnership.48 s "OTH.(3ANDSOCIALCAREAGENCIES
place money in a single pot to be
Crucial to this process is the effective spent on agreed services with clear
involvement of service users and carers aims and outcomes.
who are often in the best position to clarify s 4HEREISNODIFFERENTIATIONBETWEEN
what would best help them as well as how health and social care expenditure.
current approaches may need changing. s -ONEYCANBESPENTmEXIBLYONANYOF
Increasingly there is also a recognition that the services that have been designated.
third sector organisations have a major part
to play both as advocates and as providers
and reports monthly on expenditure
of services.
and activity.
Commissioners will have a wider
agency in proportion to their share of
audience to consult in respect of
the pool.
engagement, and a more dynamic
local map of provision with which
The arrangements for England are now
to work. This will make partnership
covered by Section 75 of the National Health
working increasingly complex and
Service Act 2006, which has consolidated
commissioners will need to invest time
the previous NHS legislation. The Next
in developing and sustaining a broader
Stage Review has highlighted the need for
network of partners in decision making,
increased integration between health and
implementation and review.
social care services as part of the drive to
improve access to and quality of care.
This cultural shift has been underway for
some time and mental health services have
been at the forefront of the engagement
agenda. Nevertheless, the additional
requirements for improved and increased

47 | 48

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

5.4 The role of the provider 5.5 Working with

Providers of services have an important
role to play if partnerships are to be Stakeholders are internal or external
effective. Commissioning should be a two organisations, groups or individuals upon
way process, something that is done with whom commissioning decisions have a
rather than to the provider. Providers have direct or indirect impact. In order to work
particular knowledge and expertise that

with stakeholders, it is important for

can help to inform commissioners when commissioners to be able to identify who
deciding strategies and setting priorities. they are and understand the effects their
decisions may have on those stakeholders.
For example commissioners should look to
5 providers for consultant psychiatrists, senior There are a number of stakeholders with
nurses and social workers who are all in a whom commissioners will need to engage.
good position to influence the provision The diagram below highlights some of
Co-production, partnership and integration

of resources.50 The Next Stage Review those which may be important as part
process has also shown how strong clinical of local involvement and consultation
engagement can deliver not only more on commissioning plans and priorities.
informed strategies, but increased levels
of support and more effective delivery. Most importantly, this diagram highlights
that service users should be at the centre
NMHDU and CSL have published a guide to of stakeholder engagement. All other
support clinical engagement. Mental Health categories of stakeholder overlap or
World Class Commissioning. A quick guide interlink with them and the meeting
for mental health professionals (August of their needs.
2009). It promotes greater understanding
and involvement of clinicians across
disciplines in the commissioning process and World Class Commissioning competencies
builds on the momentum achieved in this 1 – Locally lead the NHS
area through the mental health component 2 – Work with community partners
of the NHS Next Stage Review in the English 3 – Engage with public and patients
regions. 4 – Collaborate with clinicians

More detail can be found at: www.nmhdu.

World Class Commissioning competencies

1 – Locally lead the NHS

4 – Collaborate with clinicians
7 – Stimulate the market
10 – Manage the local health system
11 – Make sound financial investments

50 ibid

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Key stakeholders

Local Authority
Wider NHS- including social
SHA’s, DH care, housing,

leisure, transport

Local Providers
Service Users
NHS, independent Carers and families 5
& voluntary sector

Co-production, partnership and integration

Education and
Police and criminal
employment Professionals
justice system
services Clinicians,
managers, unions

Commissioners will need to manage local relationships to maintain and sustain improved
provision. They need to recognise the advocacy and expert patient experience role
that service providers can play, understand those roles and work with the motivations
of providers to create an environment of shared responsibility. They should signal
their future priorities and aspirations to current and potential providers to enable
the influencing of innovative and effective services.51

5.6 Communication
Communicating the aims and purpose of which the organisations can demonstrate
commissioning relies on the involvement of and evidence that they have involved key
key stakeholders, partners, patients and the people appropriately. The duty is set out
public, the voluntary sector, local LINks and in Section 242 of the NHS Act 2006 and
patient support groups. NHS organisations applies across all clinical areas, in addition
now have a legal duty to involve all of the to mental health.
above in their actions, plans and proposals,
and communications is the mechanism by

51 World Class Commissioning: Competencies, DH 2007 Gateway ref: 8754

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

5 Information regarding commissioning and Effective media may include:

its impact on patient care should be shared s INFORMATIONINNEWSLETTERS
openly and widely. Feedback and comment annual reports and NHS magazines
Co-production, partnership and integration

should be facilitated and encouraged. The

use of accessible, everyday language rather
be easily kept up to date at low cost
than NHS or social care jargon is paramount
at open meetings, Board meetings
A strategy for effective communication and Annual General Meetings to
about what commissioning is and why enable people to contribute.
it matters may embrace the following:
document which sets out what
commissioning means
authority websites which is easily
accessible about how it works in practice,
and who are the accountable teams
or library which lists the most common
questions of stakeholders and answers them
dedicated email address and/or Freepost
address) to enable trusts to file and
consider the views of stakeholders
commissioners/PBC/PbR, etc) to demystify
the health and social care jargon.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 6
Effective mental health commissioning

Effective mental health commissioning 6.1 World Class

must be a shared activity which is driven
by a partnership approach involving all Commissioning (WCC)
partners. There is a general consensus,
reflected in the previous edition of this World Class Commissioning will

document, that in some cases mental ensure world class clinical services
health issues are not as prominent at are procured by world class NHS staff.
Board or senior management level in PCTs PCTs and practice based commissioners
and local authorities as other aspects of will need to demonstrate better
outcomes, narrowing health inequalities,
health and social care. It is also recognised
adding life to years and years to life. 6
that mental health commissioning has
sometimes not been given priority in terms This will have a significant impact on
of skills development for those doing the commissioning mental health services.

