Service user experience in adult mental health services

Short Text

Service user experience in adult mental health services

Introduction

This pathway is about ensuring that users of adult mental health services have the best possible experience of care from the NHS.
Despite initiatives to improve the service user's experience of healthcare, further work is needed to deliver the best possible experience of care to adults using mental health services. This pathway recommends how health and social care professionals and providers can achieve this within the NHS.

Source guidance

The NICE guidance that was used to create the pathway.
Service user experience in adult mental health. NICE clinical guidance 136 (2011)

Quality standards

Quality statements

Feeling optimistic about care

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services, and their families or carers, feel optimistic that care will be effective.

Quality measure

Structure
Evidence of local arrangements to ensure that service users are supported to feel optimistic that care will be effective.
Outcome
Evidence from experience surveys and feedback that service users, and their families or carers, feel optimistic that care will be effective.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to collect feedback on the experience of care from service users and their families or carers.
Mental health and social care professionals ensure they support service users, and their families or carers, to feel optimistic that care will be effective.
Commissioners ensure they commission services that support people using mental health services, and their families or carers, to feel optimistic that care will be effective.
People using mental health services, and their families or carers, feel optimistic that care will be effective.

Source guidance references

NICE clinical guidance 136 recommendation 1.1.1

Data source

Structure
Local data collection.
Outcome
Local data collection.

Empathy, dignity and respect

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services, and their families or carers, feel they are treated with empathy, dignity and respect.

Quality measure

Structure
Evidence of local arrangements to ensure that mental health and social care professionals treat service users with empathy, dignity and respect.
Outcome
Evidence from experience surveys and feedback that service users, and their families or carers, feel they are treated with empathy, dignity and respect.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to collect feedback on the experience of care from service users and their families or carers.
Mental health and social care professionals ensure they treat service users, and their families or carers, with empathy, dignity and respect.
Commissioners ensure they commission services that have mental health and social care professionals who treat service users with empathy, dignity and respect.
People using mental health services, and their families or carers, feel they are treated with empathy, dignity and respect.

Source guidance references

NICE clinical guidance 136 recommendation 1.1.1

Data source

Structure
Local data collection.
Outcome
Local data collection. Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. Questions on treating service users with dignity and respect are contained within:

Shared decision-making and self-management

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services are actively involved in shared decision-making and supported in self-management.

Quality measure

Structure
a) Evidence of local arrangements to ensure that service users are actively involved in shared decision-making.
b) Evidence of local arrangements to ensure that service users are supported in self-management.
Process
a) Proportion of service users actively involved in shared decision making.
Numerator – the number of people in the denominator actively involved in shared decision-making.
Denominator – the number of people using mental health services.
b) Proportion of service users supported in self-management.
Numerator – the number of people in the denominator supported in self-management.
Denominator – the number of people using mental health services.
Outcome
a) Evidence from experience surveys and feedback that service users feel actively involved in shared decision-making.
b) Evidence from experience surveys and feedback that service users feel supported in self-management.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to actively involve service users in shared decision-making and support self-management.
Mental health and social care professionals ensure service users are actively involved in shared decision-making and supported in self-management.
Commissioners ensure they commission services which actively involve service users in shared decision-making and support self-management.
People using mental health services feel actively involved in making decisions about their care and treatment and supported in managing their mental health problem(s).

Source guidance references

NICE clinical guidance 136 recommendation 1.1.2

Data source

Structure
a) and b) Local data collection.
Outcome
a) Local data collection. Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. The NHS mental health inpatient survey (Q27) collects information on involvement in care and treatment decisions. The NHS community mental health survey (Q5, 10, 25 and 33) collects information on taking account of service user views.
b) Local data collection.

Continuity of care

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using community mental health services are normally supported by staff from a single, multidisciplinary community team, familiar to them and with whom they have a continuous relationship.

Quality measure

Structure
Evidence of local arrangements to ensure that service users of community mental health services are normally supported by staff from a single, multidisciplinary community team, familiar to them and with whom they have a continuous relationship.
Outcome
Evidence from experience surveys and feedback that service users of community mental health services feel they are normally supported by staff from a single, multidisciplinary community team, familiar to them and with whom they have a continuous relationship.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for service users of community mental health services to normally be supported by a single, multidisciplinary community team familiar to them and with whom they have a continuous relationship.
Mental health and social care professionals ensure that service users of community mental health services are normally supported by a single, multidisciplinary community team and that they maintain a continuous relationship with service users.
Commissioners ensure they commission services in which service users of community mental health services are normally supported by a single, multidisciplinary community team which maintains continuous relationships with service users.
People using mental health services feel supported throughout their care by a team of staff who they know.

Source guidance references

NICE clinical guidance 136 recommendation 1.4.7

Data source

Structure
Local data collection.
Outcome
Local data collection.

Using views of service users to monitor and improve services

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services feel confident that the views of service users are used to monitor and improve the performance of services.

Quality measure

Structure
a) Evidence of local arrangements to collect and use views of service users to monitor and improve the performance of services.
b) Evidence of local arrangements to have service user monitoring of services; for example, using exit interviews undertaken by trained service users.
c) Evidence of local arrangements to provide the executive board with reports on acute and non-acute mental health pathways, with a breakdown of the experience of care according to gender, sexual orientation, socioeconomic status, age, background (including cultural, ethnic and religious background) and disability.
Outcome
Evidence from surveys and feedback that service users feel confident that their views are used to monitor and improve services.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to use the views of service users in monitoring and improving the performance of services.
Mental health and social care professionals ensure service users are provided with opportunities to give feedback on their experience.
Commissioners ensure they commission services that use the views of service users to monitor and improve performance.
People using mental health services are asked about their experience of care and this is used to monitor and improve the service.

