- Max Marshall
- Senior lecturer in community psychiatry University of Manchester, Royal Preston Hospital, Lancashire PR2 9HT
Underevaluated and ineffective, but now government policy
American psychiatrists visiting Britain will experience a sense of deja vu when they encounter the recent clutch of community care “initiatives.” They will soon spot that “care management” and the “care programme approach” are no more than a rehash of “case management,” an old American idea. From politeness they will probably refrain from telling their hosts that there is little reason to believe that case management works.
Case management arose in the United States in response to the dispersal of psychiatric and social care that followed the closure of large mental hospitals. The basic idea was that a designated person, the “case manager,” would take special responsibility for a “client” in the community. The case manager would assess the client's needs and ensure, through a care plan, that suitable services were provided to meet them. The case manager would also monitor the provision of these services and maintain contact with the client.1
From the beginning the literature on “case management” has been bedevilled by a tendency to lump two different approaches under one name. The first approach could be described as “standard” case management. This is a low intensity approach in which case managers offer a largely “office based” service, brokering interventions from other agencies. Each case manager has a case load of 30 or more clients whom they see infrequently. The standard approach has several variations in which case managers take a more therapeutic role and carry smaller case loads. Yet even these “clinical” case managers tend to offer fairly low intensity intervention.
The second approach lumped under the term “case management” is more properly described as “assertive community treatment.” This bears little resemblance to “standard” case management. The assertive community treatment approach is provided by a dedicated multidisciplinary team of mental health professionals that generally includes a psychiatrist. The overall patient-staff ratio is low (about 10:1) and the level of face to face contact is high. The importance of individual case loads is played down; instead team members work with patients as and when their particular skills are required. The team concentrates on avoiding hospital admission and developing patients' independent living skills. Assertive efforts are made to retain contact with patients.2
There are at least 13 randomised controlled trials of assertive community treatment in the world literature, 12 of which have found the approach beneficial when compared with routine management. There are at least nine randomised controlled trials of standard case management and two well designed non-randomised controlled studies, all but one of which have largely negative findings. Curiously, the whole thrust of community care policy in Britain is towards the implementation of standard case management by another name.
Case management arrived in Britain in the late 1980s, giving rise to two parallel but closely related developments: social services “care management” and the health services “care programme approach.” Social services care management was the first to take off, after the publication of the Griffiths report on community care.3 This report recommended that case management (provided by social services) should be at the heart of community care for severely mentally ill people. Griffiths had a particular eye on the brokerage aspect of case management, seeing it as an efficient means of providing “tailored” packages of care. After the Griffiths report a number of confusing and disruptive “innovations” ensued. In some areas social workers were withdrawn from clinical duties to act as “purchasers of care,” plunging existing multidisciplinary teams into chaos.4 In other areas, social services “care management” teams were set up to provide clinical care in parallel with existing mental health services. Such evaluations of these teams as took place provided little evidence of efficacy, leaving social services care management in limbo.5 6
Meanwhile the case management idea was being imposed on the mental health services in the form of the “care program approach.” This was intended to run in tandem with care management, though how or why this should happen has never been clarified. Originally the approach was reserved for the most severely ill patients, to whom the mental health services were required to appoint “key workers” (or case managers). The patients were to receive an assessment of need, a written care plan, and regular reviews organised by the key worker. It is possible to see how, with proper funding and guidance, this approach might have evolved into an approximation to assertive community treatment. In practice, the care programme approach has meant standard case management for all, through a combination of lack of funding, mushrooming paperwork, and its extension to all psychiatric patients. The care programme approach has never been fully evaluated, but a partial evaluation in a recent randomised controlled trial produced disturbing findings: a doubling of hospital admission rates for the care programme group.7
Case management, a practice with little justification, has displayed an astounding ability to flourish in the age of evidence based medicine. There is a simple explanation for case management's immunity to scientific analysis: in Britain it is no longer just an intervention, but a government policy.