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Modern Community Care – What do we know that is effec‑ tive?

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Modern Community Care – What do we know that is effec‑ tive?
Modern Community Care – What do we know that is effec‑
tive?
Burns, T. *
Abstract:
Community care has been seen a remarkable
expansion in research in the last thirty years.
Such research is beset with difficulties includ‑
ing fixing models long enough to get clear
comparisons, the absence of consistency in
description (particularly of comparator ser‑
vices) and the inevitable contamination from
the ‘Pioneer’ effect of highly motivated teams.
Assertive Community Treatment (ACT) teams
are the most intensively researched but the
evidence is contradictory.
ACT is a complex intervention and a meta­
‑ regression analysis is reported here that
distinguished between the studies in terms of
their component parts to identify effective and
redundant ingredients. This analysis clari‑
fied the overwhelming impact of variation in
comparator services. It also confirmed that the
core ingredients in traditional generic CMHTs
(multidisciplinary working, home­‑based care
and combined health and social care) ensured
an equally effective outcome to the more in‑
tensively staffed and carefully prescribed ACT
teams.
Community mental health services need not
follow one prescriptive model. Developing lo‑
cal services should be guided by the research
into how effective aspects of care can be in‑
corporated into locally meaningful structures
rather than importing complex systems from
other health care cultures.
Key­‑Words: Community Psychiatry; Mental
Health Services; Assertive Community Treat‑
ment.
Introduction
Modern Community care in mental health has
evolved steadily since the second world war.
It is traditional to date deinstitutionalisation
from the introduction of the antipsychotic,
chlorpromazine, in 1952. In truth, moves had
been afoot for at least a decade. Querido had
introduced an out­‑patient service in the 1930s
in Amsterdam1; the open­‑door movement had
been initiated in the UK in the mid 1940s cul‑
minating in Dingleton Hospital becoming a
fully open­‑door service by 19482; Russia had
seen a rich development of day centres and
dispensaries.
As deinstitutionalization gathered pace with
downsizing and closing of mental hospitals,
sector community mental health teams be‑
gan to develop. These were predominantly
in response to the complex needs of increas‑
ingly disabled patients who began to live
outside hospitals. Inevitably they were multi­
‑disciplinary because patients needs were var‑
ied. In the pioneer countries (France3 and the
UK4) in the 1960s they not only recognised the
need for breadth of input but continuity of in‑
put.
44 • Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE
*Professor of Social Psychiatr: University of Oxford, Department of Psychiatry ‑­ The Warneford Hospital; e.mail: [email protected]
Modern Community Care – What do we know that is effective?
Sector teams were consolidated in the UK by
the 1959 Mental Health Act5. This act required
all hospitals which admitted compulsory pa‑
tients to provide them with outpatient care
after discharge. It also required collaboration
between health and social services in the man‑
agement of severe mental illness, in particular,
involuntary care. These two conditions drove
a sectorization of care. It was not possible to
provide out­‑patient care to all their discharged
patients if hospitals did not sub­‑divide respon‑
sibilities to smaller units. Similarly, it wasn’t
possible to establish and maintain profession‑
al working relationships with social services
across a broad canvas – local arrangements
had to be made.
The multi­‑disciplinary sector team which
evolved in France and the UK has persisted in
the UK since that time and has spread. By the
late 1980s nearly all inhabitants in Britain
were served by such teams4 and they were in‑
troduced to considerable international interest
in northern Italy after Law 1806,8.
Mental Health Services Research
Whilst clinical services were evolving rapidly
and with increasing sophistication there was
initially very little research into community
mental health care. Partly this was cultural
(the rise of evidence based medicine9 and
health services research is a recent phenom‑
enon). Partly it reflected the problems facing
clinicians. They need to respond to press‑
ing needs and can rarely afford the luxury
of hypothesis driven service configuration.
In addition services continued to improve
gradually with few obvious “break­‑points”
that promote evaluation. Research in this
area is further complicated by the rapidity
of change. Mental health services research‑
ers are invariably aiming at a moving target
as there are a number of external drivers to
change which go beyond therapeutic devel‑
opments (e.g. politics, the media, social at‑
titudes).
