The Spokes Inquiry

The Spokes InquiryReference Spokes² made appropriate and reasonable recommendations that could be summarised as ‘when psychiatric patients, particularly those with severe mental illness, are discharged from hospital there needs to be an after-care plan in place for both health and social services’. The implementation of these plans was not specified exactly and the Royal College of Psychiatrists was asked to create such an aftercare policy. There already was a system called case management, which had devotees, but most of the evidence was imported unwisely from the USA where the notion of universal care was anathema to the land of the free market.

So the CPA was introduced as a diluted form of case management appropriate for the NHS. Note the wording. It was not a mandatory requirement for practitioners to do this or that, but a gentle nudge to ensure a coordinated system of care, an approach rather than a directive. It certainly worked to a point; consultants could no longer discharge patients to follow-up by the general practitioner without some sort of care plan in place. The CPA was introduced so gently that its implementation was almost imperceptible, allowing a randomised trial to take place using the old system of care as the comparator. The results showed that many fewer patients were lost to follow-up, but readmissions were much more common once good follow-up was in place.Reference Tyrer, Morgan, Van Horn, Jayakody, Evans and Brummell³

Early years of the CPA

The notion of care plans – and the need for a single person, the care coordinator, to synthesise care with the parties involved – is a sensible one and many health professionals felt they were doing it already. It was held together successfully at first through the efficiency and cooperation of community psychiatric teams, whose contribution and value, including a reduction in deaths,Reference Simmonds, Coid, Joseph, Marriott and Tyrer⁴ has been somewhat underestimated as these teams have never had the glamour of assertive outreach and crisis resolution teams. Where it began to fail was not a fault of the approach but a lack of resources to implement it properly, so it was never applied universally. It is very odd that no organisation within the healthcare system made any attempt to cost the full implementation of the CPA. What may also not have been anticipated was the rapid growth of managers once cost pressures increased,Reference Goldberg⁵ and whose attempts to improve integration of care were often resented by practitioners as undue interference.Reference Norman and Peck⁶

Thus, 15 years after its introduction, Simpson et al Reference Simpson, Bowers and Miller⁷ concluded after a careful review in 2003:

Standard and Enhanced CPA

In 2008 the Enhanced CPA was subsequently introduced for people ‘who need: multi-agency support; active engagement; intense intervention; support with dual diagnoses; and who are at higher risk’.⁸ It was also emphasised that acceptance for enhanced care ‘should not be used as a “gateway” to social services or as a “badge” of entitlement’⁸ to other services. But of course it was used that way, as it was bound to be; thus it merely added another layer of bureaucracy to an over-burdened system.

The consequence has been an increasing transfer of face-to-face clinical care to a paperchase cynical affair that does no credit to anybody, least of all the patients, who all too frequently see a technocrat facing a desk instead of a sympathetic carer across the room. The tick box has now become the kick box, an exercise to get a patient off one team's case load and on to another, promoting discontinuity and disruption of care.

What is the solution?

There are many lessons to be learned about the CPA. First, it has to be accepted by all health professionals, politicians and society at large that suicides and violent deaths in the community perpetrated by psychiatric patients can never be prevented altogether. Putting this another way: extreme statistical outliers should not determine policy. Second, and probably most importantly, good psychiatric and social care is flexible and collaborative and can never be prescribed by statute. I recently discharged myself from hospital prematurely against medical advice. But I insisted the record was not recorded as ‘against advice’ by writing in detail in the hospital notes why it was better for me to leave hospital as my aftercare was well arranged and would lead to cost savings. (They accepted this and were probably pleased to see me go.)

Third, allow practitioners and patients, working together, to do what is best and not to be too risk averse. Kingdon recommends that we should develop ‘more individualised and sophisticated pathway-based systems’.Reference Kingdon¹ This is in itself a telling criticism of the CPA. Once we have such individualised systems, we leave the directives behind; we use a combination of skills and resources to produce a plan that is, more often than not, unique and cannot be classified. Such plans can never be truly evidence based.

So, in summary, the CPA needs reform by becoming simpler rather than more complicated. It is there to prevent poor care, not to interfere with care that is already competent or good. Its wording should be chosen with care to allow good clinicians to be reinforced and praised in their tasks, for nervous ones to be encouraged and for those who are under par to receive a gentle rap on the knuckles to improve their game. It can also be a great deal shorter.