Survey of community mental health teams

Aims and method The aim of the study was to describe community mental health teams (CMHTs) working in Scotland. Interviews,a focus group, and a postal questionnaire survey of identified CMHTswere carried out. ResultsOf the 53teamsidentified,42(79%)completed questionnaires.Theaverage team sizewas 11people. Community psychiatric nurseswere in all teams, social workersand psychiatristswere in most,but psychologists were in only half. Needs assessments occurred in only 17%of teams. Fifty-one per cent of teams had open referralsystems,and 38%of referralscomprised people with long-termmental health problems.Fifteenper cent of referrals were considered by teams to be inappropriate. Clinical implications Ambiguitiesabout appropriate structures, patient groups and interprofessionaland inter-agency working requirefurther consideration and evaluation if CMHTcare isto be optimally effective.


The study
The aim was to describe community health teams (CMHTs) working in Scotland. Stage 1 comprised interviews and a focus group with purchasers and providers (Table 1)

from health
Stage 2 comprised a questionnaire survey of all identified CMHTs in Scotland. The questionnaire was developed from existing research (in parti cular Onyett et ai (1994)), and from stage 1 of the study. Teams were included if they: (a) were formally recognised as a multi-disciplinary team by purchasers and providers; (b) served adults with mental health problems as the primary client group; (c) did not offer specialist services only for people within any specific restricted group.
Within each of the 15 Scottish health board areas, an individua] responsible for community mental health, either at the board or at relevant trusts, was contacted by telephone to find out how many teams there were and to identify someone who could liaise with them. In areas with teams, questionnaires and explanatory letters were sent to the liaison person. In areas without teams, a second telephone interview with the initial contact was undertaken to ascertain why CMHTs had not been implemen ted; and establish whether there were plans to implement CMHTs. Psychiatric Bulletin (1998), 22, 733-739 Findings A total of 53 CMHTs were identified in nine health boards: six health board areas did not have CMHTs (Table 2). Each CMHT received a questionnaire, and 42 (79%) were returned completed. The six areas without CMHTs re ported that although forms of multi-disciplinary working were in place, these were not regarded as formal CMHTs. Reasons for the absence of formal CMHTs included lack of resources and infrastructure, opposition from clinicians (general practitioners (GPs)) and satisfaction with current practice. Four of these areas planned to implement teams, in at least three cases by April 1997. The other two areas had no such plans.
Community psychiatric nurses (CPNs) were present in all teams (Table 3). The next most frequent discipline was consultant psychiatrist (90%), followed by social worker (81%), occupa tional therapist (81%), and doctor other than consultant psychiatrist (76%). Clinical psychol ogists were represented in only 55% of teams. Disciplines other than those listed were present in 11 (26%) of teams, the most frequent categories being pharmacist, physiotherapist and social work assistant. Table 3 also shows the median FTEs for each discipline, which most closely reflects the relative contribution of each to team working. The contribution of CPNs was at least twice that of any other discipline. Consultant psychiatrists, although present in most teams, had a half-time commitment, as did clinical psychologists (who are much fewer in number). The median number of people joining teams over the previous year was 3 (1â€"4). The median number of people leaving teams over the previous year was 1 (0.75-2), indicating that team size is increasing. Thirty-two (76%) teams had a dedicated office for administrative work. Of these, 16 (52%) were based in community health centres or com munity resource centres. Seven (22%) teams had an office base within a hospital in-patient unit. Eight teams (25%) were based at other types of site, including medical centres, hospital out-patient units, nursing homes and general office blocks.

Catchment area and population
Forty teams (95%) had a catchment area, the median size of which was 80 square miles (15-543 square miles). Twenty-five (62.5%) of these teams were aligned to general practices, whereas 15 (37.5%) were aligned to geographical local ities. The median size of population served by teams was 47000 (30000-80000). The median number of GPs with whom the teams worked was 27 (20-54).