There have been a number of criticisms of
the quality of early mental health services
research10. These criticisms reflect several in‑
herent problems. Two affect mental health
services research more than other health ser‑
vices research. One is the bias introduced by
personal commitment. Studies are very long,
the interventions are complex and are based
on relationships and consequently research‑
ers are often highly committed to the service
they are evaluating. A second is that research
findings are high contextualised and depend‑
ent on local service configurations and policy
issues. They translate poorly internationally11
and this has often been compounded by patri‑
otism. Notwithstanding these barriers, mental
health services research into community care
has now become a major international exer‑
cise12,13.
Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE • 45
Burns, T. *
Phases of Community Care Devel‑
opment
The development of community mental health
care can be helpfully conceptualised as hav‑
ing three major phases. The first phase was
that of deinstitutionalisation and the estab‑
lishment of community mental health teams
by clinicians without a reflective academic
framework. This phase can be considered one
of ‘evolution’ and runs from the mid 1950s
through to the end of the 1970s. With the pub‑
lication of Stein and Test’s landmark study14
in 1980, mental health services research es‑
tablished itself as a major endeavour, and with
it the establishment of evidence­‑based mental
health teams. The most highly researched
model for these teams was Assertive Commu‑
nity Treatment14,15. This period which ran from
1980 to 2000 can be considered the period of
‘revolution’. The third period arose when the
steady stream of convincing results about
evidence­‑based teams was first confounded by
contradictory results. In particular, two large
UK studies (UK70016,17 and PRiSM17) failed to
find the advantages which had been increas‑
ingly taken for granted.
This “counter­‑revolution” period which takes
us into the present has introduced a much
more rigorous and scientific evaluation of the
components of care. This paper will preoccupy
itself with this final phase, in particular ex‑
ploring how a careful examination of contra‑
dictions in the evidence can lead us to better
understand what is effective in modern com‑
munity care.
Assertive Community Treatment was first
presented in a series of papers in Archives of
Psychiatry in 198014,18,19. This was a seren‑
dipitous study stimulated by the closure of a
ward. Stein & Test deployed the ward staff to
be intensive case managers of their patients
at a ratio of 10:1. They took their care out of
the clinic and into patient’s homes. They were
remarkably tenacious, following up patients
one, two or three times a week and insisting
that they took their antipsychotic medication.
Their study was enormously influential. With
only 126 patients randomised between the
two services they demonstrated a remarkable
reduction in hospitalisation (over two thirds)
with significant improvements in social func‑
tioning and probably some in clinical func‑
tioning. Depending on how the study is inter‑
preted, their service was either cost neutral or
actually cost­‑saving. A striking finding of the
study was that when the service was withdrawn
(a consequence of financial constraints) all
the advantages rapidly evaporated. ACT was
therefore reconceptualised as an intensive
multi­‑disciplinary case management team
providing assertive in­‑vivo care for severely
ill psychotic patients. It was not, as originally
intended, a time limited training programme
in community living but one that had to be
provided continuously.
46 • Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE
Modern Community Care – What do we know that is effective?
The Stein & Test Study has had an overwhelm‑
ing international impact. The services have been
replicated and the studies have been replicated
although predominantly in the US. It quickly be‑
came mandated by federal funding bodies in the
US that ACT should be provided as an evidence­
‑based service. This spread to Australia20 and in
1999 became mandated in the UK21 with the es‑
tablishment of over 300 new teams. The policy
change in the UK was stimulated predominantly
by the two influential meta­‑analyses produced by
Marshall and Lockwood15,22. Their conclusions
from the evidence at time was that ACT reduced
hospitalisation overall and that standard case
management increased it.
The UK700 Trial
A note of caution however was founded by the
UK700 Trial. This very rigorous multi­‑centre
trial carefully compared the care provided
with intensive case­‑ management (caseload
sizes of 1:15) against standard case­‑manage­
ment (caseload size 1:30). Despite this ma‑
jor difference in approach (including high
fidelity ACT provision in London23) no re‑
duction in hospitalisation was found at all.