Source guidance references

NICE clinical guidance 136 recommendations 1.1.20, 1.1.21 and 1.1.22

Data source

Structure
Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. The NHS staff survey for mental health trusts (Q5) collects information on whether staff in acute mental health trusts have been trained on how to monitor and use service user feedback to make improvements.
b) and c) Local data collection.
Outcome
Local data collection.

Access to services

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People can access mental health services when they need them.

Quality measure

Structure
a) Evidence of local arrangements to ensure agreed referral methods are in place between primary and secondary care.
b) Evidence of local arrangements to ensure that people with a non-acute referral to mental health services have a face-to-face appointment that takes place within 3 weeks of referral (or within 2 weeks of any change of date).
c) Evidence of local arrangements to ensure service users are seen within 20 minutes of the agreed appointment time.
d) Evidence of local arrangements to ensure that people in crisis referred to mental health secondary care services are seen within 4 hours.
e) Evidence of local arrangements to ensure service users have access to a local 24-hour helpline staffed by mental health and social care professionals.
f) Evidence of local arrangements to ensure crisis resolution and home treatment teams are accessible 24 hours a day, 7 days a week, regardless of diagnosis.
g) Evidence of local arrangements to ensure that people admitted to a ‘place of safety’ are assessed under the Mental Health Act within 4 hours.
Process
a) Proportion of people with a non-acute referral to mental health services who had a face-to-face appointment that took place within 3 weeks of referral (or within 2 weeks of any change of date).
Numerator – the number of people in the denominator who had a face-to-face appointment that took place within 3 weeks of referral (or within 2 weeks of any change of date).
Denominator – the number of people with a non-acute referral to mental health services.
b) Proportion of service users who were seen within 20 minutes of the agreed appointment time.
Numerator – the number of people in the denominator who were seen within 20 minutes of the agreed appointment time.
Denominator – the number of service users with an agreed appointment time.
c) Proportion of service users in crisis referred to specialist mental health services who were seen within 4 hours.
Numerator – the number of people in the denominator who were seen within 4 hours.
Denominator – the number of service users in crisis referred to Quality standard for service user experience in adult mental health 13 of 31 specialist mental health services.
d) Proportion of people admitted to a ‘place of safety’ who were assessed under the Mental Health Act within 4 hours.
Numerator – the number of people in the denominator who were assessed under the Mental Health Act within 4 hours
Denominator – the number of people admitted to a ‘place of safety’.
Outcome
a) Evidence from experience surveys and feedback that service users with a non-acute referral had a face-to-face appointment that took place within 3 weeks of referral (or within 2 weeks of any change of date).
b) Evidence from experience surveys and feedback that service users with an agreed appointment time were seen within 20 minutes of that time.
c) Evidence from experience surveys and feedback that service users are able to access a local helpline 24 hours a day.
d) Evidence from experience surveys and feedback that service users in crisis referred to specialist mental health services were seen within 4 hours.
e) Evidence from experience surveys and feedback that people admitted to a ‘place of safety’ were assessed under the Mental Health Act within 4 hours.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide access to mental health services when needed.
Mental health and social care professionals ensure services users can access mental health services when they need them.
Commissioners ensure they commission services that provide access to mental health services when needed.
People can access mental health services quickly and easily when needed.

Source guidance references

NICE clinical guidance 136 recommendations 1.2.1, 1.2.3, 1.3.6, 1.5.5, 1.5.6, 1.5.7 and 1.8.8

Data source

Structure
a) to g) Local data collection.
Process
The outpatient commissioning dataset contains the data needed for calculating waiting times for non-acute appointments. More information available at HES Online.
b) to d) Local data collection.
The NHS staff survey for mental health trusts (Q5) collects information on whether staff in acute mental health trusts have been trained on how to monitor and use service user feedback to make improvements.
b) and c) Local data collection.
Outcome
a) and b) Local data collection.
c) Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. The NHS community mental health survey (Q36 to 39) contains questions on the accessibility of out-of-hours phone numbers.
d) and e) Local data collection.

Definitions

The Mental Health Act 1983 (amended 1995 and 2007).

Information and explanations

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services understand the assessment process, their diagnosis and treatment options, and receive emotional support for any sensitive issues.

Quality measure

Structure
Evidence of local arrangements to ensure that service users assessed by mental health services are provided with explanations and information so they can understand the assessment process, diagnosis and treatment options, and receive emotional support for any sensitive issues.
Process
Proportion of service users assessed by mental health services who were given explanations and information about the assessment process, their diagnosis and treatment options.
Numerator – the number of people in the denominator who were given explanations and information about the assessment process, their diagnosis and treatment options.
Denominator – the number of service users assessed by mental health services.
Outcome
a) Evidence from experience surveys and feedback that service users assessed by mental health services understand the assessment process, their diagnosis and treatment options.
b) Evidence from experience surveys and feedback that service users assessed by mental health services received emotional support for any sensitive issues.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to provide information so service users can understand the assessment process, their diagnosis and treatment options.
Mental health and social care professionals ensure they provide service users with explanations and information so they can understand the assessment process, their diagnosis and treatment options, and emotionally support them with any sensitive issues.
Commissioners ensure they commission services that provide explanations and information so service users can understand the assessment process, their diagnosis, their treatment options and are emotionally supported with any sensitive issues.
People using mental health services understand the assessment process, their diagnosis and treatment options and receive emotional support for any sensitive issues.