Re/errÃ¡is
Teams had been taking referrals for a median period of three years (1.25â€"4.75years). Twentyone (50%) teams had formal criteria for referral. The teams operated one of two referral systems. Twenty-one (51%) teams had open systems, accepting referrals from any member of the community, health and social services staff, police, relatives, friends or self referrals. Twenty (49%) teams had a closed or restricted system, accepting referrals only from pre-defined sources. The most frequent sources were GPs (85%). psychiatric and general hospital staff (35%), social services (30%), self-or relative referral (15%), primary care teams (10%) and consultant psychiatrists (10%). Two teams spe cifically indicated that they did not accept self-or relative referrals.
Twenty-two (52%) teams indicated that refer rals could be directly to an individual within the team. In 34 (81%) teams, referrals were made to the team and not to an individual. In 17 (41%), referrals could be made both to the team or to individuals within the team.
The median number of referrals received each month was 34 (20-62) and the median number of clients discharged from the team each month was 20 (15-30), indicating a rapidly expanding case load. There was a significant positive correlation between the number of referrals per month and size of the team, both in terms of people (Spearman's r^0.53, P<0.001), and FTEs (r=0.50, P<0.01). Number of referrals was not associated with type of referral system. Twentythree (55%) teams stated that they offered the first point of contact for all adult mental health referrals in the locality. This was not significantly associated with the type of referral system or numbers of referrals received.
Teams were asked to indicate what percentage of referrals represented severe and long-term mental health problems. (Severity was defined as a level of distress or disturbance that might result in a diagnosis of psychosis (e.g. schizo phrenia), psychiatric admission, or intensive community-based interventions to prevent ad mission. 'Long-term' problems were defined as those requiring intensive service use over a period of six months or more.) The median proportion of referrals to the team defined as severe and long-term mental health problems was 38% (20-40). The most common types of referrals not falling into this category were: social or situational problems and crises, alcohol and drug problems, marital and other relationship problems, and brief minor affective states. There was no significant association with size of team, type of referral system or whether the team offered the first point of contact.
The median proportion of referrals considered to be inappropriate was 10% (5-15). The most common categories of inappropriate referrals included mild to moderate depression or anxiety, situational/social crises, relationship difficul ties, and bereavement, although many others were also mentioned. There was no significant association with type of referral system, or number of referrals received.
Twenty-one (50%) teams pooled all referrals for assessment before allocation for assessment, 9 (21%) teams pooled some of their referrals, and 12 teams (29%) did not pool referrals. There was no association between pooling and size of team, case load composition, type of referral system or number of referrals.

Clinical activities
Thirty-eight (90%) teams met at least once a week, 3 (7%) teams met once every two weeks, and one team met once a month. Twenty-one (50%) teams met at an in-patient unit and 12 (29%) at a community mental health centre. The remaining teams mentioned a range of other sites, including the CMHT base, a consultant psychiatrist out-patient clinic, a consultant psychiatrist office or other hospital space, a community hospital, and a social work department.
Thirty-five (83%) teams had direct access to hospital beds via a team member such as a psychiatrist.
Five (12%) teams had to refer outside the team to gain access to beds, and two (4%) teams used other arrangements. In 34 (81%) teams, responsibility for the patient was transferred to hospital staff after admission, although 17 (50%) teams continued to provide care. In 8 (19%) teams, responsibility was retained by the team.
Fourteen teams (34%) operated a case man agement or care management system; 10 (24%) did not but planned to in the next six months; and 17 (41%) did not and had no such plans. In 9 (64%) of the teams operating case or care management, it was one of a number of tasks carried out by team members. In 3 (21%) teams, case or care managers took sole responsibility, and 2 (14%) teams made other arrangements such as rotating responsibility. Thirty teams (71%) operated a keyworker system other than case or care management.
Fifteen teams (36%) participated in the care programme approach to discharges from inpatient care; 27 (64%) did not, but 23 (85%) of these had plans to implement the care pro gramme approach within the following six months.

Management and funding
Twenty-two (52%) teams undertook regular collection of users' views of the service. Of the 19 which did not, only 6 (32%) planned to do so within the next six months ( Table 6). Involvement of service user and community members in management activities was very low, and few teams planned to increase such involvement.
Twenty-six teams (62%) indicated that they had a team manager or coordinator.
Most commonly, the professional status of the team manager/coordinator was a nurse (42%), fol lowed by CPN (27%), consultant psychiatrist (19%), social worker (8%) and joint CPN and social worker (4%). Thirty-six teams (86%) had access to administrative/clerical support. In 10 (24%) teams, leadership/management tasks were the responsibility of one member of the team. In the remaining 31 (76%) teams, there was some sharing of these tasks.
The majority of teams were funded by NHS trusts (46%) or by health and social services (44%), and managed by trusts (54%) or health and social services (36%). Only three (7%) teams were health board funded and only 2 (5%) were health board managed. One team was jointly funded by the local trust, GP locality fund, and GP research fund. Work was formally monitored or evaluated in 26 teams (62%). Table 7 shows the wide range of bodies undertaking this activity, and it Is likely that methods and tools of evaluation also vary widely.

