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A solution to the ossification of community psychiatry

  • Peter Tyrer (a1)
Summary

The aim for seamless care that has long been the ultimate goal of good community psychiatry in the UK has disappeared, and there is now much needless argument over models of delivering care that ignore its main philosophy. It is argued that this ossification of care has not only made it ineffective, but has also promoted demoralisation and burn-out in the workforce, as the locus of control has shifted from clinician to managerial imperative. An initiative that can break up the opaque structures that hinder continuity of care is now available and a suggestion is made for a flexible, invigorated community care team system based on smaller catchment areas that allows a single team to combine the elements of assertive outreach, crisis resolution and early intervention with in-patient care.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Peter Tyrer (p.tyrer@imperial.ac.uk)
Footnotes
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Declaration of interest

P.T. was a consultant with an assertive outreach team until 2009. He was also Editor of the British Journal of Psychiatry at the time of writing, but this has had no influence in the assessment of this paper.

Footnotes
References
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A solution to the ossification of community psychiatry

  • Peter Tyrer (a1)
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eLetters

Is "A solution to the ossification of community psychiatry" too late?

Thakor Mistry, Consultant Psychiatrist
27 November 2013

Professor Tyrer's article (1) has been such a comforting read, as many of his thoughts expressed will resonate with views of many average, hard working catchment area psychiatrists. The fragmentation of psychiatric services has already occurred and in the immediate few years, is likely tocontinue. Psychiatrists as professionals have difficulties sustaining therapeutic relationships (the anchor in any healing process) for any decent length of time with patients who often are traumatized, ill and vulnerable.

Professor Tyrer's solution lives up to the College's motto of "Let Wisdom Guide" and makes a lot of sense to the dying-out breed of catchmentarea psychiatrists, but has thesolution come too late? The 'product champions' of different service models are likely to rise up in defence of their brands and the new lot offragmented-care psychiatrists may have visions of themselves as super-specialists, and so may see catchment area psychiatrists as belonging to a bygone era. But maybe, in this new era of reflection, we should all spare some time and reflect on our College's motto and Professor Tyrer's words of wisdom.

References:

1. Tyrer, P. A solution to the ossification of community psychiatry.The Psychiatrist 2013; 37: 336-339
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Conflict of interest: None declared

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Where's the evidence for incorporating early intervention within the CMHT?

A. Samei Huda, Consultant
24 November 2013

Whilst it is gratifying to be regarded as the "best of the staff" by someone as esteemed by Professor Peter Tyrer, I take issue with the suggestion that Early Intervention Teams (EITs) should be broken up and their functions incorporated within a flexible CMHT (1). Following the principle of 'Let Wisdom Guide', one would like to see the evidence before taking such a step. For whilst it may be true that assertive outreach teams and other innovations in Britain proved disappointing for some of the reasons outlined in the article, this is not the case for earlyintervention. For example, there is evidence that EITs reduce hospital admission compared to CMHTs (2) and that once patients are transferred back to CMHTs, the admission rate goes up again(3). If we have a service model of proven effectiveness, particularly in reducing demand on the most expensive elements of mental health care (inpatient beds), such as EITs, why switch to an unproven service model? One can make a tentative case that the superior outcomes are due to "better skilled" EIT staff or to the extra resources these teams have- which the McCrone paper shows pays for itself by reducing demand (3), but a wise approach suggests waiting for evidence of effectiveness of these CMHTs with EIT functionality before ploughing ahead and dismantling an evidence-basedsuperior service.

References: 1. Tyrer P. A solution to the ossification of community psychiatry. The Psychiatrist 2013; 37:336-339 2. Gafoor R, Nitsch D, McCrone P, Craig TKJ, Garety PA, Power P, et al. Effect of early intervention on 5-year outcome in non-affective psychosis. Br J Psychiatry 2010; 196:372-6. 3. McCrone P, Craig TKJ, Power P, Garety PA. Cost-effectiveness of an early intervention service for people with psychosis. Br J Psychiatry 2010; 196:377-82
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Conflict of interest: Dr Huda is a Consultant in an Early Intervention Team

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New joints, same moves. The ossification of community psychiatry

Tim Oakley, Consultant Psychiatrist
24 November 2013

Community psychiatry is at a crossroads and Peter Tyrer's critique istimely and welcome. While problems in community care were developing before the economic downturn, the present financial climate has sharpened the issues and makes finding a solution more pressing than ever.

There have been significant investments in community care over recentyears. Mandated by central policy this has resulted in an increased sub-specialism, with the development of new community teams focussing on earlyintervention, crisis work and assertive outreach. The clinical effectiveness of these new teams is hotly debated but an undeniable consequence has been to diminish continuity of care and to create a more fragmented service, with multiple interfaces, each time-consuming and risky to negotiate. The residual community teams have been overwhelmed by the volume and complexity of demand, over-burdened by bureaucracy, and sometimes treated as little more than the handmaidens to specialist services.

The newly formed specialist community teams have had the advantage ofdefining their place in the system; facilitating the delivery of evidence based interventions and fidelity to models of care. Tyrer argues for the re-establishment of "completely comprehensive" teams, but the tensions that have challenged community teams will survive a structural re-configuration. Community teams need to deliver care which is individually formulated but not at the expense of neglecting evidence based treatments.Care needs to be responsive and holistic but this approach has to be balanced with the need to deliver planned treatments. How can these tensions be resolved?

Community teams cannot and should not provide every intervention for patients under their care- to do so creates dependency and a new form of institutionalisation. We need to move from providing holistic care to facilitating holistic care, working with the community, not just in it. Weneed to establish and formalise robust pathways that facilitate timely access to outside agencies, where patients can receive support for issues such as housing and benefits advice. We need to define the boundaries of unplanned, responsive care delivered by the community team. Should this be available to all patients or restricted to those most disabled by their illness? What unplanned interventions are the task of the team and which sit with other external providers? How do we create systems to deliver a flexible and timely response to need while retaining capacity for clinicians to deliver planned interventions?

Finally we need to deconstruct care co-ordination, retaining the important clinical functions but removing the unnecessary bureaucracy thatadds little to patient care. On a practical level these are the issues which challenge community teams and need to be addressed along with any structural re-organisation.

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Conflict of interest: None declared

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