Source guidance references

NICE clinical guidance 136 recommendation 1.3.3

Data source

Structure
Local data collection. Providers may be able to use questions contained within the national NHS staff survey available from NHS Surveys. The NHS staff survey for mental health trusts (Q5) collects information on whether staff in acute mental health trusts have been trained to give information to service users.
Process
Local data collection.
Outcome
a) Local data collection
b) Local data collection.

Care planning

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services jointly develop a care plan with mental health and social care professionals, and are given a copy with an agreed date to review it.

Quality measure

Structure
a) Evidence of local arrangements to ensure that service users can jointly develop a care plan with mental health and social care professionals.
b) Evidence of local arrangements to ensure that service users are given a copy of their care plan.
c) Evidence of local arrangements to ensure that service users have an agreed date to review their care plan.
Process
a) Proportion of service users who have a jointly agreed care plan.
Numerator – the number of people in the denominator who have a jointly agreed care plan.
Denominator – the number of service users.
b) Proportion of service users given a copy of their care plan.
Numerator – the number of people in the denominator given a copy of their care plan.
Denominator – the number of service users with a care plan.
c) Proportion of service users with an agreed date to review their care plan.
Numerator – the number of people in the denominator with an agreed date to review their care plan.
Denominator – the number of service users with a care plan.
Outcome
a) Evidence from experience surveys and feedback that service users jointly developed a care plan.
b) Evidence from experience surveys and feedback that service users were given a copy of their care plan.
c) Evidence from experience surveys and feedback that service users have an agreed date to review their care plan.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to jointly develop care plans, share copies with services users and agree review dates.
Mental health and social care professionals ensure service users have a jointly developed care plan, that they share copies with service users and agree review dates.
Commissioners ensure they commission services that jointly develop care plans with service users, share copies with service users and agree review dates.
People using mental health services jointly develop a care plan with mental health and social care professionals, receive a copy of the care plan and agree a date to review it.

Source guidance references

NICE clinical guidance 136 recommendation 1.4.2

Data source

Structure
a) to c) Local data collection.
Process
a) to c) Local data collection.
Outcome
a) Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. Questions on involvement in care plans are contained within the NHS community mental health survey (Q23, 24, 25 and 26).
b) Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. A question on provision of a written copy of the care plan is contained within the NHS community mental health survey (Q29).
c) Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. A question on whether a care review was held in the past 12 months is contained within the NHS community mental health survey (Q30).

Definitions

Care plans should include the needs of the individual service user, activities promoting social inclusion such as education, employment, volunteering and other specified occupations, such as leisure activities and caring for dependants.

Crisis planning

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services who may be at risk of crisis are offered a crisis plan.

Quality measure

Structure
Evidence of local arrangements to ensure that service users who may be at risk of crisis are offered a crisis plan.
Process
a) Proportion of service users who may be at risk of crisis offered a crisis plan.
Numerator – the number of people in the denominator who are offered a crisis plan.
Denominator – the number of service users who may be at risk of crisis.
b) Proportion of service users accepting an offer of a crisis plan who have a crisis plan.
Numerator – the number of people in the denominator who have a crisis plan
Denominator–- the number of service users accepting an offer of a crisis plan.
Outcome
Evidence from experience surveys and feedback that service users who may be at risk of crisis are offered a crisis plan.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to offer a crisis plan to service users who may be at risk of crisis.
Mental healthcare professionals offer a crisis plan to service users who may be at risk of crisis.
Commissioners ensure they commission services that offer a crisis plan to service users who may be at risk of crisis.
People using mental health services who may be at risk of crisis are offered a crisis plan.

Source guidance references

NICE clinical guidance 136 recommendations 1.1.11, 1.1.12 and 1.4.5

Data source

Structure
Local data collection.
Process
a) and b) Local data collection. The mental health minimum dataset contains data on creation of crisis plans for people on a Care Programme Approach (CPA) only. More information available at HES Online.
Outcome
Local data collection. Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. A question on crisis planning is contained within NHS community mental health survey (Q28).

Definitions

A crisis plan should contain:
  • possible early warning signs of a crisis and coping strategies
  • support available to help prevent hospitalisation
  • where the person would like to be admitted in the event of hospitalisation
  • the practical needs of the service user if they are admitted to hospital (for example, childcare or the care of other dependants, including pets)
  • details of advance statements and advance decisions
  • whether and the degree to which families or carers are involved
  • information about 24-hour access to services
  • named contacts.

Assessment in a crisis

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People accessing crisis support have a comprehensive assessment, undertaken by a professional competent in crisis working.

Quality measure

Structure
a) Evidence of local arrangements to ensure that service users accessing crisis support have a comprehensive assessment.
b) Evidence of local arrangements to ensure that professionals who assess people in crisis are competent in crisis working.
Process
Proportion of service users accessing crisis support who have a comprehensive assessment.
Numerator – the number of people in the denominator who have a comprehensive assessment.
Denominator – the number of service users accessing crisis support.
Outcome
Evidence from experience surveys and feedback that service users accessing crisis support were asked about their relationships, their social and living circumstances and level of functioning, as well as their symptoms, behaviour, diagnosis and current treatment.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for service users accessing crisis support to have a comprehensive assessment undertaken by a professional competent in crisis working.
Mental health and social care professionals ensure service users accessing crisis support have a comprehensive assessment by a professional competent in crisis working.
Commissioners ensure they commission crisis support services in which professionals competent in crisis working undertake comprehensive assessments.
People accessing crisis support have an assessment in which they are asked about their living conditions, how well they are managing in everyday life, their relationships, symptoms, behaviour, diagnosis and any treatment they are having.

