Routine Enquiry, the Care Programme Approach (CPA) and Mental Health Services

Guest blog by Charlie Brooker, Honorary Professor, Centre for Sociology and Criminology, Royal Holloway, University of London

The CPA has been a requirement for nearly 30 years and aimed to ensure that people with a serious mental health problem received a care plan/package. In 2008 it was amended such that it became national Department of Health policy, that, once trained, all mental health staff would conduct Routine Enquiry (RE) with all those people subject to the Care Programme Approach (CPA). Routine Enquiry involves asking direct questions in relation to the abuse/sexual violence experience of a specified population group when they present to a service.

It is sad to say, that despite this policy exhortation, RE has not become part of routine clinical practice across England. Our latest national survey of the implementation of RE (posted here on Dr Larkin’s website) and undertaken in 2017 shows disappointing results:

• the vast majority of Trusts do not know what proportion of staff have been trained in RE
• when RE occurs it is not routinely audited
• returns on RE to NHS Digital have diminished from 43% of all Mental Health Trusts to 11%.
• Although half of Trusts stated that they had formal trauma pathways within their services only one of these provided us with an example (and this was for Domestic Violence).

The role of the CQC

This is clearly an area where the Care Quality Commission (CQC) should be playing a role. The CQC inspects in relation to four main key areas of enquiry: safety, effectiveness, caring and well-led. Under ‘safety’, the following indicator is outlined: are there reliable systems in place to keep people safe and safeguarded from abuse? However, no CQC inspection report comments on the adequacy of RE, nor is it investigated. Finally, since the introduction of RE into the CPA as a requirement in 2008 there has been no national policy initiative that has addressed either the topic of RE or the development of Trauma Services.  That this is the case is confirmed by the National Audit Office in their recent review of policy for mental health service delivery.

However, there is also a strong case for leadership to emanate from within the mental health professions of which mental health nursing forms by far the largest element. In a recent review, my colleague, Ted White and I, took mental health nursing to task for their almost virtual absence in this arena.

Sharing best practice

There are several excellent examples of mental health nursing leadership where trauma-led practice has been implemented. One such example is the mental health nursing degree programme at Stirling University led by Margaret Conlon.

Another good example would be the work undertaken by Sean Page in North Wales on in-patient wards. The aim of the research was to co-produce qualitative understanding aimed at reducing the risk of sexual violence within mental health in-patient settings.

However, the examples above are rare and chime with the findings of the CPA survey we publish.

The only policy document where RE is mandated is the CPA guidance. However, ‘The Community Mental Health Framework for Adults and Older Adults’  published in 2019 by NHS England, NHS Improvement and the National Collaborating Centre for Mental Health means that the CPA will soon become history. The vague paragraph below summarises the demise of the CPA as outlined in the Framework document:

‘This Framework therefore proposes replacing the CPA for community mental health services, while retaining its sound theoretical principles based on good care coordination and high-quality care planning’ (see page 7)

On the Royal College of Psychiatrist’s website we are informed that the full implementation guidance will soon be forthcoming. This notice has not changed for several months and no doubt planning has been hampered by issues related to Covid-19.

It is possible that it is too early to judge whether RE will appear in the implementation guidance. I hope this is the case. However, it has to be pointed that RE, even when mandated through the CPA, was still inadequately put into practice. Our conclusion in the paper posted on this website was as follows:

“It seems self-evident that knowing about important adverse and traumatic events is essential if mental health services are to develop meaningful formulations and effective treatment plans. It is unacceptable, in 2020, that the extent to which service users are being asked about abuse and violence remains something of a mystery at both local and national levels. The limited amount of information that is being gathered suggests that staff training continues to be lacking and that the majority of service users are still not being asked and are therefore not being offered appropriate support and treatment.”

We look forward to seeing how these sentiments are addressed in the new Implementation Guidance for the Community Mental Health Framework.