Delivery of Psychiatric Services and the Royal College of Psychiatrists

Overview

The delivery of psychiatric services is the responsibility of various mental health Trusts in partnership with Social Services in different parts of the country. Since the Health and Care Act 2022, Integrated Care Systems (ICSs) have taken on a central planning role, bringing together NHS, local authority, and voluntary sector providers to plan and commission mental health services across each region. Mental health is a core component of the NHS Long Term Plan (2019), which committed to significant expansion of community-based provision and early intervention services.

The Royal College of Psychiatrists

The Royal College of Psychiatrists is based at 17 Belgrave Square, London SW1X 8PG (Tel: 020 7235 2351; Fax: 020 7245 1231; Email: rcpsych@rcpsych.ac.uk). It is the professional and educational body for psychiatrists in the United Kingdom and Ireland, responsible for setting standards of training, supporting continuing professional development (CPD), and providing guidance on clinical practice.

From the academic and management perspective, the College has 12 divisions, including the Republic of Ireland, Northern Ireland, Wales and Scotland Divisions.

The College Faculties

The College has 10 faculties, each responsible for a sub-specialty of psychiatry:

1. Academic Psychiatry
2. Addictions
3. Child and Adolescent Psychiatry
4. Forensic Psychiatry
5. General & Community Psychiatry
6. Liaison Psychiatry
7. Psychiatry of Learning Disability
8. Psychiatry of Old Age
9. Psychotherapy
10. Rehabilitation & Social Psychiatry

College Sections

The College has sections for emerging or specialist areas:

1. Perinatal Psychiatry
2. Eating Disorders (established June 2007)
3. Neuropsychiatry (from July 2008)

Special Interest Groups

There are further special interest groups, including:

1. Adolescent Forensic Psychiatry
2. Gay & Lesbian Mental Health
3. Management in Psychiatry
4. Mental Health Informatics
5. Philosophy of Psychiatry
6. Private and Independent Practice
7. Psychopharmacology
8. Spirituality
9. Transcultural Psychiatry
10. Women in Psychiatry

NHS Mental Health Service Structure

Mental health services in the NHS are organised across a spectrum from primary care support through to highly specialist inpatient and forensic settings. The key service types are outlined below.

Community Mental Health Teams (CMHTs)

CMHTs are the backbone of secondary mental health care. They provide assessment and ongoing treatment for adults with moderate to severe mental health problems in the community, working in partnership with GPs, social services, housing, and the voluntary sector. Teams typically include consultant psychiatrists, specialty doctors, community psychiatric nurses (CPNs), social workers, occupational therapists, clinical psychologists, and support workers.

Crisis Resolution and Home Treatment Teams (CRHTTs)

CRHTTs provide intensive community-based support during acute mental health crises, aiming to prevent hospital admission where it is safe to do so. They can provide daily or twice-daily visits and are available 24 hours a day. Where admission is avoided, the CRHTT effectively functions as the "gatekeeper" to inpatient beds.

Assertive Outreach Teams (AOTs)

AOTs (also called Assertive Community Treatment or ACT teams) work with patients who have severe and enduring mental illness — typically psychosis — who have difficulty engaging with standard CMHT services. They maintain proactive, assertive contact, often visiting patients at home, and have smaller caseloads than CMHTs to enable more intensive support. Following NHS reorganisation, some areas have integrated AOT functions back into CMHTs.

Early Intervention in Psychosis (EIP) Teams

EIP teams aim to detect and treat a first episode of psychosis within a maximum of two weeks of referral (the NHS Long Term Plan target). They work with young people and adults typically between the ages of 14 and 65 (or 35 in some areas, depending on service configuration), providing a package of care for a period of three years that includes pharmacological treatment, psychological therapy (particularly CBT for psychosis), family intervention, and supported employment or education.

Psychiatric Liaison Services

Liaison psychiatry teams are based in general hospitals and provide rapid assessment and management of mental health presentations in medical and surgical settings — including emergency departments, medical wards, and outpatient clinics. The "Core 24" standard (from the Five Year Forward View for Mental Health, 2016) mandates that all acute hospitals have a 24/7 liaison psychiatry service capable of assessing patients within one hour of urgent referral.

