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How did we let it come to this? A plea for the principle of continuity of care

  • George Lodge (a1)

The administrative imposition of new models of psychiatric care in the community has led to the fragmentation of services and a deteriorated experience for both service users and professionals. The author makes a plea for psychiatrists to reassert the principle of continuity of care, which has been all but lost from the practice of psychiatry during the past decade. It is possible to meet the clinical objectives of necessary support and treatment for service users within the community without the current multiplicity of team structures seen throughout England.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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George Lodge (
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See commentary, pp. 364-365, this issue.

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1 Wing, JK, Brown, GW. Institutionalism and Schizophrenia: A Comparative Study of Three Mental Hospitals 1960-1968. Cambridge University Press, 1970.
2 Freeman, H. Pharmacological treatment and management. In Schizophrenia: Towards a New Synthesis (ed. Wing, JK): 182–7. Academic Press, 1978.
3 Hoult, J, Rosen, A, Reynolds, I. Community orientated treatment compared to psychiatric hospital orientated treatment. Soc Sci Med 1984; 18: 1005–10.
4 Stein, LI, Test, MA. Alternative to mental hospital treatment. I. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980; 37: 392–7.
5 Birchwood, M, McGorry, P, Jackson, H. Early intervention in schizophrenia. Br J Psychiatry 1997; 170: 25.
6 Department of Health. A National Service Framework for Mental Health: Modern Standards and Service Models. Department of Health, 1999.
7 Marshall, M, Bond, G, Stein, LI, Shepherd, G, McGrew, J, Hoult, J, et al. PRiSM Psychosis Study. Design limitations, questionable conclusions. Br J Psychiatry 1999; 175: 501–3.
8 Thornicroft, G, Becker, T, Holloway, F, Johnson, S, Leese, M, McCrone, P, et al. Community mental health teams: evidence or belief? Br J Psychiatry 1999; 175: 508–13.
9 Catty, J, Burns, T, Knapp, M, Watt, H, Wright, C, Henderson, A, et al. Home treatment for mental health problems: a systematic review. Psychol Med 2002; 32: 383401.
10 Fiander, M, Burns, T, McHugo, GJ, Drake, RE. Assertive community treatment across the Atlantic: comparison of model fidelity in the UK and USA. Br J Psychiatry 2003; 182: 248–54.
11 Killaspy, H, Bebbington, P, Blizard, R, Johnson, S, Nolan, F, Pilling, S, et al. The REACT study: randomised evaluation of assertive community treatment in north London. BMJ 2006; 332: 815–20.
12 Johnson, S, Nolan, F, Hoult, J, White, IR, Bebbington, P, Sandor, A, et al. Outcomes of crises before and after introduction of a crisis resolution team. Br J Psychiatry 2005; 187: 6875.
13 Jones, P, Shiers, D, Smith, J. Early Intervention in Psychosis: Why a Specialised EIP Service Model is Preferable to a CMHT Model. Early Intervention in Psychosis, 2010 (
14 Marshall, M, Lewis, S, Lockwood, A, Drake, R, Jones, P, Croudace, TA. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62: 975–83.
15 Keown, P, Weich, S, Bhui, KS, Scott, J. Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study. BMJ 2011; 343: d3736.
16 Clark, F, Khattak, S, Nahal, N, Linde, K. Crisis Resolution and Home Treatment: the Service User and Carer Experience. National Audit Office, 2008.
17 Standing Nursing and Midwifery Advisory Committee. The Nurses' Contribution to Assertive Community Treatment. Mental Health Nursing -Addressing Acute Concerns (Practice Guidance). SNMAC, 1999 (
18 Lodge, GJ. Empowerment and the recovery model (letter). Psychiatrist 2010; 34: 116–7.
19 Department of Health. Statistical Press Notice: Mental health community teams activity data, 2011-12 Q3. Department of Health, 2012 (
20 Joy, CB, Adams, CE, Rice, K. Crisis intervention for people with severe mental illnesses. Cochrane Database Syst Rev 2006; 4: CD001087.
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How did we let it come to this? A plea for the principle of continuity of care

  • George Lodge (a1)
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Specialist community teams backed by years of quality research

Alan Rosen
15 November 2012

In response to Dr Killaspy's invited commentary on Dr Lodge's piece favouring generalist vs specialist community mental health teams, Professor Burns (1) laments that "every change, no matter how hare-brained, is hailed 'an innovation'." He implies that it is "hare-brained" to implement crisis response, early intervention and Assertive Community Treatment (ACT) specialist teams, even though they all have unambiguously strong international evidence of both persistent effectiveness (2,3) and economic advantage (4,5,6).

