The home treatment enigmaHome treatment—enigmas and fantasies
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7230.305 (Published 29 January 2000) Cite this as: BMJ 2000;320:305All rapid responses
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Editor - In their recent review Smyth and Hoult note that
Psychiatrists in the UK continue to show an enigmatic resistance to the
implementation of Home Treatment services.1 This is in spite of
overwhelming evidence in favour of this modality of care. The response to
their article by Pelosi and Jackson effectively solves the enigma.2 It
would appear that resistance to working with patients in non-institutional
environments is due to the persistance of psychiatric paternalism and
simple professional conservatism.
It would appear that Pelosi and Jackson do not really understand what
Home Treatment services are all about. They suggest that there is no
need for this modality of treatment in the UK because of the existence of
community mental health teams and well developed primary care. In
fact, Home Treatment is meant as an alternative to acute hospital
treatment. They are not meant as additional services which would
duplicate work already being carried out by General Practitioners and
Community Psychiatric Nurses. Their claim that research on Home
Treatment is
"out of date" is simply wrong.
Pelosi and Jackson fail to cite any research which supports a
maintenance of the status quo in the area of acute psychiatric care. A
recent report from the Sainsburys Trust came to the damning conclusion
that "hospital care is a non-therapeutic intervention".3 Service users
have
repeatedly asked for the availability of a range of interventions in times
of crisis.4 The increasing trend towards Home Treatment and its
inclusion in the Government's National Service Framework reflect a belated
response to such requests.
We have all worked, in various capacities, with the Bradford Home
Treatment Service which was established in 1996. This service has proved
to be very popular with patients, carers, and professional colleagues.
We asked a series of 96 patients who had experienced both Home
Treatment and Hospital care about their views on both. Eighty-one per
cent indicated a preference for Home Treatment. In addition, experience
gained from working with people from the ethnic minority communities has
shown this way of working to be particularly appropriate.
The Prime Minister has recentluy challenged Health Service staff to
abandon conservative attitudes and pracitices. Users of our services are
crying out for change. Pelosi and Jackson are entitled to their opinions
but we hope that other Psychiatrists will read Smyth and Hoult's excellent
review without the same degree of prejudice.
Patrick Bracken, Consultant Psychiatrist
Jonathan King, Senior House Officer
Hasan Daudjee, Consultant Psychiatrist
Phil Thomas, Consultant Psychiatrist
Billy Ralph, Senior House Officer
Anne Cahill, Clinical Medical Officer
References:
1 Smyth MG, Hoult J. The Home Treatment Enigma. BMJ 2000;320:305-8
2 Pelosi AJ, Jackson GA. Home Treatment-enigmas and fantasies. BMJ
2000;320:308-309.
3 Sainsbury Centre for Mental Health. Acute problems. A survey of the
quality of care in acute psychiatric wards. London. Sainsbury Centre for
Mental Health, 1998.
4 Sayce L, Christie Y, Slade M, Cobb A. Users perspectives on
emergency needs. In: Michael Phelen, Geraldine Strathdee,
Grahem Thornicrogt, EDS. Emergency mental health services in the
community. Cambridge: Cambridge University Press.
Competing interests: No competing interests
Editor - The authors of the response to Smyth and Hoult (1) have
dismissed an anodyne but comprehensive presentation of empirical research
regarding home treatment, and with it the case for the inclusion of crisis
care provision in the NHS (2). Pelosi and Jackson discount published
evaluation studies, countering with anecdotal evidence concerning the
practice of crisis care (2). We wish to offer new evidence, gleaned from a
nationwide survey of crisis service provision, concerning the scale and
character of this provision that adds to the debate and contextualises the
argument (3).
Firstly, Pelosi and Jackson described an out-of-hours crisis team
that experienced a very low level of take up of the service. We too have
carried out a case study, showing a low level of take up (4). This was in
part occasioned by the fact that few GPs (the only referring agent) knew
that the service existed. Pre-existing patterns of patient management,
particularly referrals, take time and commitment from senior professionals
to adapt to the provision of new services.
Secondly, staff of Pelosi and Jackson’s cited project became involved
with clients’ emotional and social problems and were therefore distracted
from the needs of the severely mentally ill. Our research suggests the
contrary in that many crisis systems specifically do not deal with such
problems, but rather concentrate on providing support for those with SMI
(over 55%). These data are not based on a case study, but on a survey of
all services extant at 1/5/99 (3).
