2001 - Mental Health Service Provision In England

4rL p\.ttrt. Pt,ln,t.n Ii

s tnd )wt tu4 soat 4ta) 4\5\ 4tr nkhB t?,.^.a

cL2!\isht o Mhklqntt

240l

Mental healthserviceprovisionin England JohnsonS. Zinkler M, PriebeS. Mental health servicep.oyision S. Johnsonl,M. Zinklef, S. pri6be3 in England rDeparmeft of Psychiary aid BehavourarScerces, Acta PslchiatrScand2001:104(Suppl.410): 47 55. FoyaFreiandUnve6ityColeqeMedrcat S.hoo, O Munksgaard2001. rondon,'Ci{andEdr LondoiMentartearhTrusl Objective:To describemental health serviceprovision for adultsof workins:lqejn Encland. I,lcthod:Services rn-anlnner-london!-ea.rredescribed so as lo i l l u . t f b l ec u r r e n pl e l r e f n os t \ e r l r c eo r g a n i z e L rronnE n g l a n d . Nationaltrendsare ihen discussed Results:DesDrre rerativeNlor,,puoIc er,pendirure. 5ubsrtnlial n r O g r e \h5J \ b e e nr ' l a d ej n d e l n s t t l u r i o n a l t Z axLotdu n developmentof comprehensive community-basedservices. Persislingdiffculties includehigh staf tu;nover, a minority of pallenls who do not engagewith communitv services,userand carer dissatisfaclionwith emergencyservices,and social e \ c l r . i o nb c c i r L \oef s r i ! m a .R e c e ngl o r e r n m e npro l i c l a d r u c a l ersc s o . r i n g . o r io t r h e . ep r 6 b l e mu, . i n gn e \ \s e r v t c e

mollcl. suLh r\ asscflt\e outreachand cfls-s Leam\. ( o n c l u s i o n :C l o . L r e o i l h e l a r g er s y l u m \ h s s h r c e l \ been accomnl.\hed.I.ngtJnd s no\r enler.n."a ne$ pha.c jn L o m m u n t l ys c r \ c e d e \ e l o p m e n l$. j L h I r s n g eo l ' I n n o v J l i ! e d e \ e l o p m e n ta. i m e da r r e 5 o l r i n gp r o b l e m s. r i l l e n c o u n l e r e d " f r e r . r h ei n i t ; a lp h a ' c , o f r n , e g r a r i dc o m m u n l r )s e r \ r c c oevelopment.

London andluir fD.SocaandCommun! PqclriaxySt Banhoiomew\ anddraRovai Loodoi Schooof Medicme. LondonUK

Keywods denstlt!roialir6tiDn; Enqland, heath carerc1ormi meotallieahhseryices & SonaJohnsodDelannenloi Pswhlarry and EehavrouG SciemesUCt,[4edftl Sch@l, WolhonBuildiru, 48 FidingHouse Sre6r, Fmail:s.johi$n@@ adl Ths paperwasreadi 6 prelmlnary vereion ar a symDos umonPsyclriatrc Beiormn turopedur'lg fte .onteEme25yees ot PsychiaftEnquere Trcndsand Pe6ps vesoi Psychralm neiom,BDnn Bad60desbeB?2-23Neember2000Thelympo. siumand$s publcaiorweretundeo by$e Wortd rkalb oqaD,atoi Europr. Copeihaqen andthe tede6 MnNtryof Heafi,Sonn/Ben

will thendiscussthe extentto which this snapshot js typical of the curent state of mental health Mental health servicepolicy and serviceprovicare across England. We will identify some sion in England have beencharactedzeo nor ov strengthsof the current system.arld will then L h es i n ! l e - . r a B. n e r r o d L c t i oonl a r i d e r a n g i n g describemajor p.oblems \rhich continue to be policy of reform but by continuousdevelopment debated.We will oulline some of the proposed towardsmore community,bas€d careover haif a solutions to these problems, including those JenLr\. Neu go\ernmcnlpolic) hasbeeninlro. proposed in the National ServiceFramework d:ceJ Irequenrh orcr lhrs per'od. somerrmes a l ) a n d t n e \ H S P l a n r 2 r . T h i , p a p e r i . seemingto drjve lhe processof changeforward, concernedonly with NHS provision: while the sometlmesto reflectchangeswhich havealready pdvale health care systemis an imporrant pro lekenpiacein many areas.Substantialvanaltons vider of psychologicalrreatmentssuch as psyhd'( pe_\istedberweenJreas ir Lhe serrrr'es chodynamicpsychotherapy, its role in treatment available,variations\rhich the UK governmenr o' severebnd endLrirg mental illnesses .s a is seekingto reduce through developmentand marginal one. We have focused on England jmplementatiorof the National ServiceFrame, aione, as countdes within the UK have had work for Mental Health (1) and the subsequent diffe ng policiesand patternsofservicedevelopNHS lNational Hea]th Servicelplan (2). ment. The scopeof our discussjonis limiled to ln lhis paper,rvewill flrsr providea snapsho!of specialistmental hcalth carefor adults of workthe curent slate of mental health seNicesby ing age:many impodant issuesrelatingto other descdbingse ice provisionin the London catch- psychiarricsubspecialties and to mental health ment arca in which the first author works. We care in primary care are thus omifted. Our lntroduction