Source guidance references

NICE clinical guidance 136 recommendation 1.5.3.

Data source

Structure
a) and b) Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

A comprehensive assessment includes details of the person's:
  • relationships with others
  • social and living circumstances
  • level of functioning
  • symptoms
  • behaviour
  • diagnosis
  • current treatment.

Inpatient shared decision-making

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People in hospital for mental health care, including service users formally detained under the Mental Health Act, are routinely involved in shared decision-making.

Quality measure

Structure
Evidence of local arrangements to ensure that service users in hospital, including service users formally detained under the Mental Health Act, are routinely involved in shared decision-making.
Outcome
Evidence from experience surveys and feedback that service users in hospital, including service users formally detained under the Mental Health Act, feel routinely involved in shared decision-making.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to routinely involve service users in hospital, including service users formally detained under the Mental Health Act, in shared decision-making.
Mental health and social care professionals ensure they involve service users in hospital, including service users formally detained under the Mental Health Act, in shared decision-making.
Commissioners ensure they commission services that routinely involve service users, including service users formally detained under the Mental Health Act, in shared decision-making.
People in hospital for mental health care feel involved in making decisions about their care, even when they are formally detained under the Mental Health Act.

Source guidance references

NICE clinical guidance 136 recommendation 1.6.3.

Data source

Structure
Local data collection.
Outcome
Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. A question on involvement in decisions is contained within the NHS mental health inpatient survey (Q27).

Definitions

The Mental Health Act 1983 (amended 1995 and 2007).

Contact with staff on wards

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People in hospital for mental health care have daily one-to-one contact with mental healthcare professionals known to the service user and regularly see other members of the multidisciplinary mental healthcare team.

Quality measure

Structure
a) Evidence of local arrangements to ensure that service users in hospital can see a mental healthcare professional known to the service user on a one-to-one basis every day for at least 1 hour.
b) Evidence of local arrangements to ensure that service users in hospital can see their consultant on a one-to-one basis at least once a week for at least 20 minutes.
c) Evidence of local arrangements to ensure that service users in hospital are given an opportunity to meet a specialist mental health pharmacist.
Process
a) Proportion of service users in hospital who saw a mental healthcare professional known to the service user on a one-to-one basis every day for at least 1 hour.
Numerator – the number of people in the denominator who saw a mental healthcare professional known to the service user on a one-to-one basis every day for at least 1 hour.
Denominator – the number of service users in hospital.
b) Proportion of service users in hospital who saw their consultant on a one-to-one basis at least once a week for at least 20 minutes.
Numerator – the number of people in the denominator who saw their consultant on a one-to-one basis at least once a week for at least 20 minutes.
Denominator – the number of service users in hospital.
c) Proportion of service users in hospital who saw a specialist mental health pharmacist.
Numerator – the number of people in the denominator who saw a specialist mental health pharmacist.
Denominator – the number of service users in hospital.
Outcome
a) Evidence from experience surveys and feedback that service users in hospital see a mental healthcare professional known to the service user on a one-to-one basis every day for at least 1 hour.
b) Evidence from experience surveys and feedback that people in hospital see their consultant on a one-to-one basis at least once a week for at least 20 minutes.
c) Evidence from experience surveys and feedback that people in hospital know they can meet a specialist mental health pharmacist.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for service users in hospital to have daily one-to-one contact with mental healthcare professionals known to the service user and regularly see other members of the multidisciplinary mental healthcare team.
Mental healthcare professionals ensure service users in hospital can have daily one-to-one contact with mental healthcare professionals known to the service user and regularly see other members of the multidisciplinary mental healthcare team.
Commissioners ensure they commission services that provide service users in hospital for mental health treatment and care with daily one-to-one contact with mental healthcare professionals known to the service user and the opportunity to see other members of the multidisciplinary mental healthcare team.
People in hospital for mental health care have daily one-to-one contact with mental healthcare professionals known to them and regularly see other members of the multidisciplinary mental healthcare team.

Source guidance references

NICE clinical guidance 136 recommendation 1.6.6.

Data source

Structure
a) to c) Local data collection.
Process
a) to c) Local data collection.
Outcome
a) and b) Local data collection. Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. Questions on time to discuss conditions and treatments are contained within
c) Local data collection.

Definitions

One-to-one meetings should not be undertaken as part of the multidisciplinary ward meetings which are for the clinical administration of the ward.
Recommendation 1.6.6 states:
Offer service users in hospital:
  • daily one-to-one sessions lasting at least 1 hour with a healthcare professional known to the service user
  • regular (at least weekly) one-to-one sessions lasting at least 20 minutes with their consultant
  • an opportunity to meet with a specialist mental health pharmacist to discuss medication choices and any associated risks and benefits.
Daily one-to-one sessions with healthcare professionals known to the service user need not be one session that lasts an hour. The hour contact could be made up of shorter sessions and spread throughout the day.

Meaningful activities on the ward

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People in hospital for mental health care can access meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.

Quality measure

Structure
Evidence of local arrangements to ensure that service users in hospital have access to meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.
Outcome
Evidence from experience surveys and feedback that service users in hospital feel they can access meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.

