Out-patient and ambulatory clinics

Out-patient and ambulatory clinics vary according to:

1. (a) whether patients can self-refer, or need to be referred by other agencies such as primary care;

2. (b) there are fixed appointment times or open access assessments;

3. (c) doctors alone or other disciplines also provide clinical contact;

4. (d) whether direct or indirect payment is made;

5. (e) methods used to enhance attendance rates;

6. (f) how the clinic responds to non-attenders;

7. (g) the frequency and duration of clinical contacts.

There is surprisingly little evidence on any of these key characteristics of out-patient care (Reference Becker, Thornicroft and SzmuklerBecker, 2001), but there is a strong clinical consensus in many countries that such clinics are a relatively efficient way of organising the provision of assessment and treatment, provided that the clinic sites are accessible to local populations. Nevertheless, these clinics are simply methods of arranging clinical contact between staff and patients, and so the key issue is the content of the clinical interventions: namely, to deliver treatments that are known to be evidence-based (Reference Roth and FonagyRoth & Fonagy, 1996; Reference Nathan and GormanNathan & Gorman, 2002; BMJ Publishing Group, 2003).

Community mental health teams (CMHTs)

Community mental health teams are the basic building block for community mental health services. The simplest model of provision of community care is for generic (non-specialised) teams to provide the full range of interventions (including the contributions of psychiatrists, community psychiatric nurses, social workers, psychologists and occupational therapists), prioritising adults with severe mental illness, for a local defined geographical catchment area (Reference Thornicroft, Becker and HollowayThornicroft et al, 1999; Department of Health, 2002). A series of studies and systematic reviews, comparing community mental health teams with a variety of local usual services, suggests that there are clear benefits to the introduction of generic, community-based multidisciplinary teams: they can improve engagement with services, increase user satisfaction, increase met needs and improve adherence to treatment, although they do not improve symptoms or social function (Tyrer et al, Reference Tyrer, Morgan and Van Horn1995, Reference Tyrer, Evans and Gandhi1998, Reference Tyrer, Coid and Simmonds2003; Reference Thornicroft, Wykes and HollowayThornicroft et al, 1998; Reference Burns, Thornicroft and SzmuklerBurns, 2001; Reference Simmonds, Coid and JosephSimmonds et al, 2001). In addition, continuity of care and service flexibility have been shown to be more developed where a community mental health team model is in place (Reference Sytema, Micciolo and TansellaSytema et al, 1997).

Case management. Within community mental health teams, case management is a method of delivering care, rather than being a clinical intervention in its own right, and at this stage the evidence suggests that it can most usefully be implemented within the context of the community mental health team (Reference Holloway and CarsonHolloway & Carson, 2001). It is a style of working that has been described as the ‘coordination, integration and allocation of individualised care within limited resources’ (Reference ThornicroftThornicroft, 1991). There is now a considerable literature to show that this style of working can be moderately effective in improving continuity of care, quality of life and patient satisfaction, but there is conflicting evidence as to whether it has any impact on the use of in-patient services (Reference Saarento, Hansson and SandlundSaarento et al, 1996; Reference Hansson, Muus and VindingHansson et al, 1998; Reference Mueser, Bond and DrakeMueser et al, 1998; Reference Ziguras and StuartZiguras & Stuart, 2000; Reference Ziguras, Stuart and JacksonZiguras et al, 2002). Case management needs to be carefully distinguished from the much more specific and more intensive assertive community treatment (see below).

Acute in-patient care

There is no evidence that a balanced system of mental health care can be provided without acute beds. Some services (such as home treatment teams, crisis houses and acute day hospital care, see below) may be able to offer realistic alternative care for some voluntary patients. Nevertheless, people who need urgent medical assessment, or those with severe and comorbid medical and psychiatric conditions, or those experiencing severe psychiatric relapse and behavioural disturbance, or those with high levels of suicidality or assaultativeness, or with an acute neuropsychiatric condition, or elderly patients with concomitant severe physical disorders, will usually require high-intensity immediate support in acute in-patient hospital units.

