What's New? - November 2017

This is a refresh and G-care formatting of the existing pathway for Psychosis and Schizophrenia. There are no major changes in practice/services; which includes GP/Primary Care level interventions and Specialist Mental Health services accessed via the 2gether Specialist Care Contact Centre. The 2gether Specialist Care Contact Centre can also be used to access clinical advice at any stage by the patients GP.

Psychosis and Schizophrenia Care Pathway Overview

Based on BMJ2014;348:g1173 and ,BMJ2013;346:f185

  • Psychosis is common and schizophrenia is the most common form of psychotic disorder
  • Schizophrenia affects 7 in 100 adults, onset typically between the age of 15 and 35
  • Schizophrenia remains the most common cause of major psychosis and of course can have devastating consequences.
  • It is usually associated with a prodromal period of 1-3 years, and in very high risk patients 20-40% ‘transition’ to schizophrenia within a year
  • During the pro-dromal period brief intermittent psychotic symptoms may appear
  • Poor physical health is strongly associated with schizophrenia, with men dying 20 years and women 15 years earlier than the general population
  • Approx. 50% of people have a moderately good long term outcome

Please click the relevant flowchart box to be taken directly to textual information



Red Flags
Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Crisis Resolution and Home Treatment Teams can be found here. 
2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here.


Practice Point

Please see the "Urgent Care: general" section on G-care for SWAST's guidance on Requesting Ambulance Transport (999 or Urgent).


Symptoms may include:

  • unusual beliefs or delusions
  • muddled thinking or thought disorder
  • hallucinations
  • disorganised speech
  • negative symptoms such as apathy and flattened affect
  • self-neglect

  • patients with short-lived milder symptoms of psychosis within the last 3 months
  • patients who have been functioning less well over the last 12 months e.g. withdrawing from school, college or work or not being able to spend time with family or friends. Plus a family history of psychosis
  • patients who experience brief limited intermittent psychotic symptoms (BLIPs). These are psychotic level symptoms that have naturally stopped within 7 days.

  • higher levels of stress
  • social influences (relationships, family)
  • psychological factors (beliefs about self and others)
  • feeling increasingly worried or anxious
  • major life events e.g. changing school, starting college, break up of a relationship, family problems bereavement etc.
  • using substances e.g. cannabis, ecstasy, LSD, MCAT, amphetamine, cocaine
  • childhood abuse or neglect
Differential Diagnosis
Initial Primary Care Assessment

Immediate steps in primary care:

  • respectful probing and reflective listening:
    • help the patient feel understood and valued
    • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
    • this in itself is therapeutic

Perform a mental health assessment, as shown below, to review the person's mental state and associated functional, interpersonal, and social difficulties.

  • nature, frequency, and intensity of symptoms
  • rate of onset – gradual or rapid
  • recent stressful life events and lack of social support
  • significant previous trauma
  • situations that trigger or exacerbate symptoms, including first occurrence
  • personal and family history of psychosis and schizophrenia
  • concurrent substance abuse or withdrawal
  • any self-medication
  • cultural or other individual characteristics that may be important in subsequent care

  • assess whether the person has adequate social support and is aware of sources of help
  • arrange help appropriate to level of risk
  • advise the person to seek further help if the situation deteriorates

Consider physical health screen (incl. blood tests) to rule out other causes e.g. hypothyroidism 

If a person is distressed, has a decline in social functioning and has:

  • transient or attenuated psychotic symptoms or
  • other experiences of behaviour suggestive of possible psychosis or
  • a first- degree relative with psychosis or schizophrenia

refer them for assessment without delay to the 2gether Specialist Care Contact Centre or Gloucestershire Recovery in Psychosis (GRiP) Early Intervention Service (for ages 14-35 years old).

Primary Care Referral/ Prescribing Guidance / Management

  • shared decision making should take place throughout diagnosis and treatment
  • information on the disorder, its treatment, and self-help options should be provided to patients and their families and carers
  • if appropriate, the impact of the presenting problem on the care of children and young people should also be assessed and if necessary, local safeguarding procedures followed 

1st Episode

Initial presentation to Primary Care

Consider referral to:


Patient with established diagnosis of Chronic Stable Psychosis presents with symptoms of other mental disorder:

Consider referral to:

Suspected relapse

Patient with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse:

It is not appropriate to use short term benzodiazepines within primary care for these patients.

There is a GHNHSFT Local Guidline  which provides information on the acute treatment of psychosis where benzodiazepines may be requried. It covers the use of lorazepam in an acute situation and also gives information around the risks associated with this. Please note: This is included for information only and it is not intended that this is applicable to primary care.

Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist.

Glos Joint Formulary - Drugs used in psychoses and related disorders

Please follow this link to view the Gloucestershire Formulary information on drugs used in psychoses and related disorders

Provide advice/refer/signpost patients to any of the following self-management services;

Consider referral or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

Practice Point

The Contact Centre may be contacted for advice at any stage:

Tel: 08000 151 499

Email: 2gnft.FPCC-Admin@nhs.net

Fax: 01452 894418

Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP.

Specialist Care Contact Centre - 2gether

The 2gether Contact Centre is staffed by call handlers and senior mental health practitioners. They offer referral advice, screen referrals and arrange assessment appointments. They accept referrals from GPs and health professionals in consultation with GPs. They do not accept self-referrals.


The specialist care contact centre will triage referrals depending on need to offer:

  • routine assessment with recovery- within 28 days
  • urgent assessment with recovery- within 72 hours
  • crisis assessment/intervention (if urgent concerns) by Home Treatment Team- same day- For crisis referral please call- do not use the paper referral process

Recovery assessments will consider presenting problems and the individuals more general psychological, medical and social needs.