Description of what the quality statement means for each audience

Service providers ensure systems are in place for service users in hospital to access meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.
Mental healthcare professionals ensure service users in hospital have access to meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.
Commissioners ensure they commission services that provide service users in hospital with meaningful and culturally appropriate activities 7 days a week, not restricted to 9am to 5pm.
People in hospital for mental health care feel they can join in with a range of activities, including creative and leisure activities and exercise, 7 days a week and throughout the day and evenings.

Source guidance references

NICE clinical guidance 136 recommendation 1.6.9.

Data source

Structure
Local data collection.
Outcome
Local data collection. Providers may be able to use questions contained within the national patient surveys available from NHS Surveys. The NHS mental health inpatient survey (Q31 and 32) contains questions on the provision of activities on the ward on weekdays and at the weekend.

Definitions

Meaningful and culturally appropriate activities should include creative and leisure activities, exercise, self-care and community access activities (where appropriate). Activities should be facilitated by appropriately trained health or social care professionals.

Using control and restraint, and compulsory treatment

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People in hospital for mental health care are confident that control and restraint, and compulsory treatment including rapid tranquillisation, will be used competently, safely and only as a last resort with minimum force.

Quality measure

Structure
a) Proportion of professionals using control and restraint, and compulsory treatment including rapid tranquilisation, who are trained to do so.
Numerator – the number of professionals in the denominator who are trained to use control and restraint safely and as a last resort.
Denominator – the number of professionals using control and restraint, and compulsory treatment including rapid tranquilisation.
b) Evidence of local arrangements to ensure control and restraint, and compulsory treatment including rapid tranquillisation, are used as a last resort with minimum force and only after all means of negotiation and persuasion have been tried.
Outcome
Evidence from experience surveys and feedback that service users in hospital feel control and restraint, and compulsory treatment including rapid tranquillisation, are used as a last resort with minimum force.

Description of what the quality statement means for each audience

Service providers ensure systems are in place to train professionals in the safe use of control and restraint, and compulsory treatment including rapid tranquillisation.
Mental healthcare professionals using control and restraint, and compulsory treatment including rapid tranquillisation, ensure they are trained in its safe use and use it as a last resort with minimum force.
Commissioners ensure they commission services that train professionals in the safe use of control and restraint, and compulsory treatment including rapid tranquillisation.
People in hospital for mental health care who need to be controlled or restrained or have treatment without their agreement (such as medication to calm them quickly) receive them only from trained staff. They are only used as a last resort, using minimum force and making sure that the person is safe.

Source guidance references

NICE clinical guidance 136 recommendation 1.8.10

Data source

Structure
a) The NHSLA risk management standards contain requirements on the processes in place in mental health and learning disability organisations for managing risks associated with rapid tranquilisations (Standard 4, criterion 8). Providers may be able to use questions contained within the national NHS staff survey available from NHS Surveys. The NHS staff survey for mental health trusts (Q5) collects information on training to prevent or handle violence and aggression to staff and service users.
b) Local data collection.
Outcome
Local data collection.

Combating stigma

This quality statement is taken from the service user experience in adult mental quality standard. The quality standard outlines the level of service that people using the NHS mental health services should expect to receive and should be read in full.

Quality statement

People using mental health services feel less stigmatised in the community and NHS, including within mental health services.

Quality measure

Structure
Evidence of local arrangements to ensure that a strategy is developed with other local organisations to combat stigma in the community and NHS that is associated with mental health problems and using mental health services.
Outcome
Evidence from experience surveys and feedback that service users feel less stigmatised in the community and NHS, including within mental health services.

Description of what the quality statement means for each audience

Service providers ensure strategies are in place to work with other local organisations to combat the stigma in the community and NHS that is associated with mental health problems and using mental health services.
Mental health and social care professionals ensure they work to combat the stigma in the community and NHS that is associated with mental health problems and using mental health services.
Commissioners ensure they commission services that work with other local organisations to combat the stigma in the community and NHS that is associated with mental health problems and using mental health services
People using mental health services feel less stigmatised in the community and NHS, including within mental health services.

Source guidance references

NICE clinical guidance 136 recommendations 1.1.7 and 1.1.9.

Data source

Structure
Local data collection.
Outcome
Local data collection.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

27 March 2014 Minor maintenance updates
26 March 2014 Minor maintenance updates
19 February 2013 Minor maintenance updates
29 May 2012 Minor maintenance updates

Supporting information

Glossary

The Equality Act 2010 replaces all previous anti-discrimination legislation and includes a public sector equality duty requiring public bodies to have due regard to the need to eliminate discrimination and to advance equality of opportunity and foster good relations between people who share certain protected characteristics and those who do not. The protected characteristics are age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation. The Act provides an important legal framework which should improve the experience of all mental health service users, particularly those from black and minority ethnic communities.

Care and support of service users across all points on the care pathway

View the 'Care and support of service users across all points on the care pathway' path

Access to care

Access to care

Access to care

Offering a timely appointment with mental health services

When people are referred to mental health services, ensure that:
  • they are given or sent a copy of the referral letter when this is sent to mental health services
  • they are offered a face-to-face appointment with a professional in mental health services taking place within 3 weeks of referral
  • they are informed that they can change the date and time of the appointment if they wish
  • any change in appointment does not result in a delay of more than 2 weeks.

