A solution to the ossification of community psychiatry

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.

Community psychiatry is at a crossroads and Peter Tyrer's critique 1 is timely and welcome. Although 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 recent years. Mandated by central policy this has resulted in an increased subspecialism, with the development of new community teams focusing on early intervention, 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 timeconsuming 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 of defining 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 reconfiguration. Community teams need to deliver care which is individually formulated but not at the expense of evidencebased 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. We need 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 coordination, retaining the important clinical functions but removing the unnecessary bureaucracy that adds little to patient care. On a practical level, these are the issues which challenge community teams and they need to be addressed along with any structural reorganisation. Is it too late for a solution to the ossification of community psychiatry?
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 is likely to continue in the immediate few years. 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 traumatised, ill and vulnerable. Professor Tyrer's solution lives up to the College's motto 'Let Wisdom Guide' and makes a lot of sense to the dying-out breed of catchment area psychiatrists, but has it come too late? The 'product champions' of different service models are likely to rise up in defence of their brands and the new lot of fragmented-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. Where is the evidence for incorporating early intervention treatment into the CMHT?
Although it is gratifying to be regarded as the 'best of the staff' by someone as esteemed as 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 community mental health team (CMHT). 1 Following the principle of 'Let Wisdom Guide', one would like to see the evidence before taking such a step. For while 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 early intervention. For example, there is evidence that EITs reduce hospital admission compared with 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 healthcare (in-patient 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-based superior service.

Looking at vanishing treatment effect in Europe
The article by Rosen et al 1 is a thought-provoking piece on the perception of the effectiveness of assertive community treatment in Europe. I write as a psychiatrist who has worked within assertive community teams (ACTs) on both sides of the Atlantic (the UK and Canada). Although the economic downturn and cutbacks are equally shared in both UK and Canadian health systems, the investment in specialist mental health programmes including ACT continues to gather pace in Canada due to the robust and demonstrable effectiveness of the teams. In Canada, there is a stronger fidelity to the original ACT model and a shift from the paternalistic to a more collaborative relationship with patients. There is greater emphasis on relationship building through varieties of psychosocial strategies, easier access to specialist and subsidised housing facilities and vocational opportunities.
The ACT service delivery in Canada is a true representation of the standard originally described in 1973 after 20 years of field testing in the USA. 2 It includes peer support workers who have life experience and can provide expertise that professional training cannot replicate. The peer support workers are fully integrated team members functioning in the team's generalist role. There is a 24-hour on-call service and treatment intervention is intensive with two or three face-to-face visits daily.
Undoubtedly, ACT is a clinically effective approach to managing the care of severely mentally ill people in the community. If aimed at the right patient population and when the model of care is fully adhered to, ACT can substantially reduce the costs of hospital care while improving the outcome and patient satisfaction. 3