Psychiatric services
The history of psychiatric services
The components of a mental health service
Services for psychiatric disorder in primary care
Specialist services for acute psychiatric disorder
Psychiatric services that provide long-term care
Services for people with particular needs
Some difficulties with community care
International service principles
Introduction
The last two chapters dealt with the treatment of individual patients. This chapter is concerned with the provision of psychiatric care for populations. It deals mainly with the needs of and provisions for people aged 18–65 years (‘adults of working age’).
Services for children are described on p. 640, services for the elderly on p. 490, and services for patients with learning difficulties on p. 701. The organization of psychiatric services in any country inevitably depends on the organization of general medical services in that country. This chapter will refer specifically to services in the UK, but the principles embodied in these services apply widely.
The chapter begins with an account of the historical development of psychiatric services. This is followed by descriptions of the commonly available psychiatric services and of the problems encountered with these provisions. The chapter ends with a consideration of some innovations designed to overcome these problems.
The history of psychiatric services
Until the middle of the eighteenth century, there were hardly any special provisions for the mentally ill in Europe, other than in Spain, where some hospitals were present from the Middle Ages (Chamberlain, 1966), reflecting its Islamic influence. Both Christianity and Islam regarded mental illness as the result of supernatural intervention. Within Judaeo-Christian teaching it indicated demonic possession and/or the effects of sin, but within Islamic teaching the intervention was not necessarily malign or the result of wrongdoing. Islamic medicine was more concerned with mental disorder, and the Arab physician Rhazes cared for mental patients in Baghdad in the tenth century.
In Britain until the middle of the eighteenth century, most mentally ill people lived in the community, often with help from Poor Law provisions, or were in prison. In England, the Vagrancy Act of 1744 made the first legal distinction between paupers and lunatics, and made provision for the treatment of the latter. Private ‘madhouses’ (later to be called private asylums) were developed mainly for those who could pay, but accepted some paupers supported by their parishes (Parry-Jones, 1972). At about the same time, a few hospitals or wards were established through private benefaction and public subscription. The Bethel Hospital in Norwich was founded in 1713. In London, the lunatic ward at Guy’s Hospital was established in 1728. In 1751, St Luke’s Hospital was founded as an alternative to the overcrowded Bethlem Hospital which had existed as an institution since 1247, but only latterly became exclusively a ‘madhouse.’
Moral management
At the end of the eighteenth century the Enlightenment led to a more empirical, less theological understanding of madness. This rational approach led to increased public concern in many countries about the poor standards of private and public institutions, including efforts to improve the care of the mentally ill. In Paris in 1793, Philippe Pinel iconically released patients from their chains and introduced other changes to make the care of patients more humane. In England, similar reforming ideas were proposed by William Tuke, a Quaker philanthropist who founded the Retreat in York in 1792. The Retreat provided pleasant surroundings and adequate facilities for occupation and recreation. Treatment was based on ‘moral’ (i.e. social) management consisting of kindness, calm, and activity. Tuke and Pinel both acknowledged that, although mad, patients still could respond like other humans. This contrasted with the previous authoritarian approach aimed at simply controlling patients when medical treatments (usually bleeding and purging) were peripheral to the routine care of the insane. William Tuke’s grandson, Samuel, described their system in A Description of the Retreat (1813), and the Retreat was replicated internationally. It became clear that many mentally ill patients could exert self-control and did not require physical restraint and punishment.
The asylum movement
In the early nineteenth century most mentally ill people received no care and lived as vagrants or as inmates of workhouses and gaols. Public concern about the welfare of the insane in workhouses and gaols and some private madhouses led to the County Asylum Act of 1808, which provided for the building of mental hospitals in each of the English counties. However, it was the Lunatics Act 1845 that required the building of one in every county. At first the new asylums were small and provided good treatment in spacious surroundings. Moral management was championed. The ‘non-restraint movement’, which had started with the work of Gardiner Hill at the Lincoln Asylum in 1837 and was established by John Conolly at the Middlesex County Asylum, Hanwell, in 1845, removed all physical restraints (a practice that has characterized mental healthcare in the UK ever since).