There is a relatively weak evidence base on many aspects of in-patient care, and most studies are descriptive accounts (Reference Szmukler, Holloway, Thornicroft and SzmuklerSzmukler & Holloway, 2001). There are few systematic reviews in this field, one of which found no difference in outcomes between routine admissions and planned short hospital stays (Reference Johnstone and ZoleseJohnstone & Zolese, 1999). More generally, although there is a consensus that acute in-patient services are necessary, the number of beds required is highly contingent upon what other services exist locally and upon local social and cultural characteristics (Reference Thornicroft and TansellaThornicroft & Tansella, 1999). Acute in-patient care commonly absorbs most of the mental health budget (Reference Knapp, Chisholm and AstinKnapp et al, 1997). Therefore, minimising the number of bed-days used, for example by reducing the average length of stay, may be an important goal, if the resources released in this way can be used for other service components. A related policy issue concerns how to provide acute beds in a humane and less institutionalised way that is acceptable to patients, for example in general hospital units (Reference Quirk and LelliottQuirk & Lelliott, 2001; Reference Tomov, Thornicroft and TansellaTomov, 2001).

Long-term community-based residential care

It is important to know whether patients with severe and long-term disabilities should be cared for in larger, traditional institutions, or be transferred to long-term community-based residential care. The evidence here, for areas with medium and high resource levels, is clear. When deinstitutionalisation is done carefully for those who had previously received long-term in-patient care for many years, the outcomes are more favourable for most patients who are discharged to community care (Reference TansellaTansella, 1986; Reference Thornicroft and BebbingtonThornicroft & Bebbington, 1989; Reference Shepherd, Murray, Thornicroft and SzmuklerShepherd & Murray, 2001). The Team for the Assessment of Psychiatric Services study in London (Reference LeffLeff, 1997), for example, completed a 5-year follow-up of over 95% of 670 people without dementia discharged from long-stay residential care and found that:

1. (a) two-thirds of the patients were still living in their new residence;

2. (b) there was no increase in the death rate or the suicide rate;

3. (c) very few patients became homeless, and none was lost to follow-up from a staffed home;

4. (d) over a third were briefly readmitted, and at follow-up 10% of the sample were in hospital;

5. (e) patients’ quality of life was greatly improved by the move to the community;

6. (f) there was little difference between total hospital and community costs, and overall community care was more cost-effective than long-stay hospital care.

However, there is less evidence available on the treatment and care needs of the never-institutionalised group of long-term patients (Reference Holloway, Wykes and PetchHolloway et al, 1999), and so careful local assessment of the needs of this population will be especially important. The range and capacity of community residential long-term care that will be needed in any particular area is also highly dependent upon which other services are available locally, and upon social and cultural factors, such as the amount of family care that is provided (Reference Van Wijngaarden, Schene and Koetervan Wijngaarden et al, 2003).

Employment and occupation

Rates of unemployment among people with mental disorders are usually much higher than in the general population (Reference WarrWarr, 1987; Reference WarnerWarner, 1994). Traditional methods of occupation and day care have been provided by day centres or a variety of psychiatric rehabilitation centres (Reference ShepherdShepherd, 1990; Reference Rosen, Barfoot, Thornicroft and SzmuklerRosen & Barfoot, 2001). There has been little scientific research into these traditional forms of day care, and a review of over 300 papers found no relevant randomised controlled trial (Reference Marshall, Crowther and Almaraz-SerranoMarshall et al, 2001). Non-randomised studies have given conflicting results, and for areas with medium levels of resources it is reasonable at this stage to make pragmatic decisions about the provision of rehabilitation and day care services if the more differentiated and evidence-based options discussed below are not affordable (Reference Marshall, Crowther and Almaraz-SerranoMarshall et al, 2001; Reference Catty, Burns and ComasCatty et al, 2003).

Specialised out-patient and ambulatory clinics

Specialised out-patient facilities for specific disorders or patient groups are common in many high-resource areas and may include services dedicated, for example, to those with eating disorders; patients with dual diagnosis (psychotic disorder and substance misuse); people with treatment-resistant affective or psychotic disorders; those requiring specialised forms of psychotherapy; mentally disordered offenders; mentally ill women with babies; and those with other specific disorder groups (such as post-traumatic stress disorder). Local decisions about whether to establish such specialist clinics will depend upon several factors, including their relative priority in relation to the other specialist services described below, identified services gaps and the financial opportunities available.