47

Johnsonet al. account is based where possibleon published 01 data, but we also draw on our experiences working in, researchingand discussingmental health servicesin England.The viewswe express are our own, and not the oliicial ones ol any institurion or public body. A snapshol of mentalhealthserviceprovision in England: tft€LordonEorough ol lslington In this seclion, we will describethe ser\,lces provided for Ihe population of rhe London B o r o u e ho f I . l i n g r o n .l s l j n g r o nl r a \ o c i o cconomicallyvery mixed area of Inner London, in which the extremesof British socielyare overrepresentedwith enclavesof wealtharnongarees of considerablesocialdeprivrtion. Around 20% of the populatioo of 175000 come from ethnic minodty backgrounds.For mental health care provision, thc Borough is djvided into five geographical sectors of approximalely equal size. Currently boundariesbelweensectorsare geographical, with eachsectorcoveringa number of electoral wards. So as to strengthenlinks beLueenprim.rr\ and ..r'onrlarl c:,re services. plans are beingmade to changeto sectorsbased on general practitioner lisls. with each sestor c . r r ei r g a g l o u po f l o c a g l c n e - rp. r r c ' , r i o n e r . . provided Services at sectorlevel ln-patient beds

patients are likely to have been compulsorily detainedin hospitalunderthe UK Mental Healih Act. and more than half are likell/ to have a diagnosisof psycboticillnessol someform (-1). Over the spaceof 1 yearbetweeD1998and 1999, l1l5 oompulsorydetentions under the Mental Health Act (4) took placein the wider catchment areaofwhich Islingtonfonnedpart, Camdenand IslingtonConmunily HealthSe icesNHS Trust - this area has a population of approximately 272 000. Resldentsof Islington also haveaccess1()two innovativecrisis houses.Theseare non-hospital facilitieswhich admit palientsin crisis and are staffed24 h a day. One is a women-onlyfacility funded by the local menlrl health Trusl, which admits 12 women al a time for a maximum of 4 weeks.It occupiesa large nineteenth-c€ntury housein a residentialstreet,and is inlendedro servewomenwho would otherwisehaverequired admissionto e psychiatricward. Mosr women who use rhis fxcility have a previoushistory of admissionto psychiatrichospitaland rppear to be managedsal'elyat rhis house(5). Islington now has no designatedloug-stay werds, although t\\,o small wards have rehabilllalion in-patieDt beds to $hich residentsof lslingtonor neighbouring Camdenmaybeadmitled for longer slays. Most in-patient stays on a (u , eq d r d sa r e6 n l . h e w d i t t u nd f e i u e e k, o u La hendful linger for many months on lhe wards, mainly becauseof difficultiesin linding appropdate accommodation.Moving these'new longstay' patientson from the acutewardshas often presentedconsiderable problemsto cliniciansand managers,and a new mullidisciplinaryaccommodation team including nurses.socialworkers and a psychologisthas recenllybeeneslablished to cary oul detailed assessments and seek appropnateplacenents.

I a c h e c o g r J p n r c \ael L r . \ rh a 5 a r o m m u n i r l mental health leam and dedicaledbeds on an acuieln-patrentward, The acutewardsfor all the geogr!phicalsecru15 are ba.ed tngcrh
ll€ntal healthseryiceprovisionin England disabled.In 1998.the comnlunit)' nurses,social wolkers and psychiatristmoved to this omce from their prevjousi] separatebases,and began v,orking logetheras a much more closelyinleg, raledte.rm.The leam leaderis a seniornursc.The re.rm o f l o l n c l u d ee. n u c c u p a l o n at hl e r a p r sxt . half-time clinical psychologist,a half{ime consultant psychiatrist and two part-time luntor psychiatrists: around half of the rest are commupsychiatricnu$es and hall socialworkers. nit,u'. Mosl membersof the rcaunhave al least2 years postqualilicationexpericnceand several more than l0 years. The leaur hours are Monday Friday, 9 a.m. 5 p.m. Each morning one of the professiooals in lhe teamis responsiblefor receivingand deciding how to dealwith ell new refc|ralsto any professLonals in the team (inclLrding psychiatrists). New referals,clinicalproblemsand liaisonwith other rJencierared'.cu.\edc.rh vreekar a 3-hmeetrng etlendedby all team members. All Ieau membersexceptthe psychiatristhave a case-loadof patientsidenlifiedas havingsevere and enduring mental illnessfor whom they are care oo-ordinators.The Care ProgrammeApprcachis,r setofprincipleslor organizingmental lreblllr.rre rhich all UK mrntalher,thservices l,a\c herr fequ;redb\ la\ rn in pler.reni'ince 1993.The major principlesare as follows. Eech patient idenliil€d as having a severeand enduringmen|alillnessmust havean idenri6ed care co-ordinalor, \ 'ho is an experienced mental health professional.The care co-ordi, nator is responsiblefor keepingin touch with the patient,offeringsupportand respondingto -ry mdjorchdngeor cri'i.. orsdnizlng revieu.. checkingthat all the servicesin contact \rtth the personare working togethefin a co-ordinaredway and making surethal the careplan (seebelow)is put into acrion. . There is an identified consultantpsychiatrist r e . p o n . i b lfeo r r n c d r . arl n p u t L o l h e s e r v i . e users care. This is generallythe consuhant working with the team. . There are regular reviewsof the individual's needsfor clinical and social care, following which n careplan is drawn up. Io the Islington team being descdbed,the averagecaseload for lull-time staff is 25, with 230 p4tientson the team s caseload.Somestall havesmallercaseloadsbecause ofDranagement or olher responsibilities. Somepatienrscometo the centfe to neel with care co-ordjnators,but a greaterproportion are visitedat home.and s1aff are usuallyalso in regularcontactwith informai