Unfortunately, these early attitudes yielded to a more restrictive approach. More and more patients were transferred from the community and prisons to the new asylums. Initial optimism about the curability of psychiatric disorder faded with the accumulation of chronic cases and an increased focus on organic and hereditary causes. Asylums grew rapidly in size. The original York Retreat had 30 patients, and the first 16 British asylums had about 100 patients each. They averaged 300 patients by 1840, 540 patients by 1870, and 960 by 1900. Some patients with chronic illness were housed in detached annexes or houses in the grounds of the asylum. Other hospitals returned patients to the community either by boarding them out with a family (a form of care that was practised most successfully at Gheel in Belgium), or by returning them to workhouses. The Lunacy Commissioners, whose role was to oversee the care of the mentally ill, were concerned that these arrangements could lead to abuse, and were opposed to them. Nevertheless, nineteenth-century asylums, even when overcrowded, provided a standard of care for the mentally ill that was lacking elsewhere. Thus the mentally ill were protected from exploitation, and were provided with shelter, food, and general healthcare, all without cost.
With the increasing size, overcrowding, and staff shortages, there was less emphasis on moral treatment. A change to a stricter custodial regime was endorsed by the Lunacy Act 1890, which imposed restrictions on admission and discharge from hospital. The bureaucratic and rigid 1890 Lunacy Act had resulted from years of unwarranted committal, but it handicapped British psychiatric development for nearly half a century. For accounts of psychiatric hospitals in the UK and the USA in the nineteenth century, see Jones (1992) and Rothman (1971).
Arrangements for early treatment
The opening of the Maudsley Hospital in 1923 provided an outpatient service and voluntary inpatient treatment in surroundings in which teaching and research were carried out. In the years between the wars the impetus for change increased. The Mental Treatment Act 1930 repealed many of the restrictions on discharge of patients that had been imposed by the Lunacy Act 1890. It allowed county asylums to accept voluntary patients, and changed the term ‘asylum’ to ‘mental hospital’ and the term ‘lunatic’ to voluntary ‘mental patient.’ The 1930 Act also encouraged local authorities to set up outpatient clinics and to establish facilities for aftercare. Therapeutic optimism, already present after von Jauregg’s successful malaria treatment for cerebral syphilis, increased further with the introduction of insulin coma treatment (later abandoned) and electroconvulsive therapy. Efforts were made to improve conditions in hospitals, to unlock previously locked wards, and to encourage occupational activities. Similar changes took place in other countries.
In most countries, these reforms were halted by the Second World War. Psychiatric hospitals became understaffed as doctors and nurses were recruited to the war effort, and became overcrowded as some had to be evacuated for the care of the war injured (Crammer, 1990). In Germany, many psychiatric patients died in a eugenics programme—a shameful period in the history of a country that had been at the forefront of psychiatric progress in the nineteenth and early twentieth centuries (Burleigh, 2000).
Social psychiatry and the beginning of community care
After the Second World War, several influences led to further changes in psychiatric hospitals. Social attitudes had become more sympathetic towards disadvantaged people. Among psychiatrists, wartime experience of treating ‘battle neuroses’ had encouraged interest in the early treatment of mental disorder, and in the use of group treatment and social rehabilitation. In the UK, the National Health Service led to a general reorganization of medical services, including psychiatry. The introduction of chlorpromazine in 1952 made it easier to manage the disturbed behaviour of patients with psychosis. It became possible to open wards that had been locked (although some hospitals had done so before such drugs became available), to engage patients in social activities, and to discharge more of them into the community.
