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Rapid Responses: Rapid Responses published:
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Editorial misses the point
- Roger L Weeks (20 August 2007)
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Community Mental Health Teams can provide assertive treatment function
- Walter M Braude (20 August 2007)
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Assertive Community Treatment- A wasted Opportunity?
- Thomas E Elanjithara, Miriam Isaac (21 August 2007)
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Assertive Community Treatment
- Keith Greenlaw (22 August 2007)
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Roger L Weeks, GP East Sheen SW14 7DF
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Helen Killaspy's editorial on the success or failure of assertive outreach teams in community psychiatry omits to highlight the key message contained in the last words of Burns et al's systematic review of intensive case management of people with severe mental illness - 'Our study confirms a growing recognition that we should research the practices of teams rather than their labels.' The introduction of assertive outreach teams in addition to the Community Mental Health Teams (CMHTs) was typical of bad thinking in NHS management which invariably adds further layers of management or new teams to deal with problems not solved by existing structures. A more rational response to the failure of CMHTs to reduce in-patient stays and engage better with poorly or non-engaged severely mentally ill patients would have been to examine the ‘culture’ and work patterns of these teams to see why they were failing and put the extra resources diverted to assertive outreach teams into the CMHTs and target better care for this vulnerable patient group. The new assertive outreach teams let CMHTs ‘off the hook' allowing them to ‘dump’ more time-consuming and more difficult patients on the assertive outreach teams. Moreover assertive outreach teams failed not only to reduce admissions but, in my area at least, to communicate with GPs and other parts of the primary care team so that in some instances care of vulnerable patients was worse than before. Locally, I understand, the failure of the assertive outreach team has been recognised and in future the assertive outreach function will be integrated into our local CMHT which hopefully will provide a more integrated service. Is it too much to hope that the Department of Health will learn from this failure of policy driven by eye-catching label or 'spin over substance' as we now like to say? I expect it is! Competing interests: None declared |
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Walter M Braude, Consultant Psychiatrist/Associate Medical Director Hollins Park Hospital WA2 8WA
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Killapsy reviews the success of assertive outreach teams,referring in particular to Burns and colleagues` systematic review of the impact of such services on outcome. These teams (and others) were originally set up at considerable expense following the the National Service Framework for Mental Health.These teams came with the usual carrot and stick from the Department of Health--extra money for setting them up with a clear directive to create new stand alone teams.Those of us who argued at the time that this centralized "one system fits all"service irrespective of the quality of existing local services and their local demography were seen as resisting the march of progress. It is perhaps not surprising to discover that the functional characteristics of these teams and the areas that they serve have more impact on outcome than their mere existence.In fact I would argue that these teams often lead to demarcation disputes with other teams which can be counterproductive in providing treatment and care. Unlike Killapsey I cannot see why these Community Mental Health teams cannot provide these functions particularly if they prioritise their services to the most ill clients who are reluctant to engage in sevices.Is it too much to ask for these teams to focus more of their time on this patient group? Competing interests: None declared |
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Thomas E Elanjithara, Staff Grade Psychiatrist South London and Maudsley NHS Foundation Trust, 98-102,Northover,BR1 5JX, Miriam Isaac
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Dear Sir, We read with interest the editorial written by Helen Killaspy. There is a possible threat to the survival of assertive Community teams in the current financial climate of National Health Service. At this moment there are two very significant questions that need addressing. The first is about the organisation and nature of the work that such teams should be doing. It has direct implication on the potential role of the Assertive Community Team in managing mental disorders. The second question is if a long term benefit going unnoticed, by measuring inpatient bed use in short term as a negative outcome for the assertive community service. In addition to “team based approach” organisation of the services, focus on the nature of the work done by the team is also crucial. With the availability of multidisciplinary input, assertive community teams have the potential to play key role in treating severe mental disorder, promoting recovery and work on relapse prevention. Assertive community teams are better poised to address arduous issues like, complex interpersonal and familial dynamics, substance misuse and social problems. These factors play crucial role in recovery and relapse prevention stages. Team Psychologists could supervise the case managers to use essential techniques to engage and support difficult patients and families (1). There is good evidence of long term benefits of community interventions in substance misuse (2, 3). When assertive community teams have responsibility for both health and social care of the patients, it tends to reduce days spend in the hospital (4). Thus by minimal but work oriented reorganisation of the assertive treatment teams, could help them establish a “central role” in treating severe mental disorder. This leaves the inpatient care to act as a container during serious risk states and regular community health teams to provide maintenance and follow up. Though some of the economic evaluation studies done in this topic, included cost benefits over a few years, wider economic benefits are going unaccounted. Outcome parameters such as longer term hospital bed saving, life skills, quality of life, patient and carer satisfaction and use of service in general over a long period of time, should be used to measure the success of such service (6, 7). The assertive community teams established across the country should be given fair attention and opportunity to deliver its true potential. Reference: 1) An integrated medical and psychosocial treatment program for psychotic disorders.- Malla A K, Norman R M, McLean TS. Canadian journal of Psychiatry, Sep 1998,Vol 43. 2) Randomized controlled trial of Motivational Interviewing, Cognitive Behavioural therapy, Family intervention for patients with co morbid schizophrenia and substance misuse disorders.- Barrowclough, Haddock, Lewis, Mc Govern. American Journal of Psychiatry 2001,Vol 158. 3) Family intervention for co-existing mental health and drug and alcohol problems. Smith, Velleman. Clinical handbook of co existing mental health and drug and alcohol problems, 4) Crisis intervention for people with severe mental illness. Joy C, Adams C. Cochrane Library issue 2. 2006 5) Patterns and predictors of hospitalisation in first episode psychosis.- Sipos.A, Harrison.G, Gunnell .D. British Journal of Psychiatry. June 2001. Vol 178. 6) Assertive community treatment for persons with severe mental disorders: A controlled treatment outcome study. Hamernik.E, Pakenham.K, Behaviour change, 1999, vol 16. 7) Acute wards: Problems and solutions. Alternatives to acute wards: Users’ perspective. Relton. P, Thomas .P, Psychiatric bulletin Sep 2002,vol 26. Competing interests: None declared |
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Keith Greenlaw, Former clinical director Myddfai Psychotherapy Centre, pembrokeshire and derwen NHS Trust Retired
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Brief interventions can raise hopes of the sufferer and carer, only to be disillusioned when the team leaves, and the follow up is less intense. The situation can actually be made worse. Continuing support without limit is essential in illness that may be life-long. Acute interventions may reduce but cannot replace admissions to a place of safety. In severe mental illness stress repeatedly builds up to a crisis. The need is for removal from a stressful environment in the early stages. This need not be a hospital, but could be a suitably staffed hostel offering temporary sanctuary. This could be the most effective way of avoiding crises. The prospect of there being no refuge at all is just not acceptable. The sufferers from severe mental illness and their carers can be well supported by a team as described in the article as long as one essential element is present. This is a therapeutic relationship, which is largely avoided by professional staff in the belief that the patient will become dependent and deskilled. Properly taught this skill is fundamental to encouraging self management, independence and self confidence. Without it sufferers frequently feel that they are of no significance, and carers increasingly isolated. This essential element of care appears to be actively discouraged today. 'In vivo'is an amusing term for out of office visiting. certainly some of the current planning for mental illness has the air of being conceived 'in vitro'. Competing interests: None declared |
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