Ensuring a comprehensive appointment letter

When people are sent an appointment letter for mental health services it should:
  • give the name and professional designation of the person who will assess them
  • include information about the service, including a website address where available, and different options about how to get there
  • explain the process of assessment using plain language
  • specify all the information needed for the assessment, including about current medication
  • address the likely anxiety and concern often experienced by people attending mental health services for assessment
  • explain that although they can be accompanied by a family member, carer or advocate if they wish for all or part of the time, it is preferable to see the person alone for some of the assessment
  • ask if they will require anything to support their attendance (for example, an interpreter, hearing loop, wider access)
  • give a number to ring if they have problems getting to the appointment or wish to change it.

Working in partnership with primary care and local voluntary organisations

Mental health services should establish close working relationships with primary care services to ensure:
  • agreed processes for referral, consistent with those described above, are in place, and
  • primary care professionals can provide information about local mental health and social care services to the people they refer.
Local mental health services should work with primary care and local third sector, including voluntary, organisations to ensure that:
  • all people with mental health problems have equal access to services based on clinical need and irrespective of gender, sexual orientation, socioeconomic status, age, background (including cultural, ethnic and religious background) and any disability
  • services are culturally appropriate.

Ensuring equal access to services

Take into account the requirements of the Equality Act 2010 and make sure services are equally accessible to, and supportive of, all people using mental health services.

Quality standards

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/quality-standard-node-single

Implementation tools

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Assessment

Assessment

Assessment

Greeting and engaging service users

On arrival at mental health services for assessment, service users should be greeted and engaged by reception and other staff in a warm, friendly, empathic, respectful and professional manner, anticipating possible distress.
Ensure that if a service user needs to wait before an assessment, this is for no longer than 20 minutes after the agreed appointment time; explain the reasons for any delay.
Ensure that waiting rooms are comfortable, clean and warm, and have areas of privacy, especially for those who are distressed or who request this, or are accompanied by children.

Explaining the process of assessment

Before the assessment begins, the health or social care professional undertaking the assessment should ensure that the service user understands:
  • the process of assessment and how long the appointment will last
  • that the assessment will cover all aspects of their experiences and life
  • confidentiality and data protection as this applies to them
  • the basic approach of shared decision-making
  • that although they can be accompanied by a family member, carer or advocate for all or part of the time, it is preferable to see the person alone for some of the assessment
  • that they can refuse permission for any other member of staff, such as a student, to be present.

Carrying out the assessment

When carrying out an assessment:
  • ensure there is enough time for the service user to describe and discuss their problems
  • allow enough time towards the end of the appointment for summarising the conclusions of the assessment and for discussion, with questions and answers
  • explain the use and meaning of any clinical terms used
  • explain and give written material in an accessible format about any diagnosis given
  • give information about different treatment options, including drug and psychological treatments, and their side effects, to promote discussion and shared understanding
  • offer support after the assessment, particularly if sensitive issues, such as childhood trauma, have been discussed.

After the assessment

If a service user is unhappy about the assessment and diagnosis, give them time to discuss this and offer them the opportunity for a second opinion.
Copy all written communications with other health or social care professionals to the service user at the address of their choice, unless the service user declines this.
Inform service users of their right to a formal community care assessment (delivered through local authority social services), and how to access this.
Inform service users how to make complaints and how to do this safely without fear of retribution.

Quality standards

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/quality-standard-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Community care

Community care

Community care

Communicating with service users

When communicating with service users use diverse media, including letters, phone calls, emails or text messages, according to the service user's preference.

Developing a care plan

Develop care plans jointly with the service user, and:
  • include activities that promote social inclusion such as education, employment, volunteering and other occupations such as leisure activities and caring for dependants
  • provide support to help the service user realise the plan
  • give the service user an up-to-date written copy of the care plan, and agree a suitable time to review it.

Developing a crisis plan

For people who may be at risk of crisis, a crisis plan should be developed by the service user and their care coordinator, which should be respected and implemented, and incorporated into the care plan. The crisis plan should include:
  • possible early warning signs of a crisis and coping strategies
  • support available to help prevent hospitalisation
  • where the person would like to be admitted in the event of hospitalisation
  • the practical needs of the service user if they are admitted to hospital (for example, childcare or the care of other dependants, including pets)
  • details of advance statements and advance decisions (for more information see the recommendations on decisions, capacity and safeguarding in this pathway)
  • whether and the degree to which families or carers are involved
  • information about 24-hour access to services
  • named contacts.

Supporting self-management and choice of care

Support service users to develop strategies, including risk- and self-management plans, to promote and maintain independence and self-efficacy, wherever possible. Incorporate these strategies into the care plan.
Ensure that service users routinely have access to their care plan and care record, including electronic versions. Care records should contain a section in which the service user can document their views and preferences, and any differences of opinion with health and social care professionals.
If they are eligible, give service users the option to have a personal budget or direct payment so they can choose and control their social care and support, with appropriate professional and peer support as needed.

Ensuring continuity of care

Health and social care providers should ensure that service users:
  • can routinely receive care and treatment from a single multidisciplinary community team
  • are not passed from one team to another unnecessarily
  • do not undergo multiple assessments unnecessarily.

Ensuring access to recommended treatments

Ensure that service users have timely access to the psychological, psychosocial and pharmacological interventions recommended for their mental health problem in NICE guidance.

Ensuring culturally appropriate care

Mental health services should work with local third sector, including voluntary, black and minority ethnic and other minority groups to jointly ensure that culturally appropriate psychological and psychosocial treatments, consistent with NICE guidance and delivered by competent practitioners, are provided to service users from these groups.
Mental health and social care professionals inexperienced in working with service users from different cultural, ethnic, religious and other diverse backgrounds should seek advice, training and supervision from health and social care professionals who are experienced in working with these groups.