Despite these changes, services continued to be concentrated at single sites, often remote from centres of population. In the USA, Goffman (1961) vividly exposed the detrimental effects of such ‘total institutions.’ He described how their impersonal, inflexible, and authoritarian regimes eroded identity and through this ‘institutionalization’ generated chronicity. In the UK, Wing and Brown (1970) demonstrated how large mental hospitals characterized by ‘social poverty’ led to ‘clinical poverty.’ Vigorous social rehabilitation was introduced to improve conditions in hospital and to reduce the effects of years of institutional living. Occupational and industrial therapies were used to prepare chronically disabled patients for the move from hospital to sheltered accommodation or to ordinary housing (Bennett, 1983). Many long-stay patients were responsive to these vigorous new methods. There was optimism that newly admitted patients could also be helped in these ways.
Away from the hospitals, day units were established to provide continuing treatment and rehabilitation, and hostels were opened to provide sheltered accommodation. As a result of all these changes, the numbers of patients in psychiatric hospitals fell substantially in the UK and in other countries. The changes started later in the USA, with the introduction of Medicaid in 1965, but then progressed very rapidly. Despite these changes, services were still based in large mental hospitals that were often far from patients’ homes. The provision of community facilities for newly discharged patients often lagged behind need.
Hospital closure
After initial successes in discharging many institutionalized patients, it was anticipated that asylums could be closed and replaced by small psychiatric units in general hospitals, with support from community facilities. In most countries, the programme of hospital closure took place gradually. A notable exception was Italy, which at first lagged behind most other countries but later made rapid changes. In 1978, the Italian Parliament passed Law 180, which prohibited admissions to mental hospitals forthwith. It aimed to abolish the mental hospitals altogether over a period of 3 years and replace them with a comprehensive system of community care. Psychiatric ‘diagnostic’ units limited to admissions of 7 days were to be set up in general hospitals and community services to be developed for each catchment area. The scheme was based on the work of Franco Basaglia in hospitals in north-east Italy, and on the proposals of the professional and political movement that he founded. This movement—Psichiatria Democratica—combined a left-wing political view that patients in psychiatric hospitals were the victims of oppression by the capitalist system with the conviction that severe mental illness was induced more by social conditions than by biological causes. Basaglia’s charismatic personality, qualities of leadership (and a wife who was an Italian Senator) helped him to succeed with his reforms. Others found them more difficult, and their impact varied. Where the reforms were financed adequately and were implemented by enthusiastic staff (particularly in the north east), the new provisions were successful. However, in Rome and the south the new facilities were often inadequate, and problems were encountered (Fioritti et al., 1997). The state mental hospital system came to an end in 1989 (Burti, 2001).
In the UK and elsewhere the pace of change was slower, but similar problems arose. Many patients needed ongoing intensive support, and many required repeated readmissions to hospital—so-called ‘revolving-door patients.’ Rehabilitation services had to adjust their expectations and provide continuing care. Some discharged patients attended day hospitals for years without showing further improvement (Gath et al., 1973). The early expectations of de-institutionalization had clearly been over-optimistic. The policy of ‘community care’ was introduced to develop more adequate community provision.
The rise of community care
As hospitals closed, community psychiatric services acquired three responsibilities. The first was to provide treatment for those individuals with severe mental illness who would previously have remained in hospital for many years. The second was to assist primary care services in the detection, prevention, and early treatment of the less severe psychiatric disorders. The third was to treat severe acute psychiatric disorder as far as possible without lengthy admission to hospital, and as near as possible to the patient’s home. Services were to be comprehensive, to deliver continuity of care, and to be provided by multidisciplinary teams.
The framework for this ‘sectorized’ service was laid by the 1959 Mental Health Act in the UK. This Act required hospitals to provide outpatient follow-up for their own discharged patients, and also required social services involvement in both compulsory admissions and community support. A highly localized ‘sectorized’ service was therefore a practical necessity for effective joint working.
