community mental health teams

Moving out of the asyluM

Community mental health teamstom Burns

AbstractCommunity mental health teams (CMht) are one of the most com-

mon and long-established forms for delivering comprehensive mental

healthcare. their origins were both pragmatic (in the uK) and ideological

(france and italy), and they serve to ensure an effective multidisciplinary

approach to the assessment and care of mental illness. in most countries

they are restricted to the care of the severely mentally ill. this contribu-

tion covers their structure and staffing and relates it to their function.

Most serve populations of 20 000–60 000 and contain psychiatrists,

nurses and often social workers. other disciplines include psychology

and occupational therapy, and increasingly more specialist members

(e.g. vocational counsellors). staffing norms vary enormously but the uK

proposals are outlined, along with mechanisms to establish thresholds

and coordination of care. leadership issues and the tensions between

generic and specialist working are common in these teams. effective

internal communication and external liaison and clarity about an agreed

operational policy are fundamental determinants of success.

CMhts are currently under criticism and many more specialized teams

are being established. it remains to be seen to what extent they can

be replaced and to what extent these specialized teams augment their

persisting practice.

Keywords care coordination; care programme approach; multidisciplinary;

severe mental illness

The move to a more community-based mental health service is often described in terms of deinstitutionalization and the overall reduction in inpatient bed numbers. This has been paralleled by the development of community-based services to serve the varied and complex needs both of those patients discharged from hos-pital and, more importantly, of all those patients who, because of these services, either never get to hospitals or spend only brief periods in them.

Tom Burns CBE DSc FRCPsych is Professor of Social Psychiatry at the

University of Oxford, UK, and was previously Professor of Community

Psychiatry at St George’s Hospital, London. He qualified from

Cambridge University and Guy’s Hospital, London, and trained

in psychiatry in Scotland and London. His research interests are

predominantly health services research in community psychiatry,

in particular trying to understand the components of complex

interventions and the nature of the therapeutic relationship. Conflicts

of interest: none declared.

PsyChiatRy 6:8 32

The early development of community services has varied internationally. Among the best known are: • the US community mental health centre movement launched

in the early 1960s by Kennedy’s New Deal for Mental Health1

• the French secteur approach2

• catchment area teams in the UK3

• the dramatic developments in Italy in response to Law 180 in 1978.4

The US community mental health centre experience was less than satisfactory and has been superseded by developments in case management and assertive community treatment, and French interest in the secteur has fallen from attention, but community mental health teams (CMHTs) have persisted in the UK and Italy.

Characteristics of community mental health teams

The UK generic multidisciplinary community mental health team (CMHT) and its Italian counterpart have endured and are remarkably similar. They share common radical intellectual roots, despite differences in presentation, with a tendency to be anti-authoritarian and ‘casual’ in their internal relationships. Both emphasize pragmatism and teamwork characterized by role-blurring and role overlap; both strive for continuity of care across the community/inpatient boundary; both are explicitly territorial, serving a defined geographic population. Both also prioritize the needs of the severely mentally ill, although this is more explicit in Italy, while UK CMHTs offer limited care to the whole spectrum of mental health problems.

CMHTs have evolved rather than been prescribed. As a result, their composition and practices, while generally consistent, vary at the edges. Writing about them depends on clinical practice and consensus rather than research findings or strict definitions. While they first evolved for the care of adults of working age (the model described in this contribution), they are equally character-istic of old-age and child and adolescent services, with appropri-ate adjustments. Descriptions of their functioning are currently available in several public documents.5,6

Functions of the generic CMHT

The generic CMHT is a secondary care team. It is responsible for the assessment and care of complex mental health problems which

• uK community mental health teams (CMhts) have been augmented by further extension of assertive outreach and crisis resolution/home treatment teams, which has narrowed their clinical remit

• team managers have become increasingly the norm in CMhts

• With fewer inpatients (as catchment areas become smaller and CR/ht and ao teams impact) more services are experimenting with a separation of inpatient and outpatient responsibility

What’s new?

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cannot be adequately dealt with in general practice or generic social work services. Most referrals are from GPs, less often than other medical staff (particularly those in A&E) and social services.The CMHT has three distinct functions: • assessment and advice on management to patients treated in

primary care • provision of treatment and care for time-limited disorders

which are more complex or severe than those treatable in primary care

• provision of treatment and care for those with severe and enduring needs (adapted from Department of Health, 20025).

When patients are taken on for care they are subject to the Care Programme Approach (CPA) (see below and Department of Health, 19997). When patients require inpatient care they are usually admitted to a ward whose nursing team works collabora-tively with the CMHT staff, and they remain under the care of the CMHT consultant. CMHT staff take an active role in decisions about admission and discharge for their patients.

Staffing and organizationSector size in CMHTs varies considerably (from 20 000 to 60 000 population), reflecting local morbidity, resources and traditions (e.g. joint CMHTs). The Royal College of Psychiatrists’ recommen-dation is for maximum catchment areas of 30 000 and considerably less in teaching units and areas of particularly high morbidity (e.g. inner-city areas of social deprivation and high unemployment).The model currently favoured has the following criteria: • a single team that includes social care staff working from the

same location, using a single set of clinical notes • staffed predominantly by full-time members • consultant psychiatrists fully integrated into the team • a clearly defined sector population linked to identified primary

care teams.

Size of teamMultidisciplinary team-working means that most team members know something about most of their long-term patients and can advise and contribute to care. The size of a team and caseload size are important to its efficient functioning. It is difficult to maintain a team of fewer than six full-time equivalent (FTE) staff and achieve adequate skills provision or allow for annual leave, sickness, train-ing days and so on. When teams exceed about 12 members, organi-zational and information transfer tasks swamp clinical work, clarity of focus is lost and lines of responsibility become overly complex.

Staff numbersThe Mental Health Policy Implementation Guide (MHPIG) for CMHTs outlines optimal current staffing for a standard CMHT, with 1 full-time consultant and 1–1.5 non-consultant psychia-trists and 8 FTE care coordinators (see Table 1).5

Team leadership and managementConsensual functioning should be the aim in CMHTs. This has to accommodate differing priorities and arbitration in ‘stuck’ situations. Time pressures in acute teams require clarity about leadership. Maintaining clinical focus and resolving disputes over clinical priorities requires clinical oversight and authority. In current NHS practice this role of clinical team leader is most often fulfilled by the consultant psychiatrist.

PsyChiatRy 6:8 32

Day-to-day managerial tasks are increasingly the responsi-bility of a team manager. This is usually an experienced, non- medical member of the team who carries a reduced clinical load. The team manager is responsible for the routine management of the team and much of the supervision of non-medical staff. The clinical team leader and the manager need to see eye-to-eye and work closely together if the team is to flourish.

Caseloads and reviewsWithout the active management of caseloads a team is unable to respond flexibly and efficiently to referrals. Table 2 lists the optimum characteristics of caseloads.

Professional composition of care coordinators

Role Number

Community psychiatric nurses (CPns) 3–4

social workers (including approved social workers

(asWs))

2–3

occupational therapists 1–1.5

Clinical psychologists 1–1.5

Mental health support workers 1–3

administrative assistants/secretaries 1–1.5

Table 1

Caseloads: optimum characteristics

• team maximum of 250 (steadily reducing average