A complex set of ideological, economic, social and political factors combined together to bring forward the era of community mental healthcare in the UK from the second half of the last century onwards (Rogers and Pilgrim 2001). With origins clearly linked to the process of deinstitutionalization for people with long-term mental illnesses, pioneering community mental health nursing services appeared in the mid 1950s from hospital bases in Surrey and Devon (Hunter 1974). In the decades following, repeated nationwide surveys pointed to a spectacular growth in CMHN numbers. While only a handful of mental health nurses were plying their trade in people’s homes by the end of the 1950s, 7000 were doing so in England and Wales some 40 years later (Brooker and White 1997).

The remarkable rise in CMHN numbers was paralleled by a growth in specialization. Survey data generated in 1990 revealed that one in seven was, at that time, specializing in a therapeutic approach (most commonly family therapy, behaviour therapy or counselling). Just over 40% also reported specializing with a particular client group, of whom almost 60% were working with older people (White 1993). These trends were confirmed in the most recent national survey of the workforce, completed in 1996 (Brooker and White 1997). Larger numbers than in 1990 reported working with people with severe mental illnesses, while fewer described themselves as specializing in the care of older people, or in the care of children and adolescents. Respondents in 1996 also reported working specifically with people with substance misuse problems, with mentally disordered offenders, with people with eating disorders and with the homeless. Therapeutic specialization was also found to have increased, with counselling and ‘psychosocial interventions’ (discussed in more detail below) the most commonly cited approaches used.

Surveys of the UK’s CMHN workforce in 1990 and 1996 took place at critical junctures. Findings from the first study revealed that CMHNs were moving closer to colleagues based in primary care. In the 5 years to 1990 referrals to CMHNs from general medical practitioners (GPs) had increased to the extent that over a third of referrals were reported to have originated from this source. Compared to clients referred by psychiatrists, people referred to CMHNs by GPs were less likely to have had previous admissions to hospital, to be experiencing ‘chronic mental illness’ or to have a diagnosis of schizophrenia. White also found that, among CMHNs working in England at the start of the 1990s, around one-quarter had no clients on their caseloads with a diagnosis of schizophrenia (White 1993).

These were controversial findings. Working autonomously and receiving independent referrals from GPs helped further community mental health nursing’s claims to professional status (Godin 1996). Many commentators also saw in White’s 1990 data clear evidence of a worrying drift away from the provision of care to the most needy service users: people with severe, enduring, mental health problems. For example, Gournay described the apparent lack of CMHN focus on this group as ‘scandalous’ (Gournay 1994). Drawing on findings generated from a randomized controlled trial of CMHNs using counselling interventions to people with common mental disorders in primary care, Gournay also reported that the benefits to clients from seeing CMHNs were no greater than the benefits of receiving GP-only treatment (Gournay and Brooking 1994). For the sternest critics of community mental health nursing in the early and mid 1990s, therefore, CMHNs were not only seeing too many of the wrong sort of clients – the ‘worried well’ – but were also using clinical interventions with this group which did not seem to generate any positive health outcome. At this juncture readers are encouraged to consider discussion point 1 given in the ‘Discussion points’ section which appears at the end of this chapter.

Professional concerns in the early and mid 1990s of a possible loss of CMHN focus resonated with policy makers’ concerns that the post-war community care experiment was not working as intended. From the beginning of the last decade onwards mental healthcare emerged as a UK health and social policy priority. Specific actions initiated in the years up to the mid 1990s to facilitate the delivery of more effective and integrated services to people with severe mental health problems living in the community are summarized in Box 18.1.

By the 1990s, interagency and interprofessional community mental health teams (CMHTs) had become the accepted model for organizing specialist services at the local level, and were described as such in policy guidance of that period. Most CMHNs, having previously worked in single-profession teams, soon found themselves grouped together with psychiatrists, mental health social workers, occupational therapists, clinical psychologists and others (Brooker and White 1997).

CMHTs were set up in the belief that they are the best way to deliver flexible and accessible local mental health services. Their appearance was not met with universal support, however. In an influential early critique Galvin and McCarthy argued that CMHTs are prone to inadequate planning and poor management (Galvin and McCarthy 1994). While broadly supportive of the CMHT model, Onyett and colleagues noted the challenges facing CMHTs and those who manage them, including the tensions for practitioners between being members of both a team and a profession (Onyett et al 1997). Some professionals, including those traditionally enjoying high levels of autonomy, also struggled to adjust to the more managed environment encountered in the typical interprofessional team setting. In addition, CMHTs were soon found to be struggling to reconcile conflicting policy priorities. While teams were clearly directed in central government guidance to focus their collective energies on meeting the needs of the severely mentally ill, they simultaneously found themselves being pulled towards ongoing work with people with distressing, but more transient, problems in primary care settings (Hannigan 1999). Interprofessional team working is the focus of discussion point 2 appearing at the end of this chapter (for further information on interprofessional working see Chapter 21).