These general principles were applied rather differently in the UK and in the USA. In the UK, emphasis was placed initially on provision for patients discharged from long-term hospital care. In the USA, more emphasis was given to the prevention and early treatment of mental disorder as a way of avoiding admission. President Kennedy’s Community Mental Health Centers Act (1963) established community mental health centres (CMHCs) staffed from several disciplines. These centres offered psychological and social care, emphasizing crisis intervention and the treatment of acute, often relatively minor, psychiatric disorders. They had no outreach facility, so patients with chronic and severe mental illness (who seldom actively seek care) became neglected. CMHCs evolved a rather ‘anti-medical’ approach, which led to difficulties in recruiting and retaining psychiatrists (Talbott et al., 1987). This further limited their ability to care for severely ill psychotic patients. Dissatisfaction with the centres grew as people discharged from long-term hospital care found their way into private hospitals or prisons, or joined the homeless population of large cities (Goldman and Morrisey, 1985).
In the UK and elsewhere, some commonly agreed principles concerning community services developed from these early experiences:
• Minimizing inpatient care. Hospital admissions were to be brief, and as far as possible patients were to be admitted to psychiatric units in general hospitals rather than to psychiatric hospitals. Whenever practicable, people were to be treated as outpatients or day patients.
• Providing rehabilitation early on. The aim of this was to protect and possibly improve residual functioning and prevent further deterioration.
• Multidisciplinary teams. Care was to be provided by teams, usually consisting of psychiatrists, community nurses, clinical psychologists, and social workers, often working in collaboration with members of voluntary groups.
• Legal reform. New laws were introduced (e.g. the 1983 Mental Health Act and its 2007 amendment in England and Wales) to limit the uses of compulsory treatment, to encourage alternatives to inpatient care, and to strengthen the rights of the individual.
As experience increased after the reforms had begun, the following additional features were introduced:
• Care packages based on an assessment of each patient’s needs.
• Case management by a named, clinically trained care worker who led and coordinated the work of others involved in care.
• User involvement. Service users were increasingly involved in planning both their own treatment and the services for the population.
• Outreach to take services to vulnerable people who might otherwise find it difficult to engage with the care that is offered, and to arrange follow-up.
• Risk assessment carried out regularly, and more formally as part of the care plan.
These developments have contributed to the current pattern of services.
The components of a mental health service
From the 1960s to the mid-1980s, mental health services in the UK and indeed most parts of the world evolved slowly, based on professional consensus. In the 1980s, interest in evidence-based medicine spread to mental health services research. This approach was international and increased the pace of change dramatically. The fundamental components of most care, namely inpatient wards, day hospitals, and community mental health teams (CMHTs), had not been subject to research, but had established themselves without it and have proved durable. The more recent highly specialized teams (assertive outreach teams, crisis resolution/home treatment teams, and early-onset (psychosis) services) have been more policy and research driven. It is probably premature to comment on their future role. What follows is a description of the UK services, which addresses research and international evidence where this is relevant or helpful. The NHS is entering a phase of potentially profound change, and the predictability and uniformity of services are likely to change markedly during the lifetime of this book.
Inpatient wards
No comprehensive service can survive without access to 24-hour nursing supervision for acute episodes of severe illness. Surprisingly, inpatient wards are often overlooked in descriptions of comprehensive services. They serve patients at risk from neglect or suicide and those lacking insight. Wards usually accommodate 10–20 patients. It is rarely possible to effectively staff and run stand-alone units of less than three to four such wards (30–60 beds). The famed Italian Law 180 restricted wards to 15 patients, and this is a common international goal (Burns, 1998). Ward size is a trade-off between privacy and domesticity on the one hand and effective supervision on the other. Single rooms are preferable, as they afford maximum privacy and, although initially expensive, they improve flexibility and have been shown to significantly reduce conflict.
Single-sex accommodation
Concern for the safety and privacy of female patients has led to government requirements for single-sex wards. This reversal of the development that occurred in the 1960s and 1970s is non-negotiable, even if it may have been overtaken by the increasing availability of single ensuite accommodation in new units.
