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May not reduce inpatient visits, but its success in engaging marginalised patients should not be ignored
Assertive community treatment is a specific model of intensive community mental health care and a key component of the national service framework for mental health in England. Over 220 new teams using this model have been implemented since 1999.1 Assertive community treatment originated in the United States, evolving from a pioneering approach to delivery of treatment for people with mental health problems in the community.2 The treatment has been extensively researched. Good evidence exists for its efficacy outside the United Kingdom,3 but results in England have been disappointing.4 5 6 7 Possible reasons for this include differences in adherence to assertive community treatment and differences between the US and the UK in the comparison group of standard community mental health care.8 9 However, even in the UK, clients seen as being “difficult to engage” (those with whom community mental health services have found it difficult to arrange meetings) find assertive community treatment more acceptable than standard community care in terms of satisfaction with services and the amount of contact they have with them.3 7
In this week's BMJ a systematic review of randomised controlled trials by Burns and colleagues compares the impact on the use of inpatient services of various forms of intensive case management (including assertive community treatment) compared with standard community mental health care.10 It finds that the way in which the team organises its approach to the work and whether it is implemented in an area with high use of inpatient services accounts for the differences in findings regarding inpatient service use.
The assessment of the organisation of the team was based on whether the team was the primary therapy for its clients; was based off the hospital campus; met daily; shared responsibility for caseloads; was available 24 hours; had a team leader who was also a case manager; and offered services without a time limit. The authors state that these features reflected the extent that case managers worked as a team rather than as independent practitioners. This aspect of assertive community treatment is often referred to as the “team based approach,” facilitated by the team working extended hours in shifts such that several different staff are involved in a client's care. Also, daily team meetings take place to discuss the work plan and share ideas about clinical problems. Burns and colleagues suggest that similarities in the organisation of the team between community mental health teams and assertive community treatment teams could explain the lack of efficacy in the UK, and they conclude that case managers should work as teams rather than as individuals when caring for severely mentally ill individuals.10
However, another important component of home treatment models, including assertive community treatment, is “in vivo” work,11 where contact occurs at the client's home or elsewhere in the community rather than in the team office. Although home treatment teams in the US have been reported to make more in vivo visits than UK teams, community mental health teams in the UK make more in vivo visits than standard care comparison teams in the US.9 This may also explain the lack of efficacy reported in the UK studies.
Despite these similarities between assertive community treatment and community mental health care, the finding that the former is more acceptable to a particularly marginalised group of clients should not be ignored. This may result from differences in styles of client engagement, with assertive community treatment using more recovery based practice approaches,12 such as collaborating on agreed tasks and therapeutic risk taking rather than the more autocratic community mental health care approach of delivering treatment. This has potentially far reaching consequences for reducing social exclusion for this group. The team based approach seems to be a particularly important component for staff in assertive community treatment teams in providing supportive and constructive containment in working with challenging clients (unpublished data).
In the current financial context of the National Health Service in England, assertive community treatment is vulnerable, and the National Forum for Assertive Outreach has many examples of teams being disbanded and/or having their practitioners redeployed to provide the treatment within community mental health care teams. This makes little sense now that the critical success factors seem to have been identified (team based approach; extended hours; high proportion of in vivo visits). It is unfeasible to deliver these factors within a community mental health care team for three reasons. Firstly, the size of a community mental health care team's caseload makes shared caseloads and daily team meetings impractical. Secondly, a quorum of staff is required to work shifts to provide an extended hours service. Thirdly, protection of low caseloads is difficult in the pressured environment of a community mental health care team but necessary to ensure a high proportion of in vivo visits.
The problem for assertive community treatment in England is that reducing the use of inpatient services is seen as the main measure of success. This correlates with the cost of the service, but its great success in enabling staff to work with clients that community mental health care teams had failed to engage for years seems to be being ignored. The model is popular with staff working in assertive community treatment and with clients.3 7 With an increasing focus across all health specialties to provide services in the community, it seems premature to dismantle assertive community treatment teams now that we really know how they should work.
Competing interests: None declared.
Provenance and peer review: Commissioned, not externally peer reviewed.