Quality standards

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/quality-standard-node-multiple

Implementation tools

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Assessment and referral in crisis

Assessment and referral in crisis

Assessment and referral in crisis

Crisis resolution and home treatment teams

Health and social care providers should ensure that crisis resolution and home treatment teams are accessible 24 hours a day, 7 days a week, and available to service users in crisis regardless of their diagnosis.

Crisis assessment

If assessment in the service user's home environment is not possible, or if they do not want an assessment at home, take full consideration of their preferences when selecting a place for assessment.
Assessment in crisis should be undertaken by experienced health and social care professionals competent in crisis working, and should include an assessment of the service user's relationships, social and living circumstances and level of functioning, as well as their symptoms, behaviour, diagnosis and current treatment.
Immediately before assessing a service user who has been referred in crisis, find out if they have had experience of acute or non-acute mental health services, and consult their crisis plan and advance statements or advance decisions if they have made them. Find out if they have an advocate and contact them if the service user wishes. Ask if the service user has a preference for a male or female health or social care professional to conduct the assessment, and comply with their wishes wherever possible.
When undertaking a crisis assessment:
  • address and engage service users in a supportive and respectful way
  • provide clear information about the process and its possible outcomes, addressing the individual needs of the service user, as set out in the recommendations on assessment in this pathway
  • take extra care to understand and emotionally support the service user in crisis, considering their level of distress and associated fear, especially if they have never been in contact with services before, or if their prior experience of services has been difficult and/or they have had compulsory treatment under the Mental Health Act (1983; amended 1995 and 2007).

Supporting service users in a crisis

To avoid admission, aim to:
  • explore with the service user what support systems they have, including family, carers and friends
  • support a service user in crisis in their home environment
  • make early plans to help the service user maintain their day-to-day activities, including work, education, voluntary work, and other occupations such as caring for dependants and leisure activities, wherever possible.
At the end of a crisis assessment, ensure that the decision to start home treatment depends not on the diagnosis but on:
  • the level of distress
  • the severity of the problems
  • the vulnerability of the service user
  • issues of safety and support at home
  • the person's cooperation with treatment.
When a person is referred in crisis they should be seen by specialist mental health secondary care services within 4 hours of referral.
Health and social care providers should support direct self-referral to mental health services as an alternative to accessing urgent assessment via the emergency department.
Health and social care providers should provide local 24-hour helplines, staffed by mental health and social care professionals, and ensure that all GPs in the area know the telephone number.
Consider the support and care needs of families or carers of service users in crisis. Where needs are identified, ensure they are met when it is safe and practicable to do so.

Quality standards

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/quality-standard-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Assessment and treatment under the Mental Health Act

Assessment and treatment under the Mental Health Act

Assessment and treatment under the Mental Health Act

Detain service users under the Mental Health Act (1983; amended 1995 and 2007) only after all alternatives have been fully considered in conjunction with the service user if possible, and with the family or carer if the service user agrees. Alternatives may include:
  • medicines review
  • respite care
  • acute day facilities
  • home treatment
  • crisis houses.
Carry out an assessment for possible detention under the Mental Health Act (1983; amended 1995 and 2007) in a calm and considered way. Respond to the service user's needs and treat them with dignity and, whenever possible, respect their wishes.
Explain to service users, no matter how distressed, why the compulsory detention or treatment is being used. Repeat the explanation if the service user appears not to have understood or is pre-occupied or confused. Ask if the service user would like a family member, carer or advocate with them.
When detaining a service user under the Mental Health Act (1983; amended 1995 and 2007) inform the receiving mental health service about the service user so they are expecting them and ready to welcome them to the service.
When detaining a service user under the Mental Health Act (1983; amended 1995 and 2007):
  • give them verbal and written information appropriate to the section of the Act used, including 'patient rights leaflets' detailing what is happening to them and why, and what their rights are
  • repeat this information if they appear not to have understood or are pre-occupied or confused
  • give them, and their families or carers if they agree, information about the legal framework of the Mental Health Act (1983; amended 1995 and 2007)
  • ensure they have access to an Independent Mental Health Advocate (IMHA).
Inform service users detained under the Mental Health Act (1983; amended 1995 and 2007) of their right to appeal to a mental health tribunal and support them if they appeal; provide information about the structure and likely speed of the appeals process.
Inform the service user that if they are dissatisfied with their care and wish to make a complaint while under the Mental Health Act (1983; amended 1995 and 2007) they should, in the first instance, direct their complaint to the service detaining them. If they are dissatisfied with the service's response to their complaint, inform them they can complain to the Care Quality Commission and explain how to do this.
When a service user is admitted to a 'place of safety' ensure they are assessed for the Mental Health Act (1983; amended 1995 and 2007) as soon as possible, and certainly within 4 hours.
After application of the Mental Health Act (1983; amended 1995 and 2007) ensure that:
  • transition to the inpatient unit is smooth, efficient and comfortable
  • family and carers can travel with the service user if safe to do so
  • the police are involved only if the safety of the service user, family, carers, dependent children or health and social care professionals is an important consideration and cannot be managed by other means, such as involving more professionals.