Effective commissioning
commissioning. As consequence, its quality
has been variable. Delivery of world class commissioning
takes place within a commissioning
In its simplest form, commissioning can assurance system, managed by SHAs, and
be thought of as a series of activities PCTs are assessed across three domains:
that can be grouped under the four s "ETTEROUTCOMESnHAVETHEYIMPROVED
key performance management their key outcome priorities?
elements of analyse, plan, do and review s #OMPETENCIESnHOWFARHAVE
– which are sequential and of equal they developed best practice?
importance.52 All four should be used s 'OVERNANCEnHASTHEBOARDTAKEN
to maximise effectiveness. ownership of and developed a
meaningful strategy supported
This section sets out some of the key by a robust financial plan?
factors that can improve the effectiveness
of commissioning. In particular it focuses The PCT is assessed against each of the
on the usefulness of needs assessment and competency areas each year. WCC sets
the importance of the application of the out the following competencies in the
WCC competencies in improving the quality World class commissioning assurance
of commissioning. It also sets out some handbook Year 2.
guidance about the commissioning cycle,
developing local commissioning plans, and
provides some practical tips which may
aid local success.

52 North West Commissioning Roadmap -

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

1. Locally lead the NHS 3. Engage with public and patients

Are recognised as the local leader Proactively build continuous and meaningful
of the NHS. engagement with the public and patients to
shape services and improve health.
agenda in their community. PCTs will be the commissioning process for investing
natural point of contact for local political and public funds on behalf of their patients
community leaders. Through partnership, they and communities. In order to make
seek and stimulate discussion on NHS and wider commissioning decisions that reflect the
community health and well-being matters. needs, priorities and aspirations of the public
and patients, PCTs will have to engage the

2. Work with community partners public in a variety of ways (e.g. through EIAs)
Work collaboratively with community openly and honestly. They will need to be
partners to commission services that proactive in seeking out and using the views
optimise health gains and reduce and experiences of the public, patients, their
health inequalities and deliver carers, other stakeholders, and in particular,
6 increased productivity. seldom heard and equality target groups.

s 0#4SSHOULDNOTCOMMISSIONSERVICESIN 4. Collaborate with clinicians

Effective commissioning

isolation. In addition to commissioning Lead continuous and meaningful engagement

healthcare services, they will need to of a broad range of clinicians to inform
consider the wider determinants of strategy and drive quality, service design,
health and the role of other partners in and efficient and effective use of resources.
improving the health outcomes of their local s #LINICIANSAREBESTPLACEDTOADVISEAND
population. PCTs also share responsibility lead on transformational change relating to
for undertaking a Joint Strategic Needs clinical quality and effectiveness. They are the
Assessment (JSNA) with local authorities. local care pathway experts who work closely
Partners include local government, Children’s with local people understanding clinical
Trusts, healthcare providers, third sector needs. PCTs should ensure that through the
organisations and clinical partners, such as involvement of clinicians in strategic planning
practice based commissioners (PBCs) and and service design, for example, in meeting
specialist consortia. Working collaboratively the expectations of Transforming Community
with partners, PCTs will stimulate innovation, Services (TCS), services commissioned build
improvements in quality, efficiency and on the current evidence base, maximise
service design, increasing the impact of the local care pathways and utilise resources
services they commission to optimise health effectively. Professional executive committees
gains and reductions in health inequalities. (PECs) have a crucial role to play in building
and strengthening clinical leadership in
the strategic commissioning process.
Practice-based commissioning (PBC) is the
key formal route for driving innovative
and transformational change and the PCT
demonstrates fulfilment of the roles set out
in Clinical commissioning: our vision for
practice-based commissioning.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

5. Manage knowledge and assess needs 7. Stimulate the market

Manage knowledge and undertake robust Effectively stimulate the market to meet
and regular needs assessment that establish demand and secure required clinical and
a full understanding of current and future health and well-being outcomes.
local health needs and requirements. s 0#4SWILLNEEDTOHAVEINPLACEARANGEOF
s #OMMISSIONINGDECISIONSSHOULDBEBASED responsive providers that they can choose from.
on sound knowledge and evidence. By They must understand the current and future
identifying current needs and anticipating market and provider requirements. Employing
future trends, PCTs will be able to ensure that their knowledge of future priorities, needs
current and future commissioned services and community aspirations, PCTs will use their
address and respond to the needs of the investment power to influence improvement,

whole population, especially those whose choice and service design (including through
needs are the greatest. The Joint Strategic TCS) through new or existing providers to secure
Needs Assessment (JSNA) will form one the desired outcomes and quality, effectively
part of this assessment but when operated shaping their market and increasing local choice
of provision. This will include building upon
at world class levels will require more and
local social capital and encouraging provision
richer data, knowledge and intelligence than
the minimum laid out within the proposed via third sector organisations. Where adequate
duty of a JSNA. Fulfilling this competency provider choice does not exist, PCTs will need

Effective commissioning
will require a high level of knowledge clear strategies to address this need, especially
management with associated actuarial and in areas of relatively poor health experience,
analytical skill. access or outcome.