Smaller, more flexible units such as ‘crisis houses’ offering 24-hour care are a useful complement to inpatient wards. However, they are not a replacement for them, and where this has been attempted it has usually resulted in an unacceptably high rate of transfer to the psychiatric intensive care units (PICUs). Ward design and management are increasingly crucial as improved community care concentrates involuntary and disturbed inpatients in them.
Continuity of responsibility
Responsibility by the same clinical team for both community and inpatient care is unusual except in the UK and Italy, where it has delivered strikingly shorter stays and improved bed management. Continuity is difficult in dispersed populations, and increasingly even in cities as each team has fewer inpatients. A separate inpatient team ensures better inpatient standards, but with the risk of diverging approaches (e.g. a ‘medical model’ inpatient team and a ‘psychotherapeutic’ community team). It has recently become common in the UK, for reasons that are unclear but which may include the problems of wards having to cope with several admitting teams. Both the move to single-sex accommodation and specialized teams result in each team often having only one or two patients on a ward. Diffused responsibility and organizing multiple ward rounds have promoted the change, but not without cost (Burns, 2010). It appears to be in conflict with the expectation of continuity of clinical responsibility in the 1983 Mental Health Act, and particularly in the 2007 amendment permitting compulsory treatment in the community through the new provision of Supervised Community Treatment Orders (SCTOs, which are invariably referred to as Community Treatment Orders, or CTOs; see Chapter 4). The question arises as to whether the inpatient consultant or the community consultant should make the decision.
Longer inpatient care
Acute inpatient wards admit patients for weeks or a couple of months, with rapid discharge anticipated. Some patients require longer, more secure care service because of illness severity or for legal reasons. Modern rehabilitation wards are thus generally restricted to patients with persistently unacceptable behaviour.
Diagnosis-specific wards
Diagnosis- or disorder-specific wards are relatively rare in the UK. In Scandinavia and Central Europe, separate wards for alcohol and substance abuse are long established. Wards for specific, specialized problems such as anorexia nervosa or resistant schizophrenia offer highly specific regimes. These are generally regional, and in addition to acute admission wards, not an alternative. The current focus on organizing services along ‘care pathways’ may result in more specialized inpatient services, but it is too early to know whether this will happen.
Day care
Day care is provided in day hospitals and day centres, and there is not a clear distinction between them. Day hospitals are generally provided by health services, include medical and nursing staff, and can offer treatments (e.g. the prescription and monitoring of medication, psychotherapies). Day centres are provided by social services or voluntary organizations. They rarely provide specific treatments or employ clinically trained staff. However, services vary according to local context. A drop-in day centre may provide psychiatric assessment and treatment in areas of high social mobility and homelessness. Broadly speaking, day centres provide long-term social support and day hospitals provide focused interventions and treatments (Catty et al., 2005).
Acute day hospitals in Europe and partial hospitalization services in the USA have been energetically proposed as acceptable and economical alternatives to inpatient care (Marshall, 2003), but have had little impact. Day hospitals never achieved their anticipated prominence in the UK, having perhaps been overtaken as CMHTs have become more comprehensive. They serve specific groups well (e.g. mothers with small children, eating disorders, or personality problems). Day care is difficult to organize in rural settings.
Supported accommodation and residential care
The extent of inpatient care that is needed depends on local access to other supervised accommodation. Patients remain well outside hospital only with adequate support and stable, affordable accommodation. Supervision may be needed to ensure self-care, continued medication, and to anticipate and defuse crises. It can be provided by voluntary agencies, social services, or health services. Voluntary agencies tend to be more efficient at providing long-term residential care (Knapp et al., 1999), but reluctant to accept risky patients. A mixed economy works best.