We share Dr Lodge's key concerns for continuity of care and the needto engage some individuals in long-term therapeutic relationships. ACT and Early Intervention Psychosis (EIP) teams for instance are specifically designed to amplify these functions, for those who need them, and only while still needed. This has been readily addressed by having a generic front end CMHT co-located with primary care where possible and specialised back streams. This results inmutually supportive and often shared working between all these teams. Transfers, where they occur, are very slow, so continuity is preserved. . Professor Burns and colleagues argue from a false premise, as pitting generic vs specialized teams is a "straw-man" argument. They provide no evidence in support of retaining the generic status quo alone, just moral assertions. The status quo is often hailed as the 'tried and tested' condition to beat, when " there is surprisingly little evidence to show that [Community Mental Health Teams (CMHTs) alone] are an effective way of organising [community] services" (7).

Professor Burns (1) accuses Dr Killaspy of being ungenerous, unjustified and disingenuous for standing up for systematized team approaches that have strong evidence internationally, in comparison with our more habitual comfort as clinicians with undifferentiated CMHT's and more traditional, hospital-centric and sedentary outpatient care. "Newer is not necessarily better" he posits. Well, we appreciate his clinical conservatism. But, in stating that " Nobody waits to see if it makes any difference, never mind delivers an improvement" how long does he wish us to wait, while depriving severely disabled UK citizens of an effective service delivery system (ACT) which has just been celebrated for more than 40 years since initial randomised control trials studies proved strongly favourable (5,8), with waves of international replications since?

Burns and colleagues have muddied the waters by implying that indifferent results for even more diluted models of "intensive case management" in the UK like the UK700 and PRiSM studies somehow representedACT, and proved that it did not provide any advantage in UK or Europe over CMHT's. They deem ACT to be unnecessary where, in comparison, to other countries, there is an adequate health and social services "safety net". Yet its clear effectiveness in Australia and Canada has been demonstrated in the context of a public health and welfare system at least as good as the UK's at its best (2). Meanwhile these much vaunted "safety nets" are now unravelling in many parts of Europe.

This misleading position adopted by Burns & colleagues must bear some responsibility for this premature disinvestment, for the further dilution of these teams under financial pressure, and for the dampened enthusiasm for the UK research effort into ACT, when it has only just begun, with mixed results possibly due to patchy team fidelity (2,9).

Tragically, severely and persistently mentally ill Britons will suffer with neglect because of the partial dismantling or withdrawal of these essential integrative community care delivery systems. UK community based teams need their capacity to consistently follow the fidelity protocols of these specialist teams upgraded, not dismantled. This is a challenge to rigorous science, to sound commissioning, to communal action and ultimately to good government.


1.Burns, T. Newer is not automatically better. Letter, The Psychiatrist published online October 22, 2012

2.Killaspy H, Rosen A, Case Management and Assertive Community Treatment, Chapter in Oxford Textbook of Community Mental Health, 2nd edition, Thornicroft G, Szmukler G, Mueser K, Drake R, eds. Oxford UP, Oxford, 2011

3. Norman RMG, Manchanda R , Malla AK , Windell D, Harricharan R , Northcott S Symptom and functional outcomes for a 5 year early intervention program for psychoses, Schizophrenia Research 129 (2011) 111-115 4. McCrone P, Park A-L, Knapp M. Early intervention for psychosis. In: Martin Knapp, David McDaid, Michael Parsonage,eds. Mental Health Promotion and Mental Illness Prevention: The Economic Case. London: Department of Health 2011.

5. Stein, L.I. and Test, M.A. (1980). Alternatives to mental hospitaltreatment. Archives of General Psychiatry, 37, 392-7

6. McGorry P. At issue: Cochrane, early intervention, and mental health reform: analysis, paralysis, or evidence-informed progress? Schizophrenia Bulletin 2012; 38: 221–4

7. NICE Guidance on Schizophrenia CG82, 2009, updated 2011,2012, p336: 9.3.4, clinical summary.

8.Weisbrod, BA, Test MA, Stein LI. Alternative to mental hospital treatment: II. Economic benefit-cost analysis. Arch Gen Psychiatry 1980; 37 (4): 400–5

9. Harvey, C., Killaspy, H., Martino, S., White, S., Priebe, S., Wright, C. & Johnson, S. (2011). A comparison of the implementation of Assertive Community Treatment in Melbourne, Australia and London, England.Epidemiology and Psychiatric Sciences, 20, 1-11.


Alan Rosen

Professorial Fellow, School of Public Health, University of Wollongong, & Brain & Mind Research Institute, University of Sydney, Senior Consultant Psychiatrist, Far West Mental Health Service Sydney,Australia.