Thirdly, Pelosi and Jackson commended the work of GPs as the people
who have known clients for years and noted GPs' enthusiasm for care of the
mentally ill. Our work shows that of 150 crisis services sampled, GPs were
the major source of referrals in most cases. Clearly very large numbers
of GP's value and make use of crisis services as an integral part of their
care of the mentally ill.
Finally, Pelosi and Jackson referred to inexperienced clinicians
setting up services. However, hundreds of services are in operation and
each has to have an RMO. From our record, crisis teams have been operating
for an average 28 months giving 308 years of service operation, and hence
experience. Moreover, we would point out the expertise contained within
crisis services in the UK does not reside wholly, or even largely, within
psychiatry. Rather the significant minority (45%) of crisis teams are
multidisciplinary in nature with 55% mainly nursing.
1. Smyth MS, Hoult J. The home treatment enigma. BMJ 2000;320:305-08
2. Pelosi AJ, Jackson GA. Home treatment-enigmas and fantasies. BMJ
2000;320:308-09.
3. Hogan KM, Orme SA. The organisation of UK crisis services (in
prep)
4. Hogan KH. et al. Walsall Crisis Support Service Evaluation Report.
Unpublished report for Walsall Health Authority, 1997
Competing interests: No competing interests
Home Treatment
Editor - In their recent review Smyth and Hoult note that
Psychiatrists in the UK continue to show an enigmatic resistance to the
implementation of Home Treatment services.1 This is in spite of
overwhelming evidence in favour of this modality of care. The response
to their article by Pelosi and Jackson effectively solves the enigma.2
It would appear that resistance to working with patients in non-
institutional environments is due to the persistance of psychiatric
paternalism and simple professional conservatism.
It would appear that Pelosi and Jackson do not really understand what
Home Treatment services are all about. They suggest that there is no
need for this modality of treatment in the UK because of the existence of
community mental health teams and well developed primary care. In
fact, Home Treatment is meant as an alternative to acute hospital
treatment. They are not meant as additional services which would
duplicate work already being carried out by General Practitioners and
Community Psychiatric Nurses. Their claim that research on Home
Treatment is
"out of date" is simply wrong.
Pelosi and Jackson fail to cite any research which supports a
maintenance of the status quo in the area of acute psychiatric care. A
recent report from the Sainsburys Trust came to the damning conclusion
that "hospital care is a non-therapeutic intervention".3 Service users
have
repeatedly asked for the availability of a range of interventions in times
of crisis.4 The increasing trend towards Home Treatment and its
inclusion in the Government's National Service Framework reflect a belated
response to such requests.
We have all worked, in various capacities, with the Bradford Home
Treatment Service which was established in 1996. This service has proved
to be very popular with patients, carers, and professional colleagues.
We asked a series of 96 patients who had experienced both Home
Treatment and Hospital care about their views on both. Eighty-one per
cent indicated a preference for Home Treatment. In addition, experience
gained from working with people from the ethnic minority communities has
shown this way of working to be particularly appropriate.
The Prime Minister has recentluy challenged Health Service staff to
abandon conservative attitudes and pracitices. Users of our services are
crying out for change. Pelosi and Jackson are entitled to their opinions
but we hope that other Psychiatrists will read Smyth and Hoult's
excellent review without the same degree of prejudice.
Patrick Bracken, Consultant Psychiatrist
Jonathan King, Senior House Officer
Hasan Daudjee, Consultant Psychiatrist
Phil Thomas, Consultant Psychiatrist
Billy Ralph, Senior House Officer
Anne Cahill, Clinical Medical Officer
References:
1. Smyth MG, Hoult J. The Home Treatment Enigma. BMJ 2000;320:305-8
2. Pelosi AJ, Jackson GA. Home Treatment-enigmas and fantasies. BMJ
2000;320:308-309.
3. Sainsbury Centre for Mental Health. Acute problems. A survey of
the quality of care in acute psychiatric wards. London. Sainsbury Centre
for
Mental Health, 1998.
4. Sayce L, Christie Y, Slade M, Cobb A. Users perspectives on
emergency needs. In: Michael Phelen, Geraldine Strathdee, Grahem
Thornicrogt,
EDS. Emergency mental health services in the community. Cambridge:
Cambridge University Press.
Competing interests: No competing interests