Interview data
The main themes to emerge from the qualitative interviews and focus group were:

Comment
This section draws on the results both from the survey and from the interviews and focus group.
We encountered considerable confusion about what constitutes a 'CMHT, and several profes sionals drew distinctions between formal CMHTs and loose 'networks' of professionals. In one region (Lothian), it was difficult to establish whether there were any CMHTs as conflicting accounts were obtained from professionals at the health board and at the trust.

Dilemmas over the client group of CMHTs
One of the central problems faced by CMHTs concerns 'gatekeeping' and targeting their ser vice towards the severely mentally ill, in the face of the needs of a group of patients often referred to as the 'worried well'. Just over half of the patients referred to teams were said not to represent severe and long-term mental health problems. None the less, only 10% of these referrals were considered by the respondents to be 'inappropriate'. Thus, while the formal remit of the CMHTs may be to provide care for more severely ill patients, teams are operating, de Jacto, within a broader remit. The appropriate ness of client groups was a dominant theme in the interviews. The advantages of providing for patients with milder mental health problems included reducing waiting times and financial incentives in accepting such referrals from GPs. Disadvantages included reduced resources for the care of chronic mentally ill; concerns that the 'worried well' may be seen simply because they are more vocal; and risk of burn-out for staff. It was striking that only 17% of teams had available any formal assessment of the mental health needs of the population they served. As a result, the allocation of professionals to teams may be driven solely by availability rather than identified need (a top-down rather than a bottom-up approach), resulting in a lack of fit between needs and team resources, including composition. This may be a partial explanation of the relatively low number of clinical psycholo gists in teams. Similarly, some interviewees suggested that patients may be allocated to a team member on the basis of availability rather than appropriate skill. On a wide scale, this will move CMHTs towards the American model of generic mental health care workers which may be contrary to the principle of multi-disciplinary team working.
On average, CMHTs had been taking referrals for about three years. During the key-informant interviews and the focus group there was wide spread agreement that CMHTs and the team model provides a range of benefits to patients and professionals, including: continuity of care across hospital and community settings; easier access to services for the patient; potential prevention of admission to hospital; a more integrated provision of services; a more complex range of services in the community than patients had on long-stay hospital wards: professional interchange and support; improved relations with consultant psychiatrists; crossing of profes sional boundaries; increased supervision for community team members; increased com munication between health professionals In a team; and professionals being associated with a particular locality and with particular practices.
Despite these benefits, respondents felt that work still needed to be done to improve CMHTs. The problems highlighted included: staffing pro blems: interpersonal issues: professional rival ries; team leadership/management/coordination; insufficient team-building days; insufficient sup port and training for CMHT members; increased work load and paperwork for CMHT members and risk of bum-out; imbalance of case loads of different CMHTs in a given health board area; the need for clearly denned roles and responsi bilities of different team members; the danger and inappropriateness of team members becoming 'generic mental health care workers'; insufficient provision of community services; shortage of back-up services (e.g. psychiatric hospital beds): poor communication with GPs: the need for clear referral criteria for GPs; poor links and conflict between health, social work and voluntary orga nisations: focus on the development of CMHTs at the expense of the hospitals sector with conse quent demoralisation of hospital staff; insufficient training in managerial skills for clinicians who become managers; lack of initial needs assess ments and proper resource calculations for allocation of professionals to teams; idea of patient participation still needs to be fully realised; and methods of addressing the needs of patients with less severe mental health problems.
The success of teams was felt to depend on a range of variables including: adequate resources; commitment of health professionals, especially GPs; good working relationships, especially between consultant psychiatrists and others; secretarial/administrative support; coordinated strategy from health boards and trusts; an approach to organisation and operation of teams based on clinical need rather than resourcedriven; a clear remit, including appropriate client groups; and team building initiatives.