Forbes et al ^{Reference Forbes, Cash and Lawrie1} reported that the number of detained individuals increased following the setting up of an intensive home treatment team in Midlothian, with no reduction in admissions overall. In their discussion they identified a number of potential reasons for this rather disappointing result. However, they did not look at the relevance of staffing, nor the degree of adherence to the high-fidelity model of home treatment.

Middleton et al ^{Reference Middleton, Glover, Onyett and Linde2} looked at gatekeeping and concluded that admissions were more likely to be reduced if the team had a dedicated consultant psychiatrist and worked on a 24-hour basis. It was also noted that teams which were more ‘mature’ were more effective gatekeepers. In Midlothian the medical input is from a part-time staff grade doctor, the team operates from 8 am to 12 pm and in the period reported the team was only in its first year. We have little doubt that if Dr Forbes can persuade the commissioners to invest further in the service, bed reductions will be made.

Our home treatment team in Belfast was set up in April 2007 and covers a population of 350 000. It has 1.5 whole time equivalent dedicated consultants and operates 24 hours a day. We took on the role of gatekeeping all admissions in April 2009, and over the next 12 months the admissions dropped by 27%.

Forbes and colleagues propose that their team may have had a low threshold for accepting risk, in the context of the introduction of formal risk assessment procedures for all patients seen. They argue further that thresholds for risk are falling with an increasing use of community detention powers and longer-term hospital detentions.

This reflects concerns raised by the Care Quality Commission, ³ who noted that while the number of hospital detentions had not reduced, the number of community treatment orders (CTO) had ‘greatly exceeded the number anticipated at the time the new legislation was introduced’. The premise on which CTOs were predicated was that they were a less restrictive alternative to hospital admission. In truth the evidence is that they are becoming an additional way of managing perceived ‘risk’, which has now regrettably become a key driver in psychiatric practice.

There is a grave danger that the natural instincts of the large majority of psychiatrists to move away from a paternalistic and risk-averse model of care are being compromised by paying too much heed to the often confused and fear-based concerns of policy makers and the media who want us to ‘move into the community’, while simultaneously guaranteeing that adverse outcomes will not occur.