The PRiSM study had similar results, indeed
no European trial has every demonstrated a
significant reduction in hospitalisation from
ACT. It is the exploration of these contradic‑
tory findings which helped clarify what is
and isn’t effective.
Understanding the Variation ACT
Outcomes
The initial response to the UK700 and PRiSM
studies was one of polemic and debate24,25. This
could not advance the subject and therefore a
scientific exploration of these differences was
undertaken. This exploration26 used meta­
‑regression analysis. Meta­‑regression analysis
goes beyond routine meta­‑analysis in a num‑
ber of important ways. It allows skewed data to
be included; missing standard deviations can
be imputed from the data; multi­‑site trials can
be disaggregated and patient level data can be
sought and included. In addition to a powerful
meta analysis we established the model fidel‑
ity of all the reported services either from data
in the paper or by extra information from re‑
searchers. This was calculated using the estab‑
lished scale, IFACT27.
The meta­‑regression analysis was used to
test the variation in outcome against four
hypothesised contributory factors. These
were the date of the study (do earlier studies
demonstrate more reduction?) This tests of
the impact of increasing sophistication of re‑
search methodology (which has undoubtedly
improved over time). Secondly, the size of the
study (do smaller studies report a greater ef‑
fect size?) This tests for publication bias with
filtering out of negative studies by journals.
Thirdly, the effect of baseline hospitalisation
rates (do higher rates of routine hospitalisa‑
Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE • 47
Burns, T. *
tion permit greater reduction by ACT?) This is
to test the hypothesis that it is the quality of
the control services in the UK which had re‑
sulted in no improvement from ACT. And last‑
ly, the effect of model fidelity (do teams with
greater model fidelity result in greater reduc‑
tion?). The meta­‑regression analysis demon‑
strated that neither the date nor the size of
the study was significantly associated with
reduction hospitalisation. However, baseline
hospitalisation rates and model fidelity both
did have clear and statistically significant as‑
sociation with reduction hospitalisation.
Figure 1: Meta­‑regression of baseline hospitalisa‑
tion against reduction in inpatient days. Burns, T.
et al. BMJ 2007; 335:336.
Copyright ©2007 BMJ Publishing Group Ltd.
The association with baseline hospitalisation
rates (figure 1) does not help to distinguish ef‑
fective ingredients from redundant ones. It con‑
firms that there is something about the effective
component in the control group that makes
the difference but it does not help understand
which these are. However the model fidelity
measurements of the experimental teams and
their relationship to differences of outcome do.
The IFACT scale is particularly helpful in that it
contains three separate domains which are inde‑
pendently measured. These domains are resourc‑
es, practices and treatments. It is not possible to
assess treatment retrospectively but it is possible
to accurately measure practices and resources.
When these two domains are separated in the
meta­‑regression analysis it becomes clear that
resources (i.e. staffing levels – the most expen‑
sive part of the innovation) have absolutely no
effect on hospitalisation rates (figure 2). This is a
second confirmation of the finding of the UK700
study which had focused particularly on staffing
levels. However, team organisation (practices) is
responsible for all the variation (figure 3). What
this demonstrates is that it is the nature of multi­
‑disciplinary work rather than staffing levels
which was effective when ACT was introduced in
the US and Australia. In the UK effective multidis‑
ciplinary (‘ACT­‑like’) working was already pre‑
sent in the CMHT controls so there was no benefit
obtained by increasing the resources by reducing
the caseload.
48 • Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE
Modern Community Care – What do we know that is effective?
Which Ingredients Make a Difference?
Figure 2: Metaregression of IFACT staff scores
against inpatient days.
In a previous study we tested for effective in‑
gredients of home based care using cluster
analysis and regression analysis28. This is a sci‑
entifically less rigorous study than the meta­
‑regression analysis but does give some impor‑
tant clues to the clinical variables that make a
difference. In this systematic review of home
based care12 we actively included ACT and all
other forms of case management providing
their aim was to deliver home based care and
help severely mentally ill people remain out of
hospital. In this study we did not use an es‑
tablished model fidelity scale but convened an
expert consensus to identify important compo‑
nents of practice. In this expert consensus we
used a modified three stage Delphi process29
with ten experts to agree essential components
of care that could be operationalised and sent
to researchers. The service questionnaire con‑
tained 20 items most of which could be iden‑
tified as ‘absent’ or ‘present’ with a handful
requiring a simple categorical measurement.