carers.Theusualfrequency ofconlacl is every2 or 3 weeks.with weeklycontaotsfor padenlswith a high erel uf needor who hare recenr.lbeen dischargedfrom hospitalor appearto be deteriornting.More frequentcontactscansometimes be o l l e r e df o r s h o n p e r r o d \. ' h c n p d t i e n t rsr e i r c r . i . . b u f l r en o l s r o u ' i n ep " r t o f r h e , c ' \ ' i ! ( . Around 60Yuofteam patientshaveschizophrenia, schizoeffective disorderor bjpolar affeclivedisorder and most havehad hospitaladmissions. Reviewsof need under the Care Programme Approach usually take placeevery 6 months.A reviewis alsoheldcloseto the time ofdischargeif a patient is admitted. The care plan drawn up I'sts contrct details for all involved in the patient'scere,diagnosisand medication.clinical end socinl needsidentified and plans made to meet these,early warning signs of relapseand planstbr cdsismanagement.Reviewsusuallylasl around half an hour and are attendedby the patient, care co-ordinator arld psychiatrisr. Inlbrmal carersand other professionals involved in patients'caresuch as day centreworkers and housing support workers are oflen also in\it(d. The\ere\iew\rre rherndlnocca\lonon which patients have regular contact with the team's psychiatrists, but care coordinatofs arrange extra meetings wilh psychiatrisrsif concernsanse. Out-patientclinicsfor the seclorare also held a t l h e c e n l r eA. r o u n d 1 5 0n r r e . t a b l e p a t i e n t s who haveno teamcareco-ordinalorare followedup in theseclinics.and around three patientsa weekareseenfor a singleassessment and aeferred b a c k l o t s e n c r aplr i r c l r l r o n esr r. t h . i d \ r c e o n continuingmanagementin primary care. Assertive outreach andcfisisfesoutlonteams Three new community-based teamshave,in the past 3 years, been edded to the flve sector c o m m - n i . ym e n l a l\ e h . r h t e d m s ( l n e i . a n assertiveoutreachteam with a caseload of 65 patjents.lt has 10membersincludinga half{ime consuhantpsychiatdst,a half-lime clinical ps""_chologist.an occupatjonaltherapist,communit] mental healthnurses,socialworke$ and a community supporl worker. The team'stargetgroup havehad frequentadmissions,presenta substantiai risk to themselvesor others and have not engagedwell with community mental heallh teams.The team is available7 days a weekand u u f * . m d r n l )i n p a t i e n r .h o m e so r d n t o r l - e communitysettingsin which sraf are ableto find and make oontactwith patients.Staf havemore dme availableto spendwith eachpatientihan jn 49