Specialised community mental health teams

Specialised community mental health teams are by far the most researched of all the components of balanced care, and most recent randomised controlled trials and systematic reviews in this field refer to such teams (Reference Mueser, Bond and DrakeMueser et al, 1998). Two types of specialised community mental health team have been particularly well developed as adjuncts to generic teams: assertive community treatment teams and early intervention teams.

Assertive community treatment teams. Assertive community treatment teams provide a form of specialised mobile outreach treatment for people with more disabling mental disorders, and have been clearly characterised (Reference Deci, Santos and HiottDeci et al, 1995; Reference Teague, Bond and DrakeTeague et al, 1998; Reference Scott, Lehman, Thornicroft and SzmuklerScott & Lehman, 2001). There is now strong evidence that assertive community treatment can produce the following advantages in areas with high levels of resources:

1. (a) reduced admissions to hospital and use of acute beds;

2. (b) improved accommodation status and occupation;

3. (c) increased service user satisfaction.

Assertive community treatment has not been shown to produce improvements in mental state or social behaviour. It can reduce the cost of in-patient services, but does not change the overall costs of care (Reference LatimerLatimer, 1999; Reference Phillips, Burns and EdgarPhillips et al, 2001; Reference Marshall and LockwoodMarshall & Lockwood, 2003). Nevertheless, it is not known how far this approach is cross-culturally relevant and indeed there is evidence that it may be less effective where usual services already offer high levels of continuity of care, for example in the UK, than in settings where the ‘treatment as usual’ control condition may offer little to patients with severe mental illness (Burns et al, Reference Burns, Creed and Fahy1999, Reference Burns, Fioritti and Holloway2001; Reference Fiander, Burns and McHugoFiander et al, 2003).

Early intervention teams. There has been considerable interest in recent years in the prompt identification and treatment of first- or early-episode cases of psychosis. Much of this research has focused upon the time between the first clear onset of symptoms and the beginning of treatment, referred to as the ‘duration of untreated psychosis’; other studies have placed more emphasis upon providing family interventions when a young person's psychosis is first identified (Reference Addington, Coldham and JonesAddington et al, 2003; Reference Raune, Kuipers and BebbingtonRaune et al, 2004). There is now emerging evidence that longer duration of untreated psychosis is a predictor of worse outcome for the disorder; in other words, if patients wait a long time after developing a psychotic condition before they receive treatment, then they may take longer to recover and have a less favourable long-term prognosis. Few controlled trials of such interventions have been published, and a recent Cochrane systematic review (Reference Marshall and LockwoodMarshall & Lockwood, 2004) has concluded that there are ‘insufficient trials to draw any definitive conclusions,... the substantial international interest in early intervention offers an opportunity to make major positive changes in psychiatric practice, but this opportunity may be missed without a concerted international programme of research to address key unanswered questions’. It is therefore currently premature to judge whether specialised early intervention teams should be seen as a priority (Reference Larsen, Friis and HaahrLarsen et al, 2001; Reference McGorry and KillackeyMcGorry & Killackey, 2002; Reference McGorry, Yung and PhillipsMcGorry et al, 2002; Reference Warner and McGorryWarner & McGorry, 2002; Reference Friis, Larsen and MelleFriis et al, 2003; Reference Harrigan, McGorry and KrstevHarrigan et al, 2003).

Alternatives to acute in-patient care

In recent years three main alternatives to acute in-patient care have been developed: acute day hospitals, crisis houses and home treatment/crisis resolution teams.

Acute day hospitals. Acute day hospitals offer programmes of day treatment for those with acute and severe psychiatric problems, as an alternative to admission to in-patient units. A recent systematic review of nine randomised controlled trials has established that acute day hospital care is suitable for about 30% of people who would otherwise be admitted to hospital, and offers advantages in terms of faster improvement and lower cost. It is reasonable to conclude that acute day hospital care is an effective option when demand for in-patient beds is high (Reference Wiersma, Kluiter and NienhuisWiersma et al, 1995; Reference Marshall, Crowther and Almaraz-SerranoMarshall et al, 2001).