The questionnaire was sent to the 90 Principal
Investigators of the research studies included
in the systematic review and we obtained re‑
sults from 60.
Figure 3: Metaregression of IFACT practice scores
against inpatient days.
Burns, T. et al. BMJ 2007;335:336
Copyright ©2007 BMJ Publishing Group Ltd.
Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE • 49
Burns, T. *
finance ­– and medical care ­– psychotherapy,
medication­ – within the team without formal
referral). Some key features such as 24 hour
working and a high level of medical input did
not feature in this list.
We also regressed the 20 characteristics
against reduction in hospitalisation to see if
any of them demonstrated a significant asso‑
ciation. The two that did were: regularly visit‑
ing at home and responsibility for health and
social care.
Figure 4: Components of care in Home based ser‑
vices. Social Psychiatry and Psychiatric Epidemiol‑
ogy (2004) 39: 789­‑796. Wright, C, Catty, J, Watt,
H, Burns, T.
Cluster and Regression Analysis
A simple count of these 20 characteristics
found six frequently reported in experimen‑
tal services (figure 4). These were: smaller
caseloads (1:20 or below), regularly visiting at
home (a team policy for home visits beyond
emergencies), high percentage of contact at
home (over 60% of all contact conducted in
patients homes), multi­‑disciplinary team (at
least three different trained professional disci‑
plines), integrated psychiatrists (psychiatrists
attended all regular reviews not just those
which required a medical input), responsibil‑
ity for health and social care (able to access
both social care ­– housing, structured activity,
Conclusions
Most knowledge about what is effective in com‑
munity mental health care has been derived
from the steady accumulation of clinical wis‑
dom. It is important not to ignore this, despite
our emphasis on evidence­‑based medicine.
Evidence in this area, as has been pointed out
earlier, is extremely hard to obtain. The ab‑
sence of experimental evidence does not mean
the absence of knowledge. Research in this
area is enormously time consuming and ex‑
pensive. It is also complicated by the fact that
most of the interventions being researched are
complex ones where it is hard to distinguish
between a number of potentially confounding
and effective factors.
Luckily the variation in outcome has helped
us get below the surface. Had the research
into Assertive Community Treatment been
50 • Revista do Serviço de Psiquiatria do Hospital Prof. Doutor Fernando Fonseca, EPE
Modern Community Care – What do we know that is effective?
consistent in all its findings we would hard‑
ly be any further forward than we were in
1980. However the variations have forced
us to deconstruct this complex intervention
indirectly. By using the natural variation in
outcomes and provision within these studies
(both in the experimental and in the con‑
trol service) we have been able to tease out
a candidate list of those components which
appear to make a difference (the six factors
in figure 4). This process has been remark‑
able in that it has also enabled us to dismiss
the importance of a number of extremely
expensive features (e.g. 24 hour availability
and very small caseloads) which have long
been held to be essential and whose prohibi‑
tive cost has prevented the implementation of
services. Further refining of these ingredients
by a regression against the variation in re‑
duction of hospitalisation has indicated that
two of them (home visiting and combined
health and social care) are probably the most
important of the six.
We are now in a position to say with a degree
of confidence what effective home based care of
people with severe mental illness needs to look
like. It needs a multi­‑disciplinary team which
respects and includes both health and social
care perspectives. It needs doctors who work
actively within that team and are not seen as re‑
mote experts. It needs agreed case loads. The ev‑
idence does not seem to be that these case loads
need to be very small. However there needs to be
a cap on case loads so that case managers can
predict their workload and vary it.
It is worth bearing in mind those things which
are so taken for granted such that they can’t be
measured because they are ubiquitous. Conti‑
nuity of care, effective professional training
and a respectful non­‑discriminating attitude
between professionals and towards patients
appear to be uniform characteristics of good
community mental health teams. The fact that
they cannot be separated out and experimen‑
tally tested should not blind us to their core
importance to effective community mental
health care.
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