Johnsonet al. the community mental heallh teams-and make variedand multiple atrcmplsto engageand keep in touch \\ith patients.They aim to build close rclalionshipswith clientsand plan togetherways of tackling problems in areasincluding social networks. finances.bcnefitsand budgetng, acoccupa_ cornmoda!ion,leisure,useof substances, tion and heallh. wherc requircd, the! vis1i patienisdaily to givethemmedication-Discharge is planned only when consid€rablestability has beenachievedTwo crisis resolution teams have also beetr establishedin the past 2 years,one working in three mcntal health sectorsin North Islington and the other in two sectorsin South Islinglon. a juruor pnMembersoi erch leam inclr.,de chiatrist,communitymentalhealthnwses.soclal workers and commllnily support workers. The consuhantpsychialdstin the sector \\'herc the pdlienr li\e. retuins re.oon.ib.lrLyfor .enior medicai input during the period of crisis team 1rcalment.One team is led by a nu$e. the othcr b) a 5ocirl!Lorker.fhe rervicet.irgebpdtient\ \rirh psychiairic disorders lor whom, rn lhe absenceofa c sisteam.acuE hospitaladmission Other mentalhealth would be seenas necessary. services.primary careservicesand the policeare among the agencieswho refer lo the leam, and parienr. al'o reler lnem.elves.I he te.lm i. lreats and available 2,{ h a day and assesses, supports people in psychiatric emergenclesln thei own homcs, or whalever setting is most appropriateto successlullyengagingand managing them. The leen1 aims to rcspond lo \ llh n I h. ano lo scean) Pat.eol cmergencre\ 1brwhom hospitaladmissionis beingconsidered. so thal the feasibilityofintensivehometreatment Whereho.prl:rladmi5rioni: .ao be considercd. consideredrecessarydespitethe team'savailability, thc teamaimsto facilitatean earlydrscharge wilh intensivehome support. If required, they can visil patients several aimesdail! and for extendedperiods during the emergencypenod, offering advice, monitoring, help with social problemsand medicationmanagementBoth asscrtiveoutreach and crisis resolution teams adopt a team model of working, where p a u e n ra. r eh a \ ec o n l a cwL. t h . e \ e r . l l m e m boeff . r n el e J md n o s l a l Td l m l o . o n b i n et b e l rt r r i o u s skiilsto pian efectivecare.At the limc olwriting, the teamsare still in a slart-upphase:randomized evaluationsand phased increasesin caseload mean that they have nol yet reached their full working capacities and caDnot yet be expecledto have had their maxrmumrnpact on aculebed use. 50

servces 0therresidenllal Within the Borough of Islington, a Iange of specialislhousing schemesproYide places for people with mental health problems, many managed by voluntary scctor (chariteble)organizations.Theserangeftom hostelswiih 24-h slafflngto supportedflals wherea worker vrsrts tenantsweekly for pracllcal suppofl and monitoring. However, many schemesarc full, and delaysand dimcultiesolten arlseln considerable linding appropriateplaces.Finding placements whe.e individualswilh comorbid severemental illnessand substancemisusecan be supported DresentsDarticularproblems.The mein empharcneme\i\ on "i. rn plunnrng'rerl resiuenrial p r o r rncre.r.ine r.r,n of.rpponed lenancies nhere serYiceusers live in independentflats close to a ccntral ofice at which specialist support stalf are based.Daily visits iiom lhese st;ff cdn be provided in some of the schemes, bui oncethe patient is more slableand this has b e e n $ i r h d r a t r n f. : t r e n L rc J n t l 5 u . ' l ) r e l a i n lenanc] of the same flat. Accommodationof this form is currently Iavourcd- as many younger\cr!ire u\er\ $ho hir!e ne\er e\ner" enced long-term institutionalizalionare reluct_ ant lo -n.r\c lo tr.idl onll ho.lel \ctllng' *here

they feel rhey will lose privac, and independence to an unacceptableexten!, Theseschemes also provide patients wilh a long term home which they will not lose if their support needs diminish. heallhseryces 0lhefmental lslington also has six mental healthday centres, where.ocialconracl.slrplorl from 5l.rT.crcd \e and recreationalactivities and support gronps of various loms are avai]ablein a relatively inlormal setting. Some also have limiled work training or work placementschemes,although in general avaiiabilily of training for work, suppo ed placem€ntsand shelteredwork sec trrigs is very limited. The majoriiy of users of these centres have a history of contact wilh specialisimelrtalhealth se ices.One of the day cenires is dedicated to black Caribbean and users.Another providesa black Alrican serrr'ice odented programme of ps,vchotherapeulically groups. Serviceusers can attend these centres 'org rirm. A l h e a c u l ep s ) c r r l r l f .i n ' p a l i e n l unil site there is a day hospital: this 1s not an emergencylacility, but provides longer term care including psychotherapeuticallyorlented trearmenland occupationeltherlpy.