6. Prioritise investment 8. Promote improvement and innovation

Prioritise investment of all spend in Promote and specify continuous
line with different financial scenarios improvements in quality and outcomes
and according to local needs, service through clinical and provider innovation
requirements and the values of the NHS. and configuration.
NHS. They must ensure that they develop
needs of different sections of the local
the necessary capabilities and capacity to
population, PCTs, with their partners, will
drive continuing improvements in quality.
set strategic priorities and make investment
PCTs seek innovation, knowledge and best
and disinvestment decisions focused on
practice, applying this locally to demonstrate
the achievement of key clinical and other
the improvements in the quality and outcomes
outcomes. This will include investment and
of commissioned services. In partnership with
disinvestment plans to achieve health gains
local clinicians (e.g. PBCs), and providers, they
and address areas of greatest health inequality.
will specify required quality and outcomes,
Financial scenarios are considered and their
facilitating supplier and contractor innovation
impact reflected in the investment and
that delivers at best value. Through open and
disinvestment decisions proposed. effective commissioning and decommissioning
decisions, PCTs transform clinical and service
configuration, meeting local needs and
securing world class improvements in
outcomes and quality.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

9. Secure procurement skills pathway. Robust analysis of spend and its impact
Secure procurement skills that ensure on health benefit enables PCTs to make well-
robust and viable contracts. informed investment decisions. By identifying
s 0ROCUREMENTANDCONTRACTINGPROCESSES and unlocking efficiency and productivity
ensure that agreements with all sectors of improvements across all commissioned
providers (acute, primary, community, mental activity, PCTs will deliver both better health
health, third sector, independent sector, etc) outcomes and greater value for money. PCTs
are set out clearly and accurately with both manage change to maintain appropriate
commissioner and provider clear about what stability of the local health economy (LHE).
is expected. By putting in place excellent
procurement and contracting processes, Publications/PublicationsPolicyAndGuidance/

PCTs can specify quality requirements DH_105117

and outcomes (e.g. CQUIN, PROMs),
incentivise development of innovative new The Department of Health has produced
service models and ensure good working a support and development framework
6 relationships with their providers, ensuring that is intended to give commissioners
quality for service users, and value for money. access to the tools they need to deliver
the improvements required by WCC. It
10. Manage the local health system
Effective commissioning

also expects commissioners to share good

Effectively manage systems and work practice, develop internal resources, or buy
in partnership with providers to ensure in external expertise, for example through
contract compliance and continuous the Framework for Securing External Support
improvement in quality and outcomes and for Commissioners (FESC).
value for money.
s #OMMISSIONERSWILLNEEDTOMANAGETHEIR WCC should be seen in the context of a need
relationships and contracts with providers to strengthen commissioning and focus on
in order to ensure that they deliver the what should be delivered in local areas. It will
highest possible quality of service and value help PCTs to commission in a more structured
for money. This will involve working closely and responsive way, paying greater attention
with providers to sustain and improve to the needs of the local population. It will
provision, and engaging in constructive assist in reducing health inequalities and help
performance discussions to ensure continuous to develop better access to services.
improvement. Commissioners will need to
ensure that their providers understand and
promote the values of the NHS. In terms of mental health this means
that commissioners will need to ensure
11. Efficiency and effectiveness of spend that mental health priorities are
Ensuring efficiency and effectiveness reflected in the overall response of the
of spend. PCT when providing evidence for the
assessment against the competencies.
sustainable trade-off decisions and sound
investments across all spend, to deliver the
highest level of health benefit and quality of
care for a given level of spend along each care

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

6.2 The Operating The Operating Framework distinguishes

the national “must do’s” from those areas
Framework for the NHS where local organisations set their priorities
based on local needs by establishing the
The Operating Framework for the NHS in Vital Signs framework.
England is published annually and sets out
the national priorities for the NHS in the Vital Signs sets out three tiers of indicators:
year ahead. It is accompanied by annexes
s Tier One – a small number of national
(some in the document and some web-
must-do’s, with national requirements for
based only) which provide more detail on
what needs to be achieved and by when,
the priorities, how they are measured and
subject to performance management

how the arrangements for managing the
from the centre.
system will work.
s Tier Two – a small number of national
In particular the Operating Framework priorities for local delivery, providing
sets out: local organisations with some flexibility
on delivery and strongly performing 6
organisations deliver without
for the year ahead
intervention from the centre.

Effective commissioning
s Tier Three – a range of indicators available
to deliver quality
to PCTs, which, following consultation with
s 4HElNANCIALREGIME communities and partner organisations,
s 4HEBUSINESSPROCESSES they can choose areas they wish to target
s 4HECOMMISSIONINGTIMETABLE for local action and improvement. This tier
is free from central management.
The Operating Framework’s ongoing
challenges to commissioners and providers The Operating Framework demonstrates
are to: that PCT commissioning activity going
s CONTINUETODELIVERONNATIONALPRIORITIES forward can be split down by nationally
that matter most to patients and the public mandated activity, activity that can be
locally negotiated or bought into and
some which could be described as “good
prepare for the need to make substantial
to have” but which may not fit with the
efficiency savings in the future
PCTs existing strategic framework.
enablers that will help deliver the regional
In terms of mental health this means that
visions, putting quality at the centre
commissioners will need to ensure that
s DEVELOPNEWWAYSOFWORKINGAND mental health priorities are included in
leading that reflect the evidence base the Operating Plans that are developed
and principles for driving large scale and that local strategic aims can be
transformational change. aligned to the requirement of the
Operating Framework and the Vital Signs.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

6.3 Understanding local need World Class Commissioning competencies

5 – Manage knowledge and assess needs

The Local Government and Public
Involvement in Health Act (2007)
The duty to undertake JSNA is set out 6.4 The commissioning cycle
in Section 116 of the Local Government
and Public Involvement in Health Act Most definitions of commissioning paint a
(2007), and described in the draft picture of a cycle of activities at a strategic
statutory guidance Creating Strong, level including:

currently out for consultation.