Declaration of Interest: nothing to declare

Leonard I. Stein

Emeritus Professor, PsychiatryUniversity of Wisconsin School of Medicine and Public Health, Madison WiscUSA

Declaration of Interest: nothing to declare

Patrick McGorry

Executive Director OYH Research Centre Professor of Youth Mental Health, University of MelbourneMelbourne, Australia

Declaration of Interest: nothing to declare

Carol Harvey

Associate Professor,Department of Psychiatry, The University of Melbourne and North Western Mental Health, Melbourne, Australia

Declaration of Interest: nothing to declare

Max Birchwood

Professor of Youth Mental Health, University of Birmingham,Clinical Director, YouthSpace Mental Health Service, Birmingham and Solihull Mental Health Foundation TrustBirmingham, UK

Declaration of Interest: nothing to declare

Ron Diamond

Professor of PsychiatryUniversity of Wisconsin, School of Medicine and Public Health, Madison, Wisc, USA

Declaration of Interest: I am editor of a consumer oriented newsletter that is sponsored by Johnson and Johnson

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Conflict of interest: Please see declarations of interest.

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Recovery and Continuity of Care

A Chopra, Consultant Psychiatrist
05 November 2012

Dr George Lodge and Dr Helen Killaspy are both right in the points they make and there is a third way, a middle approach in what at first appears a polarised debate. Several years of National Service Framework(NSF) teams has allowed individuals to develop skills in supporting people with particular needs and at differentphases of their difficulties. However, the Recovery Movement has demonstrated that the most important role a service can provide is to enable the people it serves to achieve their life-goals. This requires theemergence of a trusting therapeutic relationship and understanding of an individuals life-goals - an essential ingredient of that is continuity of care. Specialised teams belong to an era where the goal of services was symptom reduction. Now would be an appropriate time to capitalise on the benefits of developed skill sets but within a framework of continuity of care by reintegrating the individuals from the NSF teams within catchment area based enhanced community mental health teams(CMHTs).

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Author's response

Helen Killaspy, Reader in rehabilitation psychiatry
05 November 2012

In response to my Editorial on George Lodge's call for a return to continuity of care (1,2,) Dr McMillan is quite right to point out the importance of appropriate access to inpatient beds as a critical componentof mental health services (3). That mental health systems should provide a balance of inpatient beds and community services tailored to the mental health needs and resources of the local community being served is something all mental health practitioners across the world can probably agree on. My commentary did not suggest that increased specialisation means we should do away with inpatient services, it simply stated the factthat investment in specialist community mental health teams (particularly crisis teams) through the National Service Framework for Mental Health wasassociated with a reduced need for inpatient admissions. Where I believe Dr Lodge and I also agree is on the need for continued investment in mental health rehabilitation services to prevent the inappropriate use of out of area placements for the small number of people with particularly complex and long term psychoses (4,5).

Professor Burns' response (6) states: "It is ungenerous and unjustified for Helen Killaspy to accuse George Lodge of nostalgia and wearing rose-tinted spectacles just because she disagrees with him. Newer is not automatically better." This accusation is not only unjust and ungenerous to those who have been working without feeling conflicted in both specialist and generalist services for many years, but it is without basisin fact. My commentary made clear, evidence based justification for my view. I included reference to the lack of evidence for the effectiveness of assertive community treatment (ACT) in the UK context that probably influenced subsequent disinvestment in this model. However, our research group, while contributing to such findings, simultaneously participated ina multi-centred international study which suggested that ACT in the UK mayhave not performed as effectively as in Australia due to lack of implementation of critical components that Professor Burns' own team identified through meta-analyses (7,8). His further accusation that I was "disingenuous" is a little ironic given his lack of reference to the robust international evidence on which investment in the new specialist teams was made, not to mention the expanding evidence base for early intervention services.

Dr Dodwell's response (9) accuses me of dismissing evidence on therapeutic alliance, yet I didn't mention it. It is a truism to say thatthe therapeutic alliance is important. Who would argue against the importance of being treated with humanity and respect in the therapeutic encounter? However, therapeutic alliance is not the same as continuity ofcare, which was, after all, the focus of Dr Lodge's piece.

The fundamental issue that seems to have prompted such vociferous response is whether psychiatrists can go on being Jacks and Jills of all [psychiatric] trades. My view is that our increased specialisation is a sign of the maturation of our profession and allows us to deliver better treatment, tailored to our patients needs. This does not equate to support for some kind of anarchic service redesign with the aim of promoting turf wars and passing patients from pillar to post. We need to get on with the business of incorporating the evidence we have available from our research to design systems of care that are appropriate, effective and cost-efficient, and accept that the process is iterative andsubject to socioeconomic and political vagaries. Perhaps we are more likely to succeed in this if we start with a focus on the areas where we have consensus.