N{entalhealthserviceproyisionin England England for aduhs under 65 (E). The mean length of theseadmissionwas 52 deys, but the medianonly 17 days.Thepredominantdiagnoses There are some major r€spectsin which lhis or current ,er! ice speciljed were schizophrenia,schizotypal and .rrp.hot r. reprcrcnlalrvc provision in England and Wales. Bed numbers delusional disorders, accounting for 36 806 : , , L l m i ' . , oI 'nnse da n . r r ) J I L l d l q . 5 q 0o "' p a t i e n t . l r l l . e l a i s ea \ y l r m 5h d r e b e ( n t d l l i n gs i n c ea peak in 1954of 152000 peopleoccupyingpsy- male).mood di50rders\r'irh r4 Jlj adnus5lonj chiatric beds. Eventual closure of the large f 6 i 0 ol e n _ r l em. e d l x sn l a yJ l d i y r . r n d n e u r o l i c . behaviouraland personalitydisorderswith 30 41E asylumshas been governmentpolicy since the admissions(57% femdle,medianstay 8 days). early 1960s,and. althoughimplementetionofthis Turning to communityservices.the pattem ol policy has been sloNer than initially envisaged (3). most have now closedor have only a small \cfvicepro\rrlonlbund in lilingrunis represen tative of areaswhich have beenrelativelyquick lraclion of their original patientpopulationsstill resident. While heated debate persists about to implement new service models and policy directives.Sectorization.care by multidisciplinmany other aspectsof se ice provision,there is no\\ a substantial consensusamong mentel ary communily menlal health teamsand imple mentationof the CareProgrammeApproachare health professionalsand managersthal mosl long-stayin-palient bedsoutsidesecurehospitals almost universal features of communitt_care crrr br repLecd b) cormunilt alternatives. provisionacrossEngland.Sectoizationoccurred Support for this comes lrom the TAPS study in most areasin the 1980s,eventhoughit haclnot (6), a largeprospectivestudyof outcomesfor 670 as yet becomegovernmentpolicy at the time (9). .ong-sla\pet.entr di'chirrgedfrom tuo inner Similarly, mulridlsciplinarycommunity mental health teams which carried out much ol their London asylums. Although a smal1minority $ o r k . D p a t l e n: h o m e . $ c r e . l m o s l J b , q L i l u r r \ proved very diffcuh to resettlesuccessfullyin the community.in gencralplacementoflong-s|ay by the time they became governmentpolicy patients in the comnunity appearcdsuccessiul. a r o u n dl e L r 5( , 0 . r .H o $ e ! c r .r n m a n r a r e r . i r with few problems with crime or vagrancy. has taken someyearsfor lheseteamsto obtain premiseswithin their small seographicalseclors, Positivechangeswere rcportedin quality of life and palierl\ so that in someareastheyhavecontinuedto work and 'u.,a network..rfterdi.charge. g r n e r a l 'w - ' , r n t e dr o r e m r i ni n r h e i rc o m m d n i t ) fiom ofrcesin lhe local hospital:1br example,tn Londonin 1996,only nineof 27 localaulhority placements. Mosl of the hospital bedsdedicatedto mental ereas surveyedhad community menlal health centresin every small geographicalarea, tthile illnessare now acuteor securebeds.Figuresfor l h r e ea r e d .h J d n o s u c hc e n l r e(sl l l . T b ed e t 'e , bed usein Islingtonare typicalolareaswilh high levelsof socialdeprivation,llhere aculebed use, of integralion betweenNHS mental health and social seflices also varies. Governmenl pohcy ratesof compulsorydetentjonand proporrionof in-patientswho have psycholicillnesshale gen- now requircsplansto be madefor socialworkers erally beenfound to be considerablyabovethe employed by local authority to work in ioint as nationalaverage(3). National statisticsfor 1999/ teamswilh NHS mental heallh prolessionals, 2000indicatedthat of 186290 National Health describedabovein lslington. However,there is Sc ice beds in England, l4 l7J were dcdicated considcrablevariation ir1 the exlenl to which ro mental illnessand 6834to learningdisability theseplans have so far been implemented.Tbe (7). Excludingbedsfor childrenand older adulls careco-ordinatorsyslemand the revjewsofteeds over 65, there were 14 118 sho -stay beds and seryice co-ordination required under the available for the mentally ill, 1882 in secure Care ProgrammeApproach appear now to be unirs end 4305 long-stay bcds; 90.5% oi the implemenledthroughoutthe counlry. No recentpublishednationaldala appearto be availablebed days in shoi-stay units, 92.9% in . e . u r eu n l s a n d 8 o . o 0 0l n o r g - ) l ! ) - n i l s \ e r e available on the exlen! of provision of crisis used.Three years previouslytn 199617,3'7640 teamsand acuteoutreachteams,but many such in the past bedswere dedicatsdto mental illness,including teamsappearto havebeenestablished governrecent ld 504 )horLSt3)bedslor adult"under65. 5d2,1 5 years and, as discussedbelow, these models mole ment policy will disseminate iong-siaybedsand 1575secureunit beds.Thus a accommodasmallfall has occunedin long-staybednumbers, widely- Dar-.centresand residential tion are generallyavailable,but the forms these but not in acuteor secureudt bed numbe6, Figures on use of these beds in 1999i2000 takc and levelsof provision vary considerably and, at leasl until recently,theseforms of care sho$ that t55 121 admissionswerecompletedin Current sewiceprovision in England

5l

I

Johnsonet al. have olien developedpjeoemeal, wirh little planning at catchmentarea or rcgional 1evel.Acute d:ry bospildls are availableas a componenl of emergencyseryicesin somc areas,but absen!in others. There is currently substantialinterestin the cdsishousemodelof care,exempli{iedin the women-onlyhousein lsiineton,but it is not as yet widely disseminared.