The statutory guidance emphasises
commissioning strategies to meet
that JSNA should be taken into
them in line with local and national
account by the local authority and its
targets including those set out in
partners in preparing the Sustainable
6 Community Strategy, as part of a
the Operating Framework
strengthened commitment to local s SECURINGSERVICESFROMPROVIDERS
priorities. The issues identified by JSNA to meet those needs and targets
Effective commissioning

will inform the priorities and targets s MONITORINGANDEVALUATINGOUTCOMES

set by the Local Area Agreement, the s THEABOVECOMBINEDWITHANEXPLICIT
delivery agreement for the Sustainable requirement to consult and involve a
Community Strategy. range of stakeholders, patients/service
users and carers in the process.54
Since 1 April 2008, local authorities and PCTs
have been under a statutory duty to produce a The commissioning cycle is an ongoing process
Joint Strategic Needs Assessment (JSNA).53 The covering planning, execution and management
JSNA provides the opportunity for integrated which includes assessing needs, reviewing
working and planning. The process of services and gap analysis, risk management,
conducting a JSNA should establish the current deciding priorities, strategic options, contract
and future health and well-being needs of a implementation, provider development and
population, leading to improved outcomes mapping provider performance.55
and reductions in health inequalities.
The commissioning cycle should include
The importance of understanding the the development, review and approval
needs of the local population cannot be of three plans:
underestimated and should be the starting s The strategic commissioning plan
point in any commissioning process. This should establish the direction
The JSNA provides a specific framework and priorities for at least the next five
that can engage many stakeholders and years for the PCT. It is developed every
partners in a co-ordinated process. three years and updated annually. It
should include specific reference to the
Section 2.2.8 provided detail of the NMHDU commissioning of an appropriate and
resources that can assist commissioners in effective range of mental health services.
conducting mental health JSNAs.

54 North West Commissioning Roadmap -
55 NHS South Central commissioning cycle -
The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

s The financial plan agencies in relation to meeting the needs

This sets out how the PCT plans to of the relevant population.
achieve the health outcomes and s ANANALYSISOFRELEVANTLEGISLATIONAND
financial goals set out in the strategic national guidance on services to meet
commissioning plan. It includes targets, the needs of the relevant population.
financial and activity schedules and
action plans. It is developed annually in
population, and how these are likely to
response to the Operating Framework
change in future.
for the NHS in England. (see section 6.2)
s The organisational development plan
services and resources, and the extent to
This describes the organisational

which they are likely to meet future needs.
capabilities needed to deliver the
strategic commissioning plan, the
practice on services to meet the needs of
capability gaps and how they will be
the relevant population.
filled. It is developed every three years
and updated annually.
limitations of current services, the
changes needed, and some detail about
Although these plans will be developed
the types of services which will be

Effective commissioning
to cover all areas of commissioned
commissioned, and the types which will
services, mental health should have
not be commissioned in future.
a central place within them.
of the strategy upon the range and
quality of services delivered, and upon
6.4.1 Development of local the outcomes for the population.57
commissioning strategies
for mental health As in any form of commissioning, the strategy
The Institute for Public Care (IPC) has should not be an end in itself. Rather it
defined a commissioning strategy as “a should be the framework from which
formal statement of plans for securing, the services are developed, delivered and
specifying and monitoring services to meet monitored with agreed performance targets.
people’s needs at a strategic level. It applies
to services provided by the local authority, Commissioners in health and social care
NHS, other public agencies and the private should seek to design strategies that
and voluntary sectors”.56 will create and maintain services of high
quality that deliver the best outcomes
An effective strategy will set out how for users of those services and ensure
commissioners will ensure the provision the best value to the taxpayer. Strategies
of a range of services to meet the needs should also contribute to meeting PCT
of the local population. In their work on corporate objectives and those of partner
commissioning strategies, the IPC suggest organisations. These might include local
they should contain the following elements: authority key performance indicators and
commitments of the commissioning

56 Developing a commissioning strategy in public care, Moultrie, K. Commissioning eBook, Chapter Five, pp. 2 Integrated Care Network/DH
57 Developing a commissioning strategy in public care, Moultrie, K. Commissioning eBook, Chapter Five, pp. 3 Integrated Care Network/DH

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

6.4.2 The commissioning cycle

An example of the commissioning cycle is set out below. This particular example is drawn
from Mental Health World Class Commissioning – A Guide for Mental Health Professionals,
a guide produced by CSL and NMHDU. This is one example but approaches may vary from
area to area.

8 Managing provider performance 1 Assessing needs

sustaining quality of the PCT population


service leaders

7 Provider development 2 Reviewing services and
Effective commissioning


or introducing new providers
sioning of services as appropriate

6 Contract implementation 3 Risk management

through contracting with providers and health care risks
to demonstrate clear and manage risks
defined outcomes

5 Strategic planning 4 Deciding priorities


Useful links to toolkits and relevant documents to support commissioners

at stages of the commissioning cycle can be found in Appendix 5.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

6.5 Commissioning Particular challenges for specialised services

include training specialist staff, supporting
Specialised Mental high quality research programmes, and
Health Services making the best use of scarce resources.58

Specialised services are provided in Effective commissioning of specialised

relatively few specialist centres to services ensures:
catchment populations of more than s THERIGHTPATIENTCLEARPATIENTSELECTION
one million people. They are not provided criteria and referral guidelines) is offered the
by every hospital in every town, but are right treatment (evidence based, clinically
more usually provided by larger trusts. and cost effective interventions)