Control and restraint, and compulsory treatment

Control and restraint, and compulsory treatment including rapid tranquillisation, should be used as a last resort, only after all means of negotiation and persuasion have been tried, and only by healthcare professionals trained and competent to do this. Document the reasons for such actions.
When a service user is subject to control and restraint, or receives compulsory treatment including rapid tranquillisation under the Mental Health Act (1983; amended 1995 and 2007):
  • recognise that they may consider it a violation of their rights
  • use minimum force
  • try to involve healthcare professionals whom the service user trusts
  • make sure the service user is physically safe
  • explain reasons for the episode of compulsory treatment to the service user and involved family members or carers
  • offer to discuss episodes of compulsory treatment with the service user at the time of discharge and do so in a calm and simple manner
  • ensure training in restraint involves service users.
After any episode of control and restraint, or compulsory treatment including rapid tranquillisation:
  • explain the reasons for such action to the service user and offer them the opportunity to document their experience of it in their care record, and any disagreement with healthcare professionals
  • ensure that other service users on the ward who are distressed by these events are offered support and time to discuss their experience.

Quality standards

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/quality-standard-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Hospital care

Hospital care

Hospital care

Welcoming the service user to the ward

When a service user enters hospital, greet them using the name and title they prefer, in an atmosphere of hope and optimism, with a clear focus on their emotional and psychological needs, and their preferences. Ensure that the service user feels safe and address any concerns about their safety.
Give verbal and written information to service users, and their families or carers where agreed by the service user, about:
  • the hospital and the ward in which the service user will stay
  • treatments, activities and services available
  • expected contact from health and social care professionals
  • rules of the ward (including substance misuse policy)
  • service users' rights, responsibilities and freedom to move around the ward and outside
  • meal times
  • visiting arrangements.
Make sure there is enough time for the service user to ask questions.
Shortly after service users arrive in hospital, show them around the ward and introduce them to the health and social care team as soon as possible and within the first 12 hours if the admission is at night. If possible, this should include the named healthcare professional who will be involved throughout the person's stay.
Commence formal assessment and admission processes within 2 hours of arrival.

Undertaking shared decision-making

Undertake shared decision-making routinely with service users in hospital, including, whenever possible, service users who are subject to the Mental Health Act (1983; amended 1995 and 2007).

Ensuring regular coordinated person-centred care

All health and social care professionals who work in a hospital setting should be trained as a team to use the same patient-centred approach to treatment and care.
Offer service users in hospital:
  • daily one-to-one sessions lasting at least 1 hour with a healthcare professional known to the service user
  • regular (at least weekly) one-to-one sessions lasting at least 20 minutes with their consultant
  • an opportunity to meet with a specialist mental health pharmacist to discuss medication choices and any associated risks and benefits.
Ensure that the overall coordination and management of care takes place at a regular multidisciplinary meeting led by the consultant and team manager with full access to the service user's paper and/or electronic record. Service users and their advocates should be encouraged to participate in discussions about their care and treatment, especially those relating to the use of the Mental Health Act (1983; amended 1995 and 2007). However, these meetings should not be used to see service users or carers as an alternative to their daily meeting with a known healthcare professional or their weekly one-to-one meeting with their consultant.
Health and social care providers should ensure that service users in hospital have access to the pharmacological, psychological and psychosocial treatments recommended in NICE guidance provided by competent health or social care professionals. Psychological and psychosocial treatments may be provided by health and social care professionals who work with the service user in the community.

Ensuring access to meaningful activities and choice of food

Ensure that service users in hospital have access to a wide range of meaningful and culturally appropriate occupations and activities 7 days per week, and not restricted to 9 am to 5 pm. These should include creative and leisure activities, exercise, self-care and community access activities (where appropriate). Activities should be facilitated by appropriately trained health or social care professionals.
Ensure that service users have access to the internet and telephone during their stay in hospital.
Ensure that hospital menus include a choice of foods, and that these are acceptable to service users from a range of ethnic, cultural and religious backgrounds and with specific physical health problems. Consider including service users in planning menus.

Ensuring continuity with community care

Service users receiving community care before hospital admission should be routinely visited while in hospital by the health and social care professionals responsible for their community care.

Listening to service users' views

Ensure that all service users in hospital have access to advocates who can regularly feed back to ward professionals any problems experienced by current service users on that ward. Advocates may be formal Independent Mental Health Advocates (IMHAs), or former inpatients who have been trained to be advocates for other service users not detained under the Mental Health Act (1983; amended 1995 and 2007).

Implementation tools

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Discharge and transfer of care

Discharge and transfer of care

Discharge and transfer of care

Anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people using mental health services. Ensure that:
  • such changes, especially discharge, are discussed and planned carefully beforehand with the service user and are structured and phased
  • the care plan supports effective collaboration with social care and other care providers during endings and transitions, and includes details of how to access services in times of crisis
  • when referring a service user for an assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them.
Agree discharge plans with the service user and include contingency plans in the event of problems arising after discharge. Ensure that a 24-hour helpline is available to service users so that they can discuss any problems arising after discharge.
Before discharge or transfer of care, discuss arrangements with any involved family or carers. Assess the service user's financial and home situation, including housing, before they are discharged from inpatient care.
Give service users clear information about all possible support options available to them after discharge or transfer of care.
When plans for discharge are initiated by the service, give service users at least 48 hours' notice of the date of their discharge from a ward.
When preparing a service user for discharge, give them information about the local patient advice and liaison service (PALS) and inform them they can be trained as an advocate or become involved in monitoring services if they choose.

Implementation tools

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multiple

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node

Paths in this pathway

Pathway created: March 2012 Last updated: March 2014

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

Recently viewed