cornmentators. to be a responseto very negative media discussionsof communlty care in the 1990s.A numberof actsof violenceby mentally ill individuals receivedextensivepublicit],, and were reportedas indlcaringthat caring for the severelymentallyili in lhe communityis dangerous. This theme has remained dominant in reporting on mental hedlth policy, despitesubstantial evidencethat the .ate of homicide by individuals with menralillnessin the UK hasno1 Howfar hascommunity menlalhealthcare increased as deinstitionalizationhas proceeded beensuccessfu lly implemented? (i4). Attitudesto mentalillnessamongthe public Thus subslantialstrengtls can be identilied in nirror this e)taggerated concem.A large popu seffices in England, despite a relatively low lation surveyindicatedthat attitudesto schizonalional spend on mental heaith services(12). phrenia are especially negative, \,'ith many There has bcen considerableprogressiowards b e l l e \ r nleh J t i n d i v i d u i rwi 5r L hs c b i z o p h r e n a irae deinstitionalization and thl3 development of generallyviolent and unpredictable,as well as community-basedmultidisciplinary carc, evcl being hard ro talk to. Theseviews were more though the paceofchangeand pattemsof seNice prevalent an,ong people under 65 than among d e l i \ e r ]h . r v er r r i e ob e . u c e an f e J \ .I h u \ t r m a y older people,and were widespreadeven among seem surpdsing that in 1998 the following people whose fbctual knowledgeaboul schizoannouncementappearedin tbe Briti.th Medical phreniaotherwiseseemedreasonable. The Royal Jownal (13): College of Psychiatristshas nounted a s-year campaignaimed at challengingnegetivemedia The abandonment oI carein the communilyfor pcoplewith menul illnessas it has operatedrn reporling, increasingpublic understaudingof mentai health problems and reducing stigma Ergiandfor morc than20 yearswassignailedin parliament againstrhe Inentalli,ill(16). thisweekb,vthehealthsecreury.Frank and discriminaiion Dobson . Mr Dobsonacknowledged thal carern Curently this stigma is a cenlral factor in the the communityhad failcd.Too many vulnerable \ o c i d lc r c l u . . i ounh . r h . u n r r n u ersu b e e r p e r . . D d t i e nw r . e ' cb e i n pl e , rl , , , o p e o n e i r o w n . encedby theseverelyenlallyill in England(17). creatinga dangerro ftcmselves andrhepxblic. This statementwas widely pubiicized,although Howcanservices respond etleclively subsequenlmore detailedpoiicy statementsindito mentalhealthemergencies? cated that. apai from someexpansionof secure bed provision, no large,scalereinslitionalization While community mental heallh teams olten q J \ e n v i s J g eHdo. $ c ! e r c. u r r e ncto m m u n i ri a l r e pfovide some emergeocycare, this has usually beenin ofrce hoursonlv and hashad to compete r r r J n g e m e n l$5e r e \ e r n a c i n . l d e q u " t e in a of team members. number of respects.and subsecluenrpolicy, with the other responsibilities After p.m. 5 and at weekends, the major source including the National ServiceFmmework end of emergency help in many areas has been the NHS Plan, has proposedsubstantialchanges. loc.rl casualty department or a hospilal-based How far these slatementsabout thc failure of communitycarercffectedrealiryand how far they emergencyclinic, although a dury psychiafist and socialworker havegenerallybeenavailable were a disproportionaEresporNeto skewedand wherethereis a situation stigmatizingmedia reporting on mentaj health to carry out assessments serious enough lbr immediate detentionin hosrssuescontinuesto be debated_ However,thereis pital under the Mental Health Act lo be considevidencethat- whateverthe achievements so far ered. Groups representing se ice users and carers ol mental health relonns in England, there are jmportant have oftcn expressed the view that emergency some dilemmasstill to be resolved. interventionis not sumcientlyaccessible to them, Someof thesewill now be discussed. especiallv out of normalworkinghours(18)Seflice use$ and carersalso often expressa Howcanlhe stigmaattached lo mentalillness wish to receivetreatmentasfar aspossiblein their bereduced? own homes.Smyth and Hoult (19) have argued l h " L l d c k o f i n t e n .r e h u m et r e a t m e n. < t rrice., Governmenl statements on the failure of community care appeared, al least to some suchas the clisisresolutionteamdescribeoroove_ 52