In England specialised services are either
agreed service/clinical quality standards)
commissioned regionally by ten Specialised
Commissioning Groups (SCGs), or nationally s THERIGHTPLACEOPTIMISINGGEOGRAPHICAL
by the National Commissioning Group access but avoiding unnecessary
(NCG). Where services fit in terms of local duplication of provision) 6
versus national status usually depends on s THERIGHTCOSTROBUSTCOSTINGAND
the rarity of the condition or treatment. information systems and demonstrable

Effective commissioning
value for money)
The key purpose of the current arrangements s WITHTHEFULLINVOLVEMENTOFTHEPATIENT
for commissioning specialised services is to (adequate information to enable
ensure fair access to clinically effective, high supported choice).59
quality, specialised services. The risk to an
individual PCT of having to fund expensive,
unpredictable activity is also reduced by PCTs
collaborating to commission such services
6.6 Practical tips
collectively and share the financial risk.
This section builds on the previous edition
of the Commissioning Friend for Mental
In mental health, secure services are the
Health Services, which set out a number of
most common example of specialised
“tips” to help guide commissioners in their
commissioning. Some personality disorder
development of local visions, strategies
and eating disorder services might also
and implementation. Those tips have been
be included. Those services that should be
updated and are intended to provide a
commissioned by SCGs are set out in the
practical guide for commissioners to help
Specialised Services National Definition Set.
them most effectively undertake all their
commissioning activities.
Given the complexity of mental health
services, undertaking a systematic process
that takes full account of gathering and
using evidence to underpin decision making
is all the more important.


The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Learning from local experience Stock take

Gather data on what has happened independent and voluntary sector
over the last year in the areas for Look at costs and effectiveness.
which commissioners are responsible. Identify any deficits in provision
Review of WCC framework. and unmet need.
Evaluate outcomes against contracts Identify workforce development needs.
and performance imperatives. s 5SETHENATIONALBENCHMARKSASAGUIDE
Identify what has worked well and for quality and standards
where there have been problems. National Service Frameworks

Engage in reflective dialogue with NICE guidance

providers and service users.
Care Quality Commission standards
Review best practice, what has worked
Other relevant quality and
well and what hasn’t and what the
6 outcomes were.
performance data.
Integrate your planning with local partners Agree local priorities for investment
Effective commissioning

s 2EVIEWTHECOMPETING and development.

organisational priorities. Understand where appropriate
s 0LACESTAKEHOLDERENGAGEMENT decommissioning may be needed
at the centre of planning. in order to develop new services.
Stakeholder involvement (see section 5)
to promote more effective joint
working and sustainable integration. s )DENTIFYWHOTHEYARE
effectively and engage with
them in a meaningful way.
communication open.
shape the agenda and drive forward
development and innovation.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Pay particular attention
to quality and standards.
Input review findings into
future planning, development
and commissioning.


corporate governance requirements
Develop the local strategy (see section 6.3) ensuring appropriate:
and performance imperatives. monitoring and evaluation
local needs analysis. safety

Effective commissioning
s 4AKEACCOUNTOFSERVICERE DESIGN training and development.
changing trends in practice and the
need to have an appropriately skilled
and experienced workforce.
service users and the wider public.

Manage the local market

the local needs
Secure the most clinically effective services
that strike an appropriate balance with
the need to deliver a financially efficient
health and social care system.
Consider the need for tendering.
Ensure an appropriate choice of
provision both in terms of service
options but also of providers.
Draw up clear service specifications.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Section 7
Measuring effectiveness

Mental health services differ from many From local authority social
other care services because of their care departments
complexity, the variety of settings in which From within the local PCT
they are delivered and the number of
From other sources
stakeholders who are involved. Whilst
the most visible part of the system is the s 7HATWASTHECOSTOFDRUGS
delivery of acute services, often from a s 7HATWASTHECOSTOFTALKINGTHERAPIES
local mental health trust, the vast majority

of mental health care is provided in 2. What proportion of the overall

primary care itself. From a commissioning commissioning budget did this represent?
perspective, knowing what works, whether
it has been effective in improving quality 3. How was the clinical and cost
and outcomes is an essential part of the
7 commissioning process.
effectiveness of the various forms
of investment measured?

Reviewing what has been commissioned 4. What outcomes were these investments
Measuring effectiveness

can inform future decisions about levels intended to achieve and what progress has
of investment and where that investment been made in achieving them?
should be targeted. In addition, to
commission in a world class way also 5. How much was spent on public
requires world class decommissioning, awareness and mental health promotion
removing those services that are no and how was effectiveness evaluated?
longer effective or of sufficient quality.
6. What progress has been made in the
‘Not everything that counts can meeting of national and local targets and
be counted and not everything policy imperatives?
that can be counted counts.’
7. How are users of services and their carers
involved in the commissioning process and
The following questions are intended to
local decision making?
provide prompts for commissioners to assist
them in reviewing local effectiveness.
8. What mechanisms are there to ensure
that the views of all parts of the community
1. How much did you invest in mental
are heard and what changes have occurred
health services last year?
as a result?
In primary care settings generally 9. What training and development is
From the third sector provided on mental health issues and
for whom?
From mental health trust(s)

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

These key questions are not intended to Engagement with service users and the
be exhaustive but provide a useful pointer wider public must form a central part of
to the type of issues that commissioners commissioners’ planning, development
should be considering when thinking about and evaluation processes. The use of
local effectiveness. co-production as a tool to facilitate that
engagement should be considered as vital
to ensuring service users’ views are heard,
Conclusion understood and acted upon.