Mental health services in the community are typically provided by members of multiple occupational groups, working in different agencies and physically located in workplaces which are geographically dispersed. These factors combine to make the organization of services for individuals and families a highly complex task. Widespread recognition of the difficulties associated with care coordination led to the appearance of the care programme approach (CPA), which was first launched in England at the start of the 1990s. The four key elements of the CPA, as these have been summarized in successive documents, are described in Box 18.2.

While members of any occupational group have been able to fulfil the care coordinator role, the task of negotiating and overseeing interprofessional plans of care soon became a central component of the day-to-day work of CMHNs.

At the same time as doubt was being cast on the value of CMHNs delivering counselling-style interventions to people with problems such as mild to moderate depression and anxiety (Gournay and Brooking 1994), evidence was also emerging of the value of training nurses to provide behavioural family therapy to people with severe mental illnesses and their carers (Brooker et al 1994). It has since become customary to pool together a range of clinical and social approaches to working with people with severe and disabling mental health problems under the broad title of psychosocial interventions (PSIs). The term PSI referred initially to family interventions alone, but has more recently assumed a much wider meaning (Brooker 2001). Box 18.3 draws on Brooker’s work to outline the main components of a PSI approach.

The theory and research base underpinning the individual elements of PSIs is well established. For example, the concept of expressed emotion which underpins a range of family interventions aimed at people with schizophrenia and their carers was first developed in the 1950s (Pharoah et al 2006). Similarly, the psychological management strategies emphasized in PSIs invariably include the use of cognitive behavioural techniques, an approach which has been developing over a number of decades (Jones et al 2004).

Beyond the necessity of being registered on the appropriate part of the Nursing and Midwifery Council Register, no mandatory education requirement has ever existed for UK mental health nurses aiming to practise in the community. However, since the early 1970s optional university-based courses have been available, with established programmes continuing to this day in many parts of the country. Important new evidence-based PSI courses also started to appear from the early 1990s, aimed at nurses and others wishing to develop their skills in working with people with schizophrenia and other severe mental disorders. With their origins in courses developed in London and Manchester, programmes of this type (often badged as Thorn courses, after the funding given to early schemes by the Sir Jules Thorn Charitable Trust) emerged, their curricula including training in evidence-based assessment and care management, psychological interventions and in family work (O’Carroll et al 2004).

Mental healthcare remains a key policy and practice priority. Shortly after the 1997 election, notification of the New Labour government’s early intentions came with the publication of Modernising Mental Health Services: Safe, Sound and Supportive (Department of Health 1998). This drew attention to the stigma and misunderstanding which many people with mental health difficulties experience. The document also noted that poverty and social exclusion play a powerful part in precipitating and worsening mental ill health. The government also referred in this publication to its plans for a review of the Mental Health Act 1983 in England and Wales, and restated its intention to ‘address the responsibility on individual patients to comply with their programmes of care’ (Department of Health 1998: 40).

The pace of change in mental health policy and practice in the last decade has been rapid (Hannigan and Allen 2006). Modernising Mental Health Services – which included the controversial claim that community mental healthcare in the UK had failed (see discussion point 3 below) – was soon followed in England by the launch of A National Service Framework (NSF) for Mental Health (Department of Health 1999). Similar documents have appeared elsewhere in the UK. The devolved administration in Wales, for example, produced a strategy for the mental healthcare of adults (National Assembly for Wales 2001) followed by both an original and a revised (Welsh Assembly Government 2005) NSF for the provision of services to working age adults. In Scotland, mental healthcare has been made a policy priority most recently through the construction of Delivering for Mental Health (Scottish Executive 2006a), while in Northern Ireland mental health has been identified as a key area for development in the wide-ranging Investing for Health (Department of Health, Social Services and Public Safety 2002).

National frameworks are important documents which usually set out targets and timescales for the improvement of services. For example, England’s Mental Health NSF of 1999 contained seven standards associated with five areas. These are summarized in Box 18.4.

The framework also set out a series of fundamental values which should underpin the provision of mental health services, and established a set of guiding principles. These are summarized in Box 18.5.

Under its programme of modernizing services, policy makers have also continued to promote the use of evidence in practice. A key part of this process has been the production of national clinical guidelines, which in England and Wales has been pursued through the work of the National Institute for Health and Clinical Excellence (NICE). Devolution has proved significant here, too. For example, in Scotland the responsibility to generate guidelines for practice falls to NHS Quality Improvement Scotland. This body advises health service organizations on the suitability in the Scottish context of NICE guidance developed specifically for use south of the border.

NICE in England and Wales has a rolling programme of reviews, and thus far has produced guidance on the care of people with a wide range of mental health problems. Box 18.6 details some of these documents, and includes details of the website from where copies can be downloaded.

The NICE document on the care of people with schizophrenia, a revised version of which is expected in 2009, is being formally reviewed as part of NICE’s commitment to updating its guidance and provides clear recommendations on the types of service which CMHNs (and other members of the health and social care workforce) should be providing. This guidance reaffirms the value of PSI approaches and includes various recommendations, which are summarized in Box 18.7. Readers are also encouraged to consider the issues raised in discussion point 4 below on the relationships between national-level guidelines and everyday practice.