  • the initial assessment might offer advice on management or the offer of an on-going intervention according to a care plan agreed with the service user and drawn up by their care co-ordinator and a secondary care medic.
  • the mutlidisciplinary team includes a Consultant Psychiatrist and their medical team, Community Mental Health Nurses, Occupational Therapists, Social Workers, Psychologists and Support Workers.
  • interventions will be individualised, but may include both individual and group work provided in clinical or community settings.

Arranging admission to mental health services may be indicated for severly ill patients who:

  • lack adequate support outside of a hopsital setting
  • have complicated psychiatric or general medical conditions
  • carry significant risk to themselves or others but cannot be managed safely outside a hospital setting.

Tel: 0800 015 1499

Email: 2gnft.FPCC-Admin@nhs.net

Opening hours: 9am-5pm, Mon-Fri (except Bank Holidays)

For out of hours emergency referrals please ring the Crisis Teams on 0800 169 0389.


  • a summary of the patients mental health difficulties
  • risks associated with their condition, including current/past risk, risk to others and risk of neglect
  • previous contact with mental health services
  • current contact details
  • expectations of referrer and referee
  • ability to attend appointments
  • any language difficulties

For more information please follow the resource link below.


Gloucestershire Recovery in Psychosis (GRiP) Early Intervention Team

The Gloucester Recovery in Psychosis team or “GRiP” is an Early Intervention in Psychosis team work with young people aged between 14 and 35 who are at risk of experiencing (at risk mental state or ARMS) or who are experiencing a first episode of psychosis

Typically, Early Intervention teams work in the community and will try to meet with people in a place where they feel most comfortable providing self-help information, or signposting to another more appropriate service to help with their presenting difficulties. Patients deemed ARMS will receive more targeted support from the Early Intervention Service.

GRiP has an open referral policy which means that anyone can contact the team to discuss a possible referral. This can be done via phone or in writing.

Once referred the patient will be assessed by two members of the team, usually within 10 working days. The assessment will allow us to see whether the patient fits the criteria for the GRiP Team. If the patient does meet the criteria they will be allocated a care coordinator and a care plan will be drawn up.

If the patient is not thought to be suffering from a psychotic episode and is not At Risk Mental State (ARMS), they will be referred to a team more suited to their needs with signposting to places that may be able to help.

Tel: 01452 894178
Gloucestershire Recovery in Psychosis (GRiP)
44 London Road

Crisis Resolution and Home Treatment Service (CRHT) – 2gether

Available for patients who may require hospital admission and an assessment within the next 24hrs.

2gether's Crisis Resolution & Home Treatment Service (CRHT) provides short-term intensive home and community based care during the acute phase of illness.  It is for those individuals who are at immediate risk of psychiatric hospitalisation or, due to acute relapse, are at risk of losing their independence in the community.

The team covers the following areas:

  • Cheltenham, Tewkesbury and North Cotswolds
  • Stroud and Cotswolds
  • Gloucester and Forest

Contact: In working hours (9am-5pm) call the Specialist Care Contact Centre- or use the crisis numbers

Gloucestershire - 0800 169 0398 Between 7am and 10pm please press 1 for Stroud and Cotswolds, 2 for Gloucester and Forest and 3 for Cheltenham, Tewkesbury and North Cotswolds.

Both telephone numbers are staffed 24 hours a day, 7 days a week.

Practice Liaison Nurse

Available to:

  • assess psychotic mental illness’ presented by patients where there is a suspected relapse of a previously stable psychosis and facilitate rapid access to Specialist Care services where the risk/severity/complexity warrants a Specialist Care assessment.
  • treat patients short-term where there is a suspected relapse of a previously stable psychosis and facilitate maintenance of Primary Care management where the risk/severity/complexity warrants Primary Care interventions.
Improving Access to Psychological Therapy (IAPT) / Let’s Talk – 2gether

IAPT therapists do not work directly with psychotic and schizophrenic patients. Where this is the primary issue IAPT can work with presenting comorbid conditions such as anxiety and depression when the psychosis and schizophrenia presntation has stabilised.The Mental Health Intermediate Care (Nursing) Team (MH ICT)/Triage Nurse will refer if they feel this is appropriate for the patient.


Ongoing Primary Care

Monitoring physical health

Complete a comprehensive annual health check, focusing on physical health problems that are common in people with psychosis and schizophrenia when responsibility is transferred from secondary care.

Consider using the RCGP guideline: Lester Cardiometabolic Intervention Framework

A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes.


Patient Resources

Please see the Community Resources and Patient & Carer Information & Leaflets sections.

Resources for Professionals

National Standards

Please see the National and NICE Guidance section.

There are no significant variation from the national standards in this pathway

Other Online Resources

Pathway Leads




Pete Carter

Senior Commissioning Manager

Gloucestershire Clinical Commissioning Group

Dr Iain Jarvis


Gloucestershire Clinical Commissioning Group

Alex Burrage

IAPT Clinical Lead

Let’s Talk - MH ICT, 2gether NHS Foundation Trust

Martin Ansell

Clinical Director

2gether NHS Foundation Trust

Dr Jon Haynes

Clinical Director

2gether NHS Foundation Trust

Hannah Steer

Clinical Psychologist

2gether NHS Foundation Trust

Reason for Pathway Selection

This is a refresh and G-care formatting of the existing pathway for Psychosis and Schizophrenia. There are no major changes in practice/services; which include GP/Primary Care level interventions and Specialist Mental Health services accessed via the 2gether Contact Centre. The 2gether Contact Centre can also be used to access clinical advice at any stage by the patients GP.

Completion Date

November 2017

Review Date

October 2018