Crisis houses. Crisis houses are houses in community settings which are staffed by trained mental health professionals and offer admission for some patients who would otherwise be admitted to hospital. A wide variety of respite houses, havens and refuges have been developed, but the term ‘crisis house’ is used here to mean facilities that are alternatives to non-compulsory hospital admission. The little available research evidence suggests that they are very acceptable to their residents (Reference Davies, Presilla and StrathdeeDavies et al, 1994; Sledge et al, Reference Sledge, Tebes and Rakfeldt1996a ,Reference Sledge, Tebes and Wolff b ; Reference Szmukler, Holloway, Thornicroft and SzmuklerSzmukler & Holloway, 2001), may be able to offer an alternative to hospital admission for about a quarter of those who would otherwise be admitted, and may be more cost-effective than hospital admission (Sledge et al, Reference Sledge, Tebes and Rakfeldt1996a ,Reference Sledge, Tebes and Wolff b ; Reference MosherMosher, 1999). Nevertheless, there is emerging evidence that female patients in particular prefer non-hospital alternatives (such as crisis houses) to acute in-patient treatment, and this may reflect the lack of perceived safety in hospital (Reference Killaspy, Dalton and McNicholasKillaspy et al, 2000).

Home treatment and crisis resolution teams. Home treatment and crisis resolution teams are mobile community mental health teams offering assessment for patients in psychiatric crises and providing intensive treatment and care at home. A Cochrane systematic review (Reference Catty, Burns and KnappCatty et al, 2002) found that most of the research evidence comes from the USA and the UK, and concluded that home treatment teams reduce days spent in hospital, especially if the teams make regular home visits and have responsibility for both health and social care (Reference Joy, Adams and RiceJoy et al, 2002).

Alternative types of long-stay community residential care

These are usually replacements for long-stay wards in psychiatric institutions (Reference Shepherd, Muijen and DeanShepherd et al, 1996; Reference Trieman, Smith and KendalTrieman et al, 1998; Reference Shepherd, Murray, Thornicroft and SzmuklerShepherd & Murray, 2001). Three categories of such residential care can be identified:

1. (a) 24 h staffed residential care (high-staffed hostels, residential care homes or nursing homes, depending on whether the staff have professional qualifications);

2. (b) day-staffed residential places (hostels or residential homes which are staffed during the day);

3. (c) lower supported accommodation (minimally supported hostels or residential homes with visiting staff).

There is limited evidence as to the cost-effectiveness of these types of residential care, and no completed systematic review (Reference Chilvers, Macdonald and HayesChilvers et al, 2003). It is therefore reasonable for policy makers to decide upon the need for such services with local stake-holders (Reference HafnerHafner, 1987; Reference Nordentoft, Knudsen and SchulsingerNordentoft et al, 1992; Reference Rosen, Barfoot, Thornicroft and SzmuklerRosen & Barfoot, 2001; Reference ThornicroftThornicroft, 2001).

Alternative forms of employment and occupation

Although vocational rehabilitation has been offered in various forms to people with severe mental illness for over a century, its role has weakened because of discouraging results, financial disincentives to work and pessimism about outcomes for these patients (Reference Lehman, Carpenter and GoldmanLehman et al, 1995; Reference Polak and WarnerPolak & Warner, 1996; Reference Wiersma, Nienhuis and SlooffWiersma et al, 1997). However, recent alternative forms of occupation and vocational rehabilitation have again raised employment as an outcome priority. Consumer and carer advocacy groups have set work and occupation as one of their highest priorities, to enhance both functional status and quality of life (Reference Becker, Drake and FarabaughBecker et al, 1996; Reference Thornicroft, Rose and HuxleyThornicroft et al, 2002). There are recent indications that it is possible to improve vocational and psychosocial outcomes with supported employment models, which emphasise rapid placement in competitive jobs and support from employment specialists (Reference Drake, McHugo and BeboutDrake et al, 1999). This individual placement and support model emphasises competitive employment in integrated work settings with follow-up support (Reference Priebe, Warner and HubschmidPriebe et al, 1998); studies of such programmes have been encouraging in terms of increased rates of competitive employment (Reference Marshall, Crowther and Almaraz-SerranoMarshall et al, 2001; Reference Lehman, Goldberg and DixonLehman et al, 2002).