Assertive community treatment in UK practice

Since 2000 assertive outreach has been a requirement of community mental health provision in the UK. This has led to rapid proliferation of assertive community treatment teams offering a pure form of clinical case management to people with severe mental illness. The teams provide intensive support in obtaining material essentials such as food and shelter and place a greater emphasis on social functioning and quality of life than on symptoms. People with psychotic illness with fluctuating mental state and social functioning and poor medication adherence are most likely to benefit. Teams are ideally placed to monitor clozapine treatment in the community. Teams require a broad skills mix, and team members need some competence across a wide range of areas. Teams should include a psychiatrist or have regular access to one. Ideal individual case-loads are 10–12 patients. Around-the-clock availability is no longer considered essential, particularly in view of the rise of crisis resolution/home treatment teams. Andrew Kent is a reader in psychiatry at St George’s, University of London (Department of Psychiatry, Jenner Wing, Cranmer Terrace, London SW17 0RE, UK. Email: [email protected]). He collaborated with Tom Burns on the St George’s arm of the UK700 study of intensive case management. Tom Burns is Professor of Social Psychiatry at the University of Oxford, having moved from a similar position at St Georges. At St George’s he had consultant responsibility for an assertive outreach team established in 1994 which was awarded Beacon status by the Department of Health. Running an assertive community treatment team 389 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/ with the understanding that an effective community treatment programme must assume responsibility for helping patients to meet all their needs. These needs, they argued, include the material essentials of life such as food, clothing and shelter; coping skills necessary to meet the demands of community living; motivation to persevere in the face of adversity; freedom from pathologically dependent relationships; and support and education of significant others involved with the patient in the community. The expectation that socially disabled patients would come to the clinician was replaced with the expectation that the clinician would be assertive in delivering care and go to the patient. The assumption that the patient would negotiate the difficult pathways between different caring agencies was replaced with the assumption that the clinician is responsible for ensuring coordination of inter-agency care. The role of the keyworker became pre-eminent, and keyworkers assumed responsibility for delivering a greater proportion of direct care to a much smaller number of allocated patients. Care became needsled and care programmes were designed for each individual patient. The results of Stein & Test’s original randomised controlled study of training in community living remain impressive. Over the first year, 58% of the individuals randomised to standard progressive care were readmitted to a psychiatric hospital compared with 6% of those receiving training in community living. Not only were patients on the training in community living programme more likely to live independently in the community but their clinical state improved, together with their social functioning, likelihood of employment, adherence to medication regimens and, most important of all, their quality of life (Stein & Test, 1980). These gains were achieved without additional burden on families or other informal carers and (despite the intensity of intervention) at no extra cost because of the saving on beds (Test & Stein, 1980; Weisbrod et al, 1980). These results have been interpreted to suggest that training in community living was significantly less expensive than standard progressive care. When funding for the programme was withdrawn, all of the gains were lost. This last very important finding indicated that assertive community treatment needs to be offered to patients over the longer term. This led to a change in ethos and a change in name from training in community living to assertive community treatment, reflecting a service providing continuous, longer-term support rather than one-off training. Assertive community treatment Assertive community treatment has influenced service development internationally (Marshall & Lockwood, 1998). This wider influence can be attributed in part to the rigorous manner in which Stein and Test conducted their original study, and in part to successful early replication outside of the USA. One of the most important of these early studies was a replication of training in community living in Sydney, Australia (Hoult et al, 1984). The evidence base for assertive community treatment, although showing some attenuation since the early groundbreaking studies, has remained strong in the USA (Mueser et al, 1998). The same cannot be said of the UK, where evidence for any advantage over standard community mental health team care has not been forthcoming (Holloway & Carson, 1998; Burns et al, 2002). One possible exception has been the apparent benefit of assertive community treatment for adults with learning disability (Tyrer et al, 1999). The lack of evidence for this treatment approach in the UK was not something we expected when writing in this journal 9 years ago (Kent & Burns, 1996) and it is something we shall return to later in this article. The key elements of assertive community treatment The original US model of assertive community treatment has been well described (Test, 1992). A multidisciplinary core services team (continuous treatment team) is responsible for helping its patients meet all of their needs, and does so by being the primary provider of services wherever possible. The team offers continuity of care over time and across traditional service boundaries 24 hours a day, 7 days a week. Patients are engaged and followed up assertively, and treatment is offered in the community rather than in traditional service settings. The emphasis is on helping individuals to function as independently as possible, by teaching and enhancing skills in the environment where they will be needed, rather than in day hospitals and sheltered workshops. The patient is assisted in meeting basic needs such as housing, food and work, and the development of a supportive social and family environment. Care plans for each patient are individualised and adaptable to changing needs over time. Goals such as reduced symptom severity, increased community tenure and improved social functioning are explicit. A keyworker from the team is responsible for providing and coordinating the care of each individual, helping the person to manage his or her symptoms on a day-to-day basis and overseeing medication (Box 1). As we indicated in our previous article (Kent & Burns, 1996), assertive community treatment is a pure form of clinical case management (Kanter, 1989) and lies at the opposite end of the case management