Outpatient clinics
Psychiatrists assess patients, advise them and their referrers, and provide treatments. In state-funded systems ‘office-based’ practice is rare, as most professionals work in outpatient clinics or mental health teams. Psychiatrists and psychologists may still operate independently within outpatient clinics, but with access to enhanced resources and second opinions. Outpatient clinics may operate either alongside CMHTs, or as part of them. They work better for severe illness when fully integrated with CMHTs (Wright et al., 2004). Clinics provide an efficient format for assessments and monitoring of treatment progress.
Multidisciplinary community mental health teams (CMHTs)
Most community mental health services consist of varied forms of multidisciplinary CMHT. Nurses have long worked outside hospitals (e.g. midwives, health visitors), and have made psychiatric home visits since the 1950s. Social workers, psychologists, and occupational therapists are increasingly found in CMHTs. The staffing of these teams varies internationally, but they all hold regular meetings to assess and review the management of patients. These reviews incorporate their varied professional perspectives and allocate tasks according to staff skills and patient needs. They were developed in France and the UK in the delivery of sectorized psychiatry, refined in Italy, and further elaborated in North America and Australia.
The generic-sector CMHT (‘the CMHT’)
Who it is for
The CMHT is the fundamental building block of modern community mental health services. It originated as mental hospital catchment areas (which often covered a whole city or county) were divided into sectors of 50 000–100 000 inhabitants to permit ongoing care. It provides assessment and care for patients who have been discharged from psychiatric units and for outpatients who require more support than can be provided by primary care. Current sector size in Western Europe ranges from 20 000–50 000 members of the population, determined both by resources (the size shrinking as investment increases) and by the local configuration. As more specialized teams are established, the CMHT’s remit may be narrowed and its sector size increased.
CMHTs prioritize individuals with severe mental illnesses (SMI), such as psychoses and severe affective disorders. However, diagnosis is not all—complications due to social adversity, personality difficulties, or substance abuse can make secondary mental healthcare necessary even for apparently ‘minor’ disorders. Several tools have been developed for clarifying this threshold (Slade et al., 2000), but are of limited use, and most teams rely on clinical assessments. In countries with limited private care, such as the UK, CMHTs also treat mild and transient disorders.
Staffing and management
CMHTs range from 5 or 6 to over 15 full-time staff. They emphasize skill sharing and a degree of generic working, and have evolved an informal, democratic style (Burns, 2004), with senior psychiatrists initially providing clinical leadership. With increased staff numbers and treatment complexity, ‘team managers’ now coordinate the workload. There is little consensus on their role, which can range from the purely administrative to determining clinical priorities and supervising staff. Clinically active team managers usually have reduced caseloads. If clinical leadership and team management are separated (which is common if there is a strong medical presence), the roles need to be well defined and relationships clarified.
Assessments
The key to good care is accurate assessment, and CMHTs vary in how they provide this. In general, psychiatrists are responsible for an initial assessment (often in an out-patient 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. This issue generates strong opinions, but there has been surprisingly little research into it. One study suggests that joint assessments with medical involvement may be highly efficient (Burns et al., 1993a). With highly developed primary care, non-medical assessments may be effective, but otherwise medical time should prioritize assessments. For the most severely ill patients, home-based assessments pay considerable dividends (Stein and Test, 1980; Burns et al., 1993a).
Case management
Most CMHT staff act as clinical case managers (Intagliata, 1982; Holloway et al., 1995), taking lead responsibility for the delivery, coordination, and review of care for an agreed number of patients. Early forms of case management involved individuals with limited mental health training, working in isolation, and the results were poor (Marshall et al., 2001). Currently clinical case managers provide direct care to build a trusting relationship and provide treatment and continuity for patients with complex needs. They also utilize the full range of team resources. The caseloads of staff members are explicitly limited (usually 15 to 20), and reviews are recorded and systematic. In the UK this has been formalized as the Care Programme Approach (Department of Health, 1990), which requires a named case manager (called a care-coordinator) and a document called a care plan, which records the patient’s needs or problems, the proposed interventions for them, and who is responsible for each of them, plus an agreed date for review.
