The last 30 years have seen an explosion of Mental Health Services Research alongside the shrinking and closure of mental hospitals (see Chapter 7.6). Policy considerations, particularly cost containment and public safety, have influenced the research agenda which is disproportionately Anglophone (from the United States, United Kingdom, and Australasia) and focused on new services developed as alternatives to institutional care with staffing and motivation that are not easily generalizable. More routine practices, crucial for safe and effective care, have been relatively neglected by researchers.

This chapter is mainly devoted to describing the essential components of a mental health service—its ‘building blocks’. It will then consider how they relate to one another, how they can be prioritized, and how integrated into an effective local service linking into other essential services. Lastly it will stress how their inevitable evolution should be monitored.

Services for adults (increasingly referred to as ‘adults of working age’ indicating 18–65 years) will be used as the template. In many settings these may be the only services, stretching to accommodate all comers. In better resourced health care systems a range of specialized services have evolved from this basic model and are described elsewhere in this section (refugees 7.10.1, homeless 7.10.2, and ethnic minorities 7.10.3).

‘How many beds do we need for our local population?’ is often the first question asked by planners or managers. Unfortunately there is no reliable or precise answer to this. We know that supply will drive use (perceived as need)—beds are rarely left unfilled despite enormous variation in their availability. It is also surprisingly diffi- cult to collect useable figures on bed usage nationally or internationally because of differences in methods of reporting and also the profusion of overlapping and rarely defined local terms
(e.g. night hospitals, crisis homes, step-down wards). The levels of external accommodation provision (e.g. hostels, day care) clearly also impact the need for acute beds. Similarly need for beds will reduce as community services become more comprehensive and robust.

European provision of general acute beds in 2000 in the public sector ranged from 128 per 100 000 in the Netherlands to 6 per 100 000 in Northern Italy. However, unless we know the pattern of care (in particular the level of private and social services care) these figures tell us relatively little. The United Kingdom has little parallel private care and here acute beds needed for a population of 250 000 have been estimated to range from 50 to 150 plus 5 to 20 secure or intensive care beds⁽¹⁾ dependent on morbidity (generally much higher in large urban settings). London figures for the mid-1990s were very close to this range, averaging 73 for outer and 110 for inner London, but with increased secure provision, particularly in the deprived inner city. The authors predicted a similar range of 24 h supervised hostel need (40–150 per 250 000 population) and London use was somewhat higher (99 and 162 per 250 000, respectively) but with a markedly wider range.

Current bed usage in the United Kingdom is closer to the 50 per 250 000 and well below this in stable communities. This reflects both the establishment of specialized home-treatment and assertive outreach teams and the expansion of forensic care but also a shift in expectations and practice. The average duration for admissions has been steadily reducing over the last three decades. Figures can be misleading as they are heavily skewed by short (1–2 day) admissions but the current admission for an uncomplicated psychotic relapse is likely to be between 3 and 6 weeks.

Acute inpatient wards admit patients for weeks or a couple of months. Rapid discharge is anticipated and regimes emphasize openness and independence. Even within a local service some patients will require longer or more secure care because of illness severity or for legal reasons. Modern rehabilitation practice restricts long-stay wards to patients whose behaviour is persistently unacceptable to local communities. Forensic and secure services are usually a regional or national rather than local responsibility.

Alcohol and substance abuse wards have been long established (especially in Scandinavia and Central Europe) and diagnosis- or disorder-specific wards are increasingly common. Wards for specialized patient groups such as anorexia nervosa or resistant schizophrenia provide highly specific regimes. These are generally an adjunct to acute admission wards rather than an alternative. Some services are organized in disorder-specific wards (e.g. a psychosis unit, a psychosomatic ward) instead of general wards. Such specialization is not possible in comprehensive services for populations of less than about 1 000 000. For smaller populations this increased specialization must be balanced against reduced flexibility and energy wasted in ‘boundary disputes’.

The CMHT is the fundamental building block of modern community mental health services. It originated as mental hospital catchment areas (often covering a whole city or county) were divided into sectors of 50–100 000 inhabitants to permit ongoing care. The aim was that it should be possible for most of the team to have some familiarity with most of its complex and long-term patients and to have some personal knowledge of its referrers and community resources. Current sector size in Western Europe ranges from 20–50 000 population, determined both by resources (shrinking as investment increases) and by the local configuration. As more specialized teams are established the CMHTs remit may be reduced and sector size consequently increased keeping its caseload fairly constant. 200–250 is considered the maximum for most teams to exploit multidisciplinary working. The number is less in services for highly complex and difficult patients.

CMHTs offer assessment and care for patients discharged from psychiatric units and those who cannot be adequately treated in primary care or in the private sector. They should prioritize severe mental illnesses (SMI—e.g. psychoses and severe affective disorders). However diagnosis is not all—complications from social adversity, personality difficulties, or substance abuse can make secondary mental health care necessary even for apparently ‘minor’ disorders. Tools to clarify this threshold⁽⁶⁾ have been of limited use and most teams rely on clinical assessments. In countries with limited private care CMHTs also treat mild and transient disorders. CMHTs can be remarkably inefficient if little thought is given to their structure and thresholds. To work well, there needs to be agreement on their purpose, clientele and systems of management and they have often suffered from lack of clarity and leadership.

CMHT staffing varies enormously and there is no uniform model. Teams of less than 6 can rarely provide comprehensive care or cross-cover while teams of more than about 12–15 start to become
unwieldy, overwhelmed with management and information transfer. CMHTs emphasize skill-sharing and a degree of generic working and have evolved an informal, democratic style⁽⁷⁾ which often means confusion over clinical leadership (originally provided informally by senior medical staff). With increased staff numbers and treatment complexity ‘team managers’ now coordinate workload with a role which varies from the purely administrative to setting clinical priorities and supervising staff. Establishing a clear understanding of clinical leadership in CMHTs (without inhibiting initiative and creativity) is essential for effective functioning. If leadership and management are separated (common with a strong medical presence) the roles need to be well defined and relationships good.

The key to good care is accurate assessment (see Chapter 1.8.1). Most commonly psychiatrists conduct initial assessments (usually in an outpatient clinic) and involve the team members in treatment. Increasingly other team members have taken a role in assessments, either individually or jointly with the psychiatrist. Although this issue generates strong feelings there is surprisingly little research into it. With highly developed primary care non-medical assessments may be effective but otherwise medical time should prioritize assessments. With severely ill patients home-based assessments pay considerable dividends.^{(8, 9)}

Most CMHT staff act as clinical case managers^{(10, 11)} with responsibility for coordination, delivery, and review of care for their patients. The caseloads of staff members should be explicitly limited (usually 15 to 30) and reviews recorded and systematic. In the United Kingdom this has been formalized as the Care Programme Approach.⁽¹²⁾ Fig. 7.5.1 shows a care plan indicating a patient’s needs or problems, the interventions proposed to meet them, who is responsible and who is informed, plus an agreed date for review. Such concise structured paperwork (as with the risk assessment and contingency plan (Fig. 7.5.2)) can be adapted to any service, coordinates complex care and serves as a natural focus for clinical reviews. The level of detail needs to be clinically (not managerially) determined.

CMHTs need 1–2 regular meetings (each usually 1.5–2 h) per week for both clinical and administrative business. The degree of structure depends on team style and remit.