Inpatient Psychiatric Units

Inpatient wards provide a safe environment for assessment and treatment of acute mental illness when community management is not sufficient. Most general adult inpatient units are organised by geography within a Trust. Patients may be admitted informally (voluntarily) or formally under the Mental Health Act 1983. Specialist inpatient services include Psychiatric Intensive Care Units (PICUs), rehabilitation wards, and mother and baby units.

Forensic Psychiatry Services

Forensic services provide assessment and treatment for individuals who have committed or are at risk of committing serious offences in the context of mental disorder. They operate across three levels of security: low, medium, and high (the latter including Broadmoor, Rampton, and Ashworth High Secure Hospitals). Forensic teams also provide community follow-up for conditionally discharged restricted patients and consultative opinions to courts and prisons.

Child and Adolescent Mental Health Services (CAMHS)

CAMHS is organised into four tiers, reflecting the level of need and service intensity:

• Tier 1: Universal services provided by non-specialist professionals — GPs, school nurses, teachers, and voluntary sector workers — addressing mild or emerging mental health difficulties.
• Tier 2: Primary-level CAMHS, often provided by single practitioners working in community settings (e.g. GP practices, schools, youth services), including primary mental health workers and CAMHS outreach.
• Tier 3: Specialist multidisciplinary CAMHS teams based in community or outpatient settings, providing assessment and treatment for children and young people with complex or persistent problems.
• Tier 4: Highly specialist inpatient or day patient services for the most severe presentations, including acute adolescent inpatient units, eating disorder inpatient services, and CAMHS PICUs.

The Care Programme Approach (CPA)

The Care Programme Approach (CPA) is the framework used to coordinate the care of people with severe mental health problems in England. Introduced in 1991 and revised in 2008, it involves a formal care planning process that includes:

• A comprehensive assessment of health and social care needs
• A written care plan agreed with the patient (and carers where appropriate)
• Allocation of a named care coordinator (usually a CPN or social worker)
• Regular review of the care plan

Not all patients under secondary care require the full CPA framework — local guidance determines thresholds. Section 117 of the Mental Health Act 1983 provides a statutory duty for NHS bodies and local authorities to provide aftercare for patients who have been detained for treatment (under sections 3, 37, 45A, 47, or 48). Section 117 aftercare is free of charge and cannot be withdrawn until both agencies agree that it is no longer required.

Key Sections of the Mental Health Act 1983 (Amended 2007)

The Mental Health Act 1983 (MHA), as amended by the Mental Health Act 2007, provides the legal framework for the assessment and compulsory treatment of mental disorder in England and Wales. Key sections relevant to clinical practice include:

• Section 2 — Admission for Assessment: Up to 28 days. Requires two medical recommendations (one of whom must be a Section 12 approved doctor) and an application by an Approved Mental Health Professional (AMHP) or nearest relative. Used when the diagnosis is not established.
• Section 3 — Admission for Treatment: Up to six months, renewable. Requires the same as Section 2 plus specification of appropriate treatment. Used when the diagnosis is known and treatment is required.
• Section 4 — Emergency Admission: Up to 72 hours. Requires one medical recommendation and an AMHP (or nearest relative) application. Used only in genuine emergencies when there is no time to obtain a second medical recommendation.
• Section 5(2) — Doctor's Holding Power: Up to 72 hours. Can be applied by the responsible clinician (or nominated deputy) for an informal inpatient who wishes to leave but is at risk. This allows time for a full assessment under Section 2 or 3 to be arranged.
• Section 5(4) — Nurse's Holding Power: Up to six hours. Can be applied by a registered mental health or learning disability nurse. Allows emergency detention of an informal inpatient until a doctor can attend.
• Section 136 — Police Powers: Up to 24 hours (reduced from 72 hours by the Policing and Crime Act 2017). Allows a police officer to remove a person from a public place to a place of safety if they appear to be suffering from mental disorder and in immediate need of care or control. The revised Act restricts use of police stations as places of safety except in exceptional circumstances.
• Section 117 — Aftercare: Not a detaining section, but a duty on health and social care to provide free aftercare to patients who have been detained under sections 3, 37, 45A, 47, or 48.

A proposed Mental Health Act Reform (currently progressing through Parliament, as of 2025) aims to replace the broad definition of mental disorder, strengthen patient autonomy and advance choice, and reduce the disproportionate use of detention against Black, Asian and Minority Ethnic patients.