Letters

Case management confers substantial benefits

These terms are not difficult to distinguish, and much is to be achieved by distinguishing them. The meaning of case management evolved rapidly, reflecting the context in which it operated and increasing understanding of its working. Initially the focus was on the coordination of care and obtaining access to support and benefits by an office based administrator, who often had no health or social services background. This model ("brokerage case management") was soon recognised to be of limited value in serious mental illness, and this was confirmed by controlled studies.³ Case managers shifted their emphasis to more direct care ("full support" or "clinical case management"), which has become the dominant approach in the United States.

Clinical case management increasingly emphasises outreach, small caseloads, and a broad clinical remit. Consequently, the term is now virtually synonymous with what is done by the assertive community treatment team (itself a concept that evolved from "training in community living"). These teams have been subjected to over 13 randomised controlled trials, which have overwhelmingly shown their value.⁴

The research evidence is therefore clear and unusually abundant. Brokerage case management (renamed care management in British social services) is costly, with no added benefits for patients,^{3 5} and its adoption as policy in England threatens to damage mental health social work severely.² Case management (clinical case management) has been extensively researched and confers substantial benefits.

Use of the care programme approach with long term and complex problems arises logically from the philosophy of case management, is clinically coherent, and generates little controversy. Insistence that every patient of the mental health services should be included in this approach is a bureaucratic diktat that perpetuates confusion over whether it is clinically derived practice or an administrative procedure.

All three processes have a clear clinical identity. For two of them adequate evidence exists to make informed decisions about their value. For the care programme approach, clinicians need to take responsibility for shaping and researching it. Administratively coherent but clinically nonsensical definitions should not be allowed to confuse thinking or determine practice.

Professor St George's Hospital Medical School, Department of Mental Health Sciences, London SW17 0RE

Tom Burns 

1. Marshall M. Case management: a dubious practice. BMJ 1996;312:523-4. (2 March.) [Free Full Text]
2. Care-management: a disastrous mistake [editorial]. Lancet 1996;345:399-401.
3. Franklin JL, Solovik B, Mason M, Clemons JR, Miller GE. An evaluation of case management. Am J Public Health 1994;77:674-8. [Abstract/Free Full Text]
4. Solomon P. The efficacy of case management services for severely mentally disabled clients. Community Ment Health J 1992;28:163-80. [Medline]
5. Marshall M, Lockwood A, Gath D. Social services case-management for long-term mental disorders: a randomised controlled trial. Lancet 1995;345:409-12. [Medline]