References(1). Lodge, G. How did we let it come to this? A plea for the principle of continuity of care The Psychiatrist 2012 36:361-363(2). Killaspy, H. Importance of specialisation in psychiatric services: Commentary on... How did we let it come to this? The Psychiatrist 2012 36:364-365; doi:10.1192/pb.bp.112.039537 (3). McCrieff, F. Missing points, Letter The Psychiatrist published online 15 October, 2012(4). Killaspy, H & Meier, R. A Fair Deal for Mental Health Rehabilitation Services. The Psychiatrist, 2010, 34: 265-267(5). Guidance for Commissioners of Services for People with Complex mental Health Needs. Joint Commissioning Panel for Mental Health, Royal College of Psychiatrists, 2012(6). Burns, T. Newer is not automatically better. Letter, The Psychiatrist published online October 22, 2012.(7). Harvey, C., Killaspy, H., Martino, S., White, S., Priebe, S., Wright, C., Johnson, S. A comparison of the implementation of Assertive Community Treatment in Melbourne, Australia and London, England. Epidemiology and Psychiatric Sciences, 20, 151-161.(8). Burns, T., Catty, J., Dash, M. Roberts, C., Lockwood, A., Marshall, M. Use of intensive case management to reduce time in hospital in people withsevere mental illness: systematic review and meta-regression. BMJ, 2007; 335:336 (9). Dodwell, D. Personal therapeutic relationship does matter. Letter, The Psychiatrist, published online November 2, 2012

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Newer is not automatically better

tom burns, Professor of social psychiatry
22 October 2012

It is ungenerous and unjustified for Helen Killaspy (1) to accuse George Lodge (2) of nostalgia and wearing rose-tinted spectacles just because she disagrees with him. Newer is not automatically better. We havehad altogether too much frenetic reorganization of mental health services where every change, no matter how hare-brained, is hailed 'an innovation'.Nobody waits to see if it makes any difference, never mind delivers an improvement. It is whether an idea is right or not, not how long it has been around, that matters. Similarly it is disingenuous of her to claim that the service changes she describes were 'informed by research'.

New developments arise from a mixture of creative thinking and professional ambition, and nothing wrong with that. By the very nature of the beast, evidence comes later. We need the new services in place to research them rigorously or make judgments from mature experience. The National Service Framework is a case in point. Only one of the new teams imposed had any evidence for it at the time, and AOT's international evidence was unraveling in the UK context as they were being rolled out(3), (4). There was not a single RCT of crisis teams until Johnson's excellent,but still unrepeated, 2005 study, (5). The only two RCTs of early intervention teams also came later, and neither found a significant advantage in their declared primary outcomes, (6), (7). A more measured position is probably justified.

Continuity of care can be a complex concept to define8 but it is not that difficult to recognize. We can all grasp the importance of being treated by familiar faces who know our situation and illness, of not beingpassed on, and not having to repeat our history to an endless stream of new staff that we then have to try and learn to trust. Everybody who is asked, patients, staff or families, insists that they value continuity. I know I do.

Whatever else mental illnesses are they are experienced, expressed and treated in relationships. George Lodge (2) is right that these relationships have been given altogether too low a priority in recent planning and strategy. Our decade of fragmentation may have contributed some improved understanding of process, but undoubtedly at a cost of simple humanity and attention to the unique individuals for whom the wholeedifice exists. Helen Killaspy (1) is right that we have a progressive discipline, responsive to an expanding evidence base (nothing new there). That does not mean that every change is improvement, nor that more specialized services (with their inevitable fragmentation of care) are necessarily better for patients.

References (1)Killaspy H. Importance of specialisation in psychiatric services. The Psychiatrist 2012; 36: 364-5. (2)Lodge G. How did we let it come to this? A plea for the principle of continuity of care. The Psychiatrist 2012; 36: 361-3. (3)Burns T, Marshall M, Catty J, Lockwood A, Dash M, Roberts C. Variable outcomes in case management trials - an exploration of current theories using meta-regression and meta-analysis: Final Report. London: Department of Health, 2005. (4)Burns T, Creed F, Fahy T, Thompson S, Tyrer P, White I. Intensive versusstandard case management for severe psychotic illness: a randomised trial.UK 700 Group. Lancet 1999; 353: 2185-9. (5)Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 599. (6)Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2004; 329: 1067-70. (7)Petersen L, Jeppesen P, Thorup A, Abel MB, Ohlenschlaeger J, ChristensenTO, et al. A randomised multicentre trial of integrated versus standard treatment for patients with a first episode of psychotic illness. BMJ 2005; 331: 602. (8)Burns T, Catty J, White S, Clement S, Ellis G, Jones IR, et al. Continuity of care in mental health: understanding and measuring a complexphenomenon. Psychol Med 2009; 39: 313-23.

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