Care plans are often supplemented with a risk assessment and a contingency (crisis) plan. This should not need more than two pages, but vigilance is required to prevent it from becoming weighed down with administrative details that obscure its clinical purpose. Such simple structured paperwork can be adapted to any service. It fulfils a vital coordinating role in complex care, and serves as a natural focus for clinical reviews. The value of this document (as with the risk assessment and contingency plan) lies in its brevity. Too much information is as risky as too little, and the level of detail needs to be clinically (not managerially) determined.
Team meetings
CMHTs always have one, and often two, regular meetings per week for both clinical and administrative business. They last between 1 and 2 hours, and the level of structure varies.
Allocation of referrals. Deciding who will assess new patients need occupy only 10 minutes at the beginning of the routine meeting, or can simply be delegated to a senior member to decide. Referrals can be allocated according to who is first available, or by matching the clinical problem against available skill and training. It is remarkable how many CMHTs fail to have an agreed timetable for new assessments (as is routine in outpatient clinics). Much time is saved if each member has agreed regular assessment ‘slots.’ There is then no need to ‘coordinate diaries’ for joint assessments, and patients can be directly booked into available slots if the member is absent at allocation. Time spent discussing allocations (and particularly having a ‘referral meeting’) before assessment is unprofitable, and most well-functioning teams delegate the task.
Patient reviews. Reviews are needed for new patients, routine monitoring, crises, and discharge. They can range from simply reporting the problem and proposed treatment in uncomplicated cases, through to detailed, structured, multidisciplinary case conferences. These may include other services (e.g. general practitioner, housing, child protection). New patient reviews are particularly important for providing a broad, experienced overview, particularly if assessments are distributed across the team. They also ensure rational and fair allocation to caseloads. Routine monitoring is often overlooked, yet is probably the most important review for team efficiency. It shapes and redirects treatment and identifies patients who are ready for discharge. The burden on individual staff members is regularly monitored. Routine monitoring is a statutory requirement of the Care Programme Approach, and is good practice in all case management. Crisis reviews are unscheduled but allow case managers to seek advice when they are unsure. Discharge reviews provide an excellent opportunity for audit and learning within the team.
Managing waiting lists and caseloads. Effective CMHTs need to guarantee prompt access. Routine assessments should take place within 2–4 weeks. Striving for a shorter waiting time is rarely productive, and waiting times of much over 4 weeks have a rapidly rising rate of failed appointments (Burns et al., 1993a). Urgent assessments (which include most psychotic episodes) need to be seen within a week, and usually within a couple of days. Emergency assessments are for those associated with immediate risk (e.g. hostile behaviour or suicidal intent) and ideally need to be seen the same day.
A practical approach to managing waiting times is to count the number of referrals in the preceding year and allocate routine assessment slots for about 120% of that rate. Thus if a team that had 300 referrals in the previous year allocates 7 slots a week, there will be one extra available each week for urgent assessments and emergencies. Easy access to routine assessments reduces pressure for urgent and emergency referrals, and is much more efficient than emergency rotas.
Communication and liaison
Team meetings ensure internal communication, but CMHTs also need good links with the wide network of professional colleagues. Most routine communication takes place by letter, phone, or during individual clinical care. More structured liaison is advisable with primary care and general hospitals. Hospital links may be between specific CMHTs and wards, or CMHTs may provide input to patients from their sectors. Dedicated liaison psychiatry and psychosomatic services are common in well-resourced services.
General practice liaison. GP liaison systems originated in Balint groups but are now more likely to involve shared care or co-location of CMHTs in GP health centres (Burns and Bale, 1997). An effective and sustainable system involves regular (usually monthly) timetabled meetings between the two teams, or a ‘link’ CMHT member attending the GP health centre. It is important always to be clear about responsibilities; blurring of boundaries is risky.
Liaison with other agencies. The same principles apply to liaison with other agencies (social services, housing, and charitable and voluntary sector providers). Whether regular meetings are cost-effective will depend on the volume of shared work. Professional confidentiality and information sharing are more sensitive.
