Community mental health teams (CMHT) have been the mainstay of community based provision for 20-30 years providing long term support to people with serious mental health problems.
The introduction of specialist teams as part of the National Health Service (NHS) Plan in 2000 was based on the evidence existing at the time68: they have had a major impact on service delivery in England but integrated teams are now re-emerging in some areas.
The evidence that specialist teams alongside CMHTs are more effective than fully integrated CMHTs has developed since their initial establishment:
- overall gains have been made in terms of improved access, engagement and early intervention and effects on suicide rates69.
- the Patient Survey results70 show that people using mental health services are generally very positive about the staff they had seen although they are rather less positive about in-patient admission.
- engagement of patients is improved with assertive outreach but, in the UK, there is no evidence of effects on admissions or symptoms71. This lack of clinical effectiveness may be due to overlap in the “active ingredients” with those delivered by other community mental health services such as home treatment and out of hours availability, and the limited use of evidence-based interventions when engagement has occurred.
- economic and clinical benefits have been demonstrated for early intervention for psychosis19
- The disadvantage of the specialist teams is a lack of flexibility in the matching of resources to need, for example, integrated teams may be more appropriate in geographically dispersed rural communities with lower morbidity than in inner cities and can achieve economies of scale (e.g. similar case loads, skills and expectations for all team members).
- However integration of teams may lead to the gains that have been found with the specialist teams being lost: there is evidence from the Netherlandsthat assertive outreach and CMHTs can be effectively combined which contrasts with study findings in London71 72.
- Comparison did not provide support for CMHTs having low individual caseloads of 15 as opposed to 3073 but higher caseloads have been associated with less focus on people with severe problems74.
- Evidence in relationship to the cost-effective differentiation of roles within MDTs is predominantly based on expert consensus75. Availability of psychiatrists to assess, consult and selectively manage the most unwell patients has been prioritised over provision of more routine care. Psychiatric outpatient clinics may be practical solutions to the need for risk monitoring, medication management and support to people with moderate to severe problems (though poor practice including passing people from one junior doctor to another have devalued them) but there is limited evidence about the optimal use of them.
- Differentiation between inpatient and community consultants has occurred in some areas. People favour continuity of care76but reduction in bed numbers may influence practice, e.g. high numbers of consultant teams visiting individual inpatient wards may necessitate consolidation.
- Differentiation into separate assessment and treatment teams has not been evaluated in adult services.