Are small case-loads beautiful in severe mental illness?

A small case-load is becoming one of the shibboleths of community psychiatry. The shibboleths of community psychiatry. The paper by Burns paper by Burns et al et al (2000, this issue) focuses (2000, this issue) focuses on this matter with a comparison of two on this matter with a comparison of two models of service delivery in recurrent psy-models of service delivery in recurrent psychotic illness: intensive and standard case chotic illness: intensive and standard case management. The main difference between management. The main difference between these two models was the case-load per key-these two models was the case-load per key-worker; those in intensive case management worker; those in intensive case management (ICM) had no more than 15 per keyworker (ICM) had no more than 15 per keyworker whereas standard case management (SCM) whereas standard case management (SCM) had case-loads of between 30 and 35. In had case-loads of between 30 and 35. In addition, however, those in the intensive addition, however, those in the intensive management service also received a brief management service also received a brief course of training in the Boulder Community course of training in the Boulder Community Support System (CSS) model of care; this Support System (CSS) model of care; this shows similarities with assertive community shows similarities with assertive community treatment (ACT) practised elsewhere in the treatment (ACT) practised elsewhere in the The results of the study may at first sight The results of the study may at first sight be unexceptional. Those allocated in the ran-be unexceptional. Those allocated in the ran-domised trial to ICM received more input domised trial to ICM received more input from all sources, both directly and indirectly, from all sources, both directly and indirectly, than those allocated to SCM. This was parti-than those allocated to SCM. This was particularly marked for face-to-face contacts with cularly marked for face-to-face contacts with the patients concerned and even more so for the patients concerned and even more so for failed face-to-face contacts, most of which failed face-to-face contacts, most of which were attempted at the patient's home. The were attempted at the patient's home. The significance of the findings becomes greater significance of the findings becomes greater when one considers other findings from the when one considers other findings from the UK700 Group and the general policy context UK700 Group and the general policy context of ACT. The main question the …