Mental health and well-being is one part of Finally, it is suggested that commissioners
a wider health and social care agenda. The in health and social care consider the
effects of mental illness are wide ranging following five key points as they strive
and have a significant impact on society to improve quality and effectiveness:
as a whole. Commissioning has a crucial s 2EVIEWOUTCOMESNOTJUSTACTIVITY

part to play in shaping the delivery of local s -AKEDECISIONSBASEDONQUALITY
services and should be at the forefront of not just cost.
health and social care priorities. s %NGAGEUSERSOFSERVICESASWELL
as clinicians.
Improvement in the quality of mental
health commissioning is critical to longer
term success in reducing the negative s (IGHQUALITYCOMMISSIONINGLEADS
to high quality services.

Measuring effectiveness
impact of mental ill health. Research
has suggested that focusing on the
commissioning function alone will not By the nature of their role, commissioners
produce good outcomes. The Health Service are often a step away from services. Bridging
Management Centre of the University the gap between themselves and the services
of Birmingham report published in they commission and creating a bond of
December 2007 recommends that all parts understanding and engagement will better
of the healthcare system need to adopt enable strategy to respond to reality.
appropriate competencies and behaviours
for the system as a whole to work. The Applying some of the levers and tools
report notes that competency depends described in this document should help
not just on knowledge and skills, but also to move towards more effective and
on values.60 These must be at the heart co-ordinated commissioning. In turn this
of commissioning priorities. World Class should lead to better outcomes.
Commissioning provides a framework
within which to deliver these values. Commissioning must be strategic, but its
impact must have a positive and direct
effect on service users. Striving to be
world class as commissioners should help
to achieve the aim of creating world class
services that demonstrably improve the
health and well-being of those using them.

60 Towards World Class Commissioning Competency - Woodin & Wade, HSMC University of Birmingham December 2007

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 1
NHS Targets in 2009/2010

Most of the NHS Plan targets related to mental health have now been worked through and
delivered. There is no longer an emphasis on old style “input” targets like team numbers
and workforce.

Actual targets that remain priorities for 2009/10 are:

(maintaining length of care required)

(based on a three year average - 2009 through 2011)

The key priorities set in the 2009/10 operating framework were to deliver on national
requirements (Tier 1) national priorities (Tier 2) and Local Actions (Tier 3) as set in Vital
Signs. Mental Health indicators are as listed below:
s Tier 1
A1 Suicide and injury of undetermined intent mortality rate
s Tier 2
NHS Targets in 2009/2010

IAPT (proportion of people with depression and/or anxiety disorders who are offered
psychological therapy
s Tier 3
Social Inclusion (supporting people in vulnerable circumstances)

1. Proportion of adults in contact with secondary mental health services in

settled accommodation
2. Proportion of adults in contact with secondary mental health services in employment

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 2
National Mental Health Workforce Strategy

In 2004 NIMHE produced the National 6. To develop leadership and

Mental Health Workforce Strategy. It set out change management skills within
plans and guidance for commissioners and professional and managerial staff
providers to develop a workforce with the in all stakeholder organisations
competencies to provide person-centred, and multidisciplinary settings.62
socially inclusive and recovery-oriented
services, primarily in a multi-disciplinary
Although the targets contained in the
setting.61 It contained six key aims:
strategy were to be met by 2006, the six
key aims remain relevant. They should
1. To improve workforce design and
form the basis of commissioners’ workforce
planning so as to root it in local services
planning. This will help to ensure the
planning and make it understandable
maintenance and development of an
and meaningful to people in local
appropriately skilled and experienced

services and other key organisations.
mental health workforce.

2. To identify and use creative means

to recruit and retain people in the
workforce in order to increase the
overall numbers in successive years.
3. To facilitate new ways of working across
professional boundaries. To make the

National Mental Health Workforce Strategy

best use of specialist staff to meet the
needs of service users and carers.

4. To create new roles to tap into a new

recruitment pool and complement
existing staff groups.

5. To develop the workforce through revised

education, training and development at
pre and post qualification levels and for
continuing professional and practitioner
development, increasingly focusing on the
shared and distinct capabilities required
to meet both staff and user needs.

61 National Mental Health Workforce Strategy, NIMHE, 2004

62 ibid

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 3
The Ten Essential Shared Capabilties

The original Commissioning Friend for 3. Practising ethically: Recognising the

Mental Health Services63 highlighted ten key rights and aspirations of service users
areas that commissioners should measure and their families, acknowledging
themselves against when addressing mental power differentials and minimising them
health issues. They were originally included whenever possible. Providing treatment
in The ten essential shared capabilities for and care that is accountable to service users
mental health practice64 published in 2004. and carers within the boundaries prescribed
The capabilities remain valid and are set by national (professional), legal and local
out here for commissioners to consider in codes of ethical practice.
the context of improving the quality of
commissioning and local service delivery. 4. Challenging inequality: Addressing
the causes and consequences of stigma,
1. Working in partnership: Developing discrimination, social inequality and
and maintaining constructive working exclusion on service users, carers and mental
relationships with service users, carers, health services. Creating, developing or
families, colleagues, lay people and wider maintaining valued social roles for people

community networks. Work positively in the communities they come from.

to resolve tensions created by conflicts
of interest or aspiration that may arise 5. Promoting recovery: Working in
between the partners in care. partnership to provide care and treatment
that enable service users and carers to
2. Respecting diversity: Working in tackle mental health problems with hope
A3 partnership with service users, carers, and optimism and to work towards a valued
families and colleagues to provide care and lifestyle within and beyond the limits of any
interventions that not only make a positive mental health problem.
The Ten Essential Shared Capabilties

difference but also do so in ways that

respect and value diversity including age, 6. Identifying people’s needs and
race, culture, disability, gender, spirituality strengths: Working in partnership to gather
and sexuality. information to agree health and social
care needs in the context of the preferred
lifestyle and aspirations of service users,
their families, carers and friends.