\{entrl healtbserviceproyisionin England has beena surprisinggap in UK servicedevelopmcnt, especiallyin inner city areaswheredemand for acute beds currently often outstripssupplv. Corernmcnp t o l l c ) n u u \ t . p u l : I c 5l n a l c n s t 5 resolutionteamsshould be provided acrossthe country to meet thesedemandsfor bettEraljlcss to emergencycareand hometreatment,with 335 suchleamsto be introducedby 2003. The crisisresolutionteamhasnot, however,as yet found universalacceptance as the bestwav of p r o \ i d i n ge l r e r g e n c r) n L e r \ e n t i o nl h. e y l i a \ e been criticized as disruplive to continuity of care,as patients-careis transferredto a different leamjust at the time when they are mosi unweli (20). The reliance on older studiesas evidence for the elfectivenessof lhese teams has also b e e nc r i l i c i , / e rd\. r l a n d r ' d E n g l r . hc o r n m u n i r r , ( r ! i c c sn o w u o r k r r i r \ o a r i < n ri .n c o m m u n . t l s e t . , n gt so . r g r e a t eer \ r c n it l t a nl h e( . ' r r f . r n . o n services in earlierresearchstudies(21).Burnsalso suggests that rhe crisis resolutionteam model is an ardficialone,as deteriorationsin the heahhof pe!1enlsgeneraily occur over some weeks or monthsmlher than abruptly in the middleol the n i : l r t :t l _ u ,r h e . r r ncr f g o o dc o m m u n : rs1e r v r c t s : h o u l d b e c r r : i sp r e \ c r l t o nr a t h e rr h a n c r r s i s resolution.An altemativeto the crisisresolution tcam may be th€ enhancedcommunity mentai healthteem,in $hich availabiliryof l]1oreworkers mighi allow sector leams to provide an extended-hoursemergeocyservice and more inlensrvehome treatrnenl,

appropdateness of this model for the UK (23). This debatehas focusedespeciallyon the lack of evrdencethat teams with 1ow caseloadshave producedbetteroutcomesin rcsearchevaluations in the UK. This vielv has been met with the argumentthet most of the intensivecommunity servicesevaluatedin the UK have not adhered closely to the AssertiveCommunity Trealment model, eventhough this is the lom of care lor lhe d i]]culLlo engdgetor \|hrch rheret, morl supportingevidencefrom researchcaried out in orher countr.ies(24). Man)r dimcuh-to-engagepatients have comorbid subslancemisuse,and treatmentof'dual diagnosis'of substance misuseand severemenEt illness is also currently receivingconsid€rable xttentionin England(25).Additionaltrainingfor generic mental health slaf in working with substancemisusersis a stralegy favoured in man,rarcas,but httle evidenceis so far available r \ t o t h eb e s r\ r ) o f t n c o r p o r r r r n i ngr e r r e r r i o n , lbr dual diagnosis;nto NHS services. Doesefleclivecommunity caferequire a commuoaty treatment order?

Wilhin the mental health professions.the move towards incre:rsinglyintensivecommunity-based trertment has fuelled a hexted debate about whether i! should be possible to administer n ( d i c r t i o nr o m p L , l . o r i $ l \i r h o u ra o mr . i o n r o hospital. Outside the professions,public and media anxietiesabout violenceamong the menHowcanservicesmanage dilficultlo engage patients? tally ill have created a favourable climatc ol oprnion ibr the inrroduction of a compulsory While standardcommunity mentalheahh tcams community treatmenl law. Plans lor the fortha p p e . i3rb l cr o l e e pl n c o n r J r ql l t h " n d m o n i r o f coming revisionof the Mental Health Act indinost people with severe mental illnesses.a cale lhat new legislntionr,ill al1owcompulsory minorit,'_remain very dimcult to engage.Thcse edministrationof edicationin the community tend especiallyto be youngerpeoplewho have (16).A further proposalfor this newlegislationis generallychaotic lives and poor socialsupport. that it shouldincludepowersio detaincompulmey have a history of offendingand comorbid sorily in hospilal individualswith severepersonsubstancemisuse, and often feel that conven- alit-\7 disorderwho appearto presenla risk, even lional servicesand socialinstitutionshtve little to where thcy do not meet the previouslyapplied offer them (22). They are heavy users of incdterion thar their psychiatricdisordershouldbe patient se ices, often on a compulsory basis. treatable.This has exciledconsiderablecontroAsseftive oulreach teams of rhe type recently v e f . y . . r r d u i d e , p r e ar di e u a m o n g . < r r i cues e r . established in Islingronare now proposedas the rnd mcnld nei.lLh prole.sr.nal\r. rhatthisDo\er most appropriateway of trying to meetthe needs is both etlically conlentiousand likely to be very of this group and prevent lhem from spending dimcuLtto impiementin practjce(27). long periods in hospiral or ensagingin acls of liolence. Many areashave very recentlvestablishedsuch teams,and the NHS Plan (2) states Howcanhighqualityslatlbe recruiled services? in mental heahh that rhey should be available throughout the andmaintained country by 2001.As with crisisresoiurionteams, A diiiculty frequentll underminlngattempts10 there continues to be some debate about the d e lr e r h i g bq u a l i r ]c L r er n d , i e ! e l o pi n n o v a r , ! e