Mental health services research
The last 30 years have witnessed a change in how mental health services are planned and evaluated. A new academic activity, mental health services research (MHSR), has come into existence which has attempted to subject services and systems to the same evidence-based medicine approach to rigorous testing (e.g. controlled studies, randomized controlled trials, meta-analyses) that has been used previously with treatments. This has had two profound effects. First it has internationalized thinking about optimal services. The language of science means that findings from another part of the world can be applied locally. Secondly, it has shifted the locus of control in service development away from clinicians and towards academics and policy makers.
There are undoubted benefits to MHSR. For example, thinking and communication are markedly clearer, and some ineffective practices (e.g. traditional ‘brokerage’ case management) have been identified and abandoned. However, there are also drawbacks, particularly the risk of over-interpretation of results and their application without recognition of the modifying effects of the local context. This is briefly outlined in the cases of Assertive Community Treatment (ACT) teams. Three fundamental conceptual problems have characterized MHSR:
• a tendency to equate a service with a treatment, rather than with the platform for delivering treatment
• the assumption that the ‘control’ services in randomized controlled trials are inert and consistent, when in fact they are active and variable ‘comparator’ services
• a tendency to ignore the ‘pioneer’ effect—shiny new demonstration services with charismatic leaders have an inherent advantage.
MHSR methodology is improving, but these pitfalls in interpreting studies always need to be considered.
Mental Health National Service Framework (NSF) 1999
Mental health services in England and Wales were radically reformed following the publication of the National Service Framework in 1999 (Department of Health, 1999) and the NHS Plan in 2000 (Department of Health, 2000). These drew heavily on MHSR and pioneering services in North Birmingham and Australia. They initially recommended the complete replacement of the UK’s sectorized generic CMHTs with four ‘functional’ teams—assertive outreach, crisis resolution and home treatment, early intervention and primary care liaison teams. The sheer impracticality of such a massive reorganization (for which there simply were not adequate trained staff) and challenges to the strength of the evidence modified the proposal, and CMHTs were retained and primary care liaison teams abandoned.
An ambitious programme to establish the first three types of functional teams was put in place, starting with the creation of 300 assertive outreach teams (AOTS). These three teams are described below. The research evidence will be briefly addressed but, as demonstrated by that on AOTs, can change radically over time.
Assertive outreach teams (AOTs)
The most extensively replicated and researched specialist CMHT is the AOT. This is based on the assertive community treatment (ACT) model, whose landmark study by Stein and Test was published in 1980. This demonstrated improved clinical and social outcomes with substantially reduced hospitalization at slightly lower overall costs. Two Cochrane reviews with meta-analyses, one of case management showing an increase in hospitalization, and one of ACT showing a reduction (Marshall and Lockwood, 1998; Marshall et al., 2001), were instrumental in the adoption of ACT in the UK. AOTs (see Box 21.1) are costly, with one full-time case manager for about 10 patients. Consequently they are reserved for the most difficult (‘hard to engage’ or ‘revolving-door’) psychotic patients, who have frequent, often dangerous, relapses.
The AOT approach is based on proactive outreach—visiting patients at home and persisting with visits even when patients are reluctant. It exploits teamworking, with daily meetings and several members working with most patients, rather than exclusive individual relationships. This is needed for reasons of safety (it may not be safe to visit some patients alone) and also because of the complexity of patients’ needs. The approach is very practical (e.g. it involves taking patients shopping, sorting out their accommodation, and delivering their medicines daily if necessary) and goes well beyond traditional professional boundaries. Despite strong convictions that AOTs must closely follow Stein and Test’s original practice (assessed by ‘model fidelity’ measures) (Teague et al., 1998)) or outcomes will be poor (McHugo et al., 1999), the evidence for this is questionable (Fiander et al., 2003; Burns et al., 2005). Local clinical adjustments are both sensible and justified.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