63 The Commissioning Friend for Mental Health Services, NATPACT/NIMHE, 2005

64 The ten essential shared capabilities for mental health practice: A framework for the whole of the mental health workforce, DH/NIMHE August 2004

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

7. Providing service user centred care:

Negotiating achievable and meaningful
goals, primarily from the perspective of
service users and their families. Influencing
and seeking the means to achieve these
goals and clarifying the responsibilities of
the people who will provide any help that is
needed, including systematically evaluating
outcomes and achievements.

8. Making a difference: Facilitating access

to and delivering the best quality, evidence-
based, values-based health and social
care interventions to meet the needs and
aspirations of service users, their families
and carers.

9. Promoting safety and positive risk

taking: Empowering the person to decide
the level of risk they are prepared to
take with their health and safety. This
includes working with the tension between

promoting safety and positive risk taking,
including assessing and dealing with
possible risks for service users, carers,
family members, and the wider public.

10. Personal development and learning:

Keeping up-to-date with changes in A3
practice and participating in life-long
learning, personal and professional

The Ten Essential Shared Capabilties

development for one’s self and colleagues
through supervision, appraisal and
reflective practice.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 4
Useful Links: Meeting the needs of particular groups

Meeting the needs Age Appropriate Briefing:

of particular groups Guide for Commissioners
The range of needs within mental health
services is varied and complex. The
following summaries highlight some of
the key groups with web links to more
NMHDU, Children and Young People’s
information about services and policy
workstreams, various resources
guidance for commissioners looking to
develop specific services for those groups.
Specialist Commissioning
Children and Young People
The policy imperatives and key service A Legal Guide to the Care and Treatment
developments are set out in the NSF of Young People with Mental Disorder
and can be found at: (NIMHE 2009)
NationalServiceFrameworkdocuments/index.htm aspects-of-the-care-and-treatment-of-children-

Healthy lives, brighter futures

– The strategy for children and young Older People
people’s health The policy imperatives and key service developments are set out in the NSF
Publicationsandstatistics/Publications/ and can be found at:
A4 deliveringadultsocialcare/olderpeople/index.htm
Children and young people in mind: the
final report of the National CAMHS Review National Dementia Strategy
Useful Links: Meeting the needs of particular groups
CAMHSReview-Bookmark.pdf Deliveringadultsocialcare/Olderpeople/
Child and Adolescent Mental Heath
Services Dataset development Dementia Services Guide (Healthcare for London/ Commissioning Support for
list/camhs London, October 2009)

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Mental Health Minimum Dataset: Adults Facing Chronic Exclusion (ACE) is a

Inpatient, Outpatient, Day hospital three year pilot programme to tackle long
& Contact datasets term social exclusion. More detail can be found at:
Learning disabilities task_force/adults.aspx
Valuing people now: a new three-year
strategy for people with learning disabilities People with personality disorder – the policy and guidance for delivering services
Deliveringadultsocialcare/Learningdisabilities/ for people with personality disorder can
index.htm be found at:
People with Learning Disabilities in Publications/PublicationsPolicyAndGuidance/
England: Report on the number of people DH_4009546
with a learning disability in England Substance misuse – the details of
current policy, performance and service
Black and ethnic minority communities – development can be found at:
the policy imperatives are set out in the
Delivering Race Equality guidance and
can be found at:

Health services for offenders are now a PCT

responsibility. Details about current policy
and service development can be found at:

The Bradley Report makes specific

recommendations for the development of A4
court diversion services and mental health
services for offenders. It can be found at: Useful Links: Meeting the needs of particular groups

Social inclusion is part of the wider agenda

of improving access to services for people
with mental health problems. More detail
about policy and service development can
be found at:

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 5
Useful Links: The Commissioning Process

The following websites provide useful Joint Strategic Needs

information and resources for commissioners. Assessment (JSNA)
The list is not intended to be exhaustive but
Department of Health Joint strategic needs
gives a starting point and adds to those links
assessment official guidance
set out in the main document.
Commissioning Guidance DH_081097
IMHA Guidance for Commissioners NMHDU (2009) - Joint Strategic Needs Assessment and Mental Health
mental-health-advocacy-guidance.pdf Commissioning Toolkit - A practical guide
Carers needs-assessment-and-mental-health-
Publication: Commissioning for Carers commissioning-toolkit-2009.doc
(September 2009) Better Commissioning Learning and
do?pageId=13255730 Improvement Network – joint strategic
needs assessment resource.
Children and Young People
Briefing for Commissioner’s on providing BetterCommissioning/Commissioningpolicy/jsna/
Age Appropriate Services (June 2009) Stakeholder Involvement

Public and Patient Involvement Toolkit

Older People
Joint Commissioning Framework Dementia
A5 NationalDementiaStrategy/DH_083362
Communities in Control: Real People,
Real Power (2008)
Personality Disorder
Commissioner’s Guide – Commissioning for
Useful Links: The Commissioning Process

Personality Disorder (June 2009)
Mental Health World Class Commissioning:
A guide for professionals (NMHDU 2009).

