SCIE Introduction mental health services

Ways of working

Care Pathways and approaches

Recovery model

The recovery model is a framework or guiding principle that focuses on working with the individual service user to identify their strengths and build resilience. It also focuses on working with individuals to regain control, support recovery, and to lead a life meaningful to them after experiencing a serious mental illness. It is not just about treating or managing their symptoms.

Recovery does not always mean complete recovery from a mental health problem. For many people, it is about staying in control of their life despite their mental health problem.

For further information and resources, go to the Mental Health Foundation website


People with mental health problems can benefit from personalised social care as it increases choice and control and identifies what works best for them. The concept includes prevention, early intervention and self-directed support. The individual is in control of arranging and managing their own support system through a personalised budget.

For more information on personalisation, read the SCIE Key Issues: Personalisation resource.


When a person is referred to AMH services, a mental health professional is usually allocated to assess the individual’s health and social care needs. The outcome of this assessment may be an intervention by the service, advice, or referral to another service. All assessments should include an assessment of risks to the individual, and the possible impact of this on them, their family and others, including the public.

Considerable emphasis is now placed on AMH professionals to understand the impact on children in a household where a parent or sibling has mental health problems. It is important to understand the potential impact a parent’s mental health can have on a child’s welfare and safety, particularly if looking after the child is part of the parent’s mental health problem. If this is the case, urgent action may be needed. AMH services should assess the impact of parental mental health on the child and make referrals to children’s social care services or other targeted/specialised children’s services.

There is often confusion about the type of assessment being carried out. When requesting or receiving information from an assessment, do ask the AMH worker what assessment has been undertaken, and what it covers, so that you can identify what other information you might need or be able to provide.

The assessment of an individual’s mental health includes their:

Following assessment those service users who do not need intervention from AMH services will be referred back to their GP. In some cases AMH services will suggest non-specialist services for these individuals.

Service users who do need intervention from AMH services may get that help from specific professionals or from several members of the multidisciplinary team (MDT), depending on risk and the nature of the intervention needed. Where the MDT provides an intervention, a care plan is agreed in writing with the service user.

All assessments should include a description of the symptoms and the risk management plan, which should be created and agreed with the service user. However, there may be situations where the risk is sufficiently high for the team to make a decision to provide services even if the service user does not give consent.

Not all of those referred will want to engage in mental health services, and unless there are particular risks, AMH services cannot make an individual accept help no matter how much other professionals feel it would be useful.

It is important to understand the many misconceptions in society about mental illness and the stigma associated with experiencing mental distress. This may have an impact on the person, their family and their willingness to engage with services.

Care plan

Following assessment, the information gathered is used to form a care plan that addresses all areas of need and identifies what support will be offered, and by whom. The plan should be reviewed regularly. It may involve other agencies, and their contribution should be explained in the plan. The service user needs to give consent to share this plan and the assessment with other professionals.

Crisis and contingency plan

This should form part of the care plan. It identifies early warning signs for any setbacks and what to do if the person is becoming unwell.

Care coordinator

Most interventions will be led and organised by a care coordinator. The care coordinator is often the key person to contact. They are usually a mental health professional such as a nurse, social worker or occupational therapist. They provide a link between the individual, their family and other professionals, and work with the service user to make sure their care plan is effective. They are responsible for making sure that regular reviews take place and coordinating work with other agencies.

Confidentiality and information sharing

This is often a complex and anxiety-provoking area for practitioners. The Government has developed ‘seven golden rules’ for information sharing:

  1. Remember that the Data Protection Act is not a barrier to information sharing but a framework to ensure that personal information is shared appropriately.
  2. Be open and honest with the person (and/or their family where appropriate) from the outset about why, what, how and with whom information will, or could be shared, and seek their agreement, unless it is unsafe or inappropriate to do so.
  3. Seek advice if in any doubt, without disclosing the identity of the person where possible.
  4. Share with consent where appropriate and where possible, and respect the wishes of those who do not consent to share information. You may still share information without consent if, in your judgement, that lack of consent can be overridden in the public interest. You will need to base your judgement on the facts of the case.
  5. Consider safety and base your information-sharing decisions on considerations of the safety and wellbeing of the person and others who may be affected by their actions.
  6. Necessary, proportionate, relevant, accurate, timely and secure: Ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who need to have it, is accurate and up-to-date, is shared in a timely fashion, and is shared securely.
  7. Keep a record of decisions and the reasons for them, whether it is to share information or not. If you decide to share, record what you have shared, withwhom and for what purpose.

Extract from Department for Children, Schools and Families (2008) Information sharing: Guidance for practitioners and managers.

All agencies will also have local procedures on information sharing. Check with your local health trust, Local Safeguarding Children Board, or local authority.