53

Johnsonet al. se icesis thal in many arcasthere are shofiages of qualiiiedmentalheallh staff of all professions l : 8 ) . M o ' l m c n t r l h e d l l I s e r v i c eas r e l r l i n g constrntly to recruil qualiliedprofessiolals,and slaff retentionis also a centraldiliculty in many areas.This diliculty is likely to becomemore acuteas the severalhundrednew crisrsresolutlon teams and assertiveoutrcach teams curently planned are established(2). High slaff tumover also often prevcntsmultidisciplinaryteams beand functioning,as stalT comingfulty eslablished team leaders often leave their posls including after relativ€lyshort periods.There is evidence that levelsof burnout' in staff are high (2E),and concerns have also been expressedthdt new servicemodels involving intensive comlnunity \^'orkingwilh patienlswho presenta risk ofhamr to Selfor othels-suchas assertiveoutleachand likely to crisisresoiutionteams,may be especially be associatedwith high levelsof staff burnollt. to be evaluated EvidencealloDingthis suggesiion adequatelyis no! as yei available-but certainly these service models are unlikely to succeed unlc'sslulledaDdmolr!a,eJclrfl cJn be relruited. The recent prominenceof these concems about the mental healih workforce has made dcveiopmentand implementationol betler slrategiesfor staff trainjng. support and rctention ma]or priorilies in bolh th€ National Service Frameworkfor Mental Heallh (l) and the NHS Plan (2). As discussed above,suicidesand, in particular. homicidesby psychiatricpaiients are often reported in the media.and stail may be namedin the press following a seious adverseincidenl involving a patient in whose care they are involved. Their namesmay appear in national newspapersaftea the event or some time later $hen a public inquiry report on the event has been published (29). Fear of being publicly pilloded in this way followillg homicidesand suicidesmay lead staff to focus more on assessment and conlainmentof dsk than on achieving therapeuticcl'Iange.Priebe(30) has commented on the consequentdevelopmentin the NHS of a 'blame culture' characterizedby anxiety aild delensrveness. Howcanmenlalhealthinlerventiorc in primarycarebemademoreefleclive? Vosl rncnr"lhealh problem.ir Ihe L K conlinL,e to be managedin primary care, jncluding the grear majoriiy of people wilh depressionand anxiety disorders.There has also been much discussionabout ways of developingsharedcare

betwecnprimary and secondarycereibr severely meDtallyill individuals.Fuil discussionof this complexareais outsidethe scopeoi thjs paper. but debatescontinue about the bcst vra) to reducethe large varialionswhich currenuyexlst in GPs' skil1sin identifyingand trealingmental illnessand in treatmentsavailablein primarycare (31) and about the most eliective ways of increesinginregrationbetweenpdmary cale and specialistmental healthservices(32).One ol the inte entionsproposedin the recentNHS Plan (2) is the introduclion acrossthe country of a thousand graduale primary mental healtb care workerswith training in brief therapyrnelhods. Conclusion Now that closureof the largeasylumshaslargely b e ( nr c c o m p l i . h eadn d . i n e! \ c r \ o f r o m r r J n \i m e n r . r le . l I l r c r m ' r sI n p a c e t. n J l d n di 5e n l e r ing its next phaseof commllnity care development. Vrgorousattempls are being made to fiil the gapsand resolvethe problemsstill identified. Since England has a national health system, central decisionscan be taken and new poljcies issuedfrequentl), bul implemenlationol these policies rray none the less prove problematic. of current .{ criticrl determinantof the success initiativesis likely ro be the outcomeoi attempts to improve recruitment,retentionand moraleof mentalhealthprofessionals. nelerences L Depdfimelt ofHealth Nalionnl servicefrahework foi menlal health modc.n slardardsand senr.e models. LoDdon:The StationeryOilicc, 1999. 2. Depa.Imentof Health The NHS Plan London The Sutionery Offce, 2000 i. JoHNsoNS, LELLIon P. M€rlal health se.vrcesh LoDdon:eviden.efidn researc!aDd roulile dala lD: J o t s \ " o \ S . R A v A \ q L o o \ ' o o r o e . " 1 . .e d 5 . Londod\ menlal hcahh.London:Kinss Fu!d, 1997 4. Depannent of Healtl Memo.endln for the Select Colmillee on Herhh: public exFndlture queslronlaire 2000.Publishedon the lDternerat: http:i/ri/w. jr! rliametrl.th€ slationerl {,mce.co uki pa/cn I 99900r cDsele.i/cnheahh/882/8E210.h1m 5. K[LAspy H, DALToNJ, McNrcHoLAsS, JoHNsoNS Dfayror Park. an allematrveio lospikl adnissjonibr somen !! acut€ mental health c.isis. Psychiat Bull - .l1 0 4 . 2000i24:t0 6. TRTEMAN N. Lrrr J, GLovERG. Outcohe of long stay psychiatricpatiefts resellledin ihc colmun,lyl p . o s p e c t i l ceo h o ns l u d y .B M I 1 9 9 9 i 3 1 9 : l1l 6 . 7. GovernmeDt Stalislical Service. Hospitdl activity staristics Published on th€ D.paitment ol Heallh website atr htlp://www.doh.eo'trk/hospitalacxvLtyi slaiisticsil999-001 8. Golernment Staiisllcal Serlice. Hospitll episode stalistics(prljninary reportt. l,ondor: GolernmeD!