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Together UK: A good pratice guide NHS Institute PCT portal – CQUIN
for valuing and respecting service
user involvement commissioning/pct_portal/cquin.html
togethergoodpracticeguide.pdf Payment by Results
Department of Health link to all the latest
Official guidance for Local Involvement on Mental Health PbR.
Networks (LINks) Financeandplanning/NHSFinancialReforms/
Publications/PublicationsPolicyAndGuidance/ DH_4137762
Mental Health Contract
PCT Roadmap for Mental Health Services. NHS Mental Health Contract
Roadmap that aligns commissioning
process procurement skills with world Commissioning/Systemmanagement/
class commissioning competencies. DH_085048
General Commissioning
and Mental Health
North West Commissioning Roadmap:
A good site for signposting. The Commissioning Circle – Resource Library
php?pageNo=503 This resource lists documents according
to their fit with the World Class
Outcomes Commissioning Competency framework.
Department of Health (2009) Outcomes

compendium: helping you select the right
NHS Evidence - Mental Health Library
tools for best mental health care practice
This is a resource that pulls together
in your field.
all the latest news and publications in
mental health, as well as producing a
regular newsletter.
DH_093316 A5
Commissioning for Quality
Useful Links: The Commissioning Process

and Innovation (CQUIN)

Using the Commissioning for Quality and
Innovation (CQUIN) payment framework.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Integrated Care Network Department of Health:

– details of integration policy, guidance World Class Commissioning Site.
and development and associated World Class Commissioning: Supports delivery
commissioning guidance. of a more strategic and long-term approach to commissioning services, with a clear focus
on delivering improved health outcomes.
New Horizons
Department of Health (2009): New Horizons commissioning/worldclasscommissioning/index.htm
NewHorizons/index.htm National Mental Health Development
Unit: hosts a national Mental Health
Department of Health Commissioning programme.
Department of Health (2007)
Commissioning framework for health and
well-being. London: Department of Health Personalisation Department of Health: Personalisation
Publications/PublicationsPolicyAndGuidance/ website, including access to a toolkit,
DH_072604 subscription to a newsletter.
Department of Health (1999) National
service framework for mental health. SCIE Publication:
London: Department of Health Commissioners and personalisation
Publications/PublicationsPolicyAndGuidance/ ataglance06.asp
Personalisation The Rough Guide
Department of Health (2004) The national (Social Care Institute of Excellence 2008)
service framework for mental health – five
years on. London: Department of Health
Appendix In Control (2008) Smart commissioning:

Publications/PublicationsPolicyAndGuidance/ exploring the impact of personalisation
DH_4099120 on commissioning,
Department of Health (2008) High quality Library.aspx?pageid=386&cc=GB
A5 care for all: NHS next stage review –
final report (the Darzi report). London:
Department of Health
Useful Links: The Commissioning Process


The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Comprehensive Area Assessments

Comprehensive Area Assessments

Audit Commission Page on Comprehensive

Area Assessments

Practice Based Commissioning (PBC)

Department of Health link to all the latest
on PBC.

Publication: Reinvigorate, Replace or

Abandon (Kings Fund 2008)

Useful Links: The Commissioning Process

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Appendix 6
Useful Links

Social Care Mental Health Act 1983

DH Green Paper. Shaping the future of (as amended by Mental Health Act 2007)
care together. The consultation will run Mental Health Act 2007: key documents
from 14 July 2009 to 13 November 2009. DH_089882
DH_102338 Code of Practice to Mental Health Act 1983
(revised 2008)
Putting People First (DH 2007) outlines
Government’s vision for a personalised Publications/PublicationsPolicyAndGuidance/
adult social care system. DH_084597
Publications/PublicationsPolicyAndGuidance/ Mental Capacity Act 2005
DH_081118 Mental Capacity Act 2005: Key documents
Department of Health: Our Health, Deliveringadultsocialcare/MentalCapacity/
Our Care, Our Say: a new direction MentalCapacityAct2005/index.htm
for community services (DH 2006) Data Sources and Data Collection
Ourhealthourcareoursay/DH_065882 Data
Mental Health Minimum Dataset :
Legislation Inpatient, Outpatient, Day hospital
Legislation & Contact datasets and rates of access
The Local Government and Public to services by PCT area
Involvement in Health Act 2007
ukpga_20070028_en_1 National Statistics: Data on admissions,
spending, benefit claimants
Health and Social Care Act 2008
A6 Legislation/Actsandbills/HealthandSocialCareBill/ Working for Health: Dame Carol
Black review
Useful Links

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners

Adult Psychiatric Morbidity Survey The Equality Act (2006)

– for prevalence and unmet need ukpga_20060003_en_1.htm

Existing data around population and Single Equality Bill

geography; mapping information
population-and-geography The Race Relation (Amendment) Act 2000
Count Me In 2008: Results of the 2008 ukpga_20000034_en_1
national census of inpatients in mental
health and learning disability services in The Disability Discrimination Act 2005
England and Wales. ukpga_20050013_en_1

Mental Health Observatory

The Marmot Review

Government Equalities Office

Delivering Race Equality
Delivering Race Equality: an action plan
for reform (DH 2005).
DH_4100773 A6
Mainstreaming gender and women’s
Useful Links

mental health: implementation guidance.

The Commissioning Friend for Mental Health Services
A guide for health and social care commissioners


Thanks to Steve Appleton of Contact Consulting for revising

The Commissioning Friend for Mental Health Services.

Thanks are also due to the following people for their help and guidance:

Maurice Burns NMHDU

Sue Christie Project lead, CSL
David Daniel Department of Health
Sean Farran CSL
Richard Gorf Sutton & Merton PCT
Claire Helman Together
Louise Howell Project lead, NMHDU
David Jobbins CSL
Kieron Murphy NMHDU
James Seward Department of Health
Linda Seymour Sainsbury Centre for Mental Health
Clive Stevenson CSL
Jim Symington NMHDU

Editorial: Sue Christie and Jessamy Hayes

Readers are advised that all links are correct at the time of going to press. If you have
problems accessing the documents through the direct links, they should be readily found
via a search from the relevant site’s home page.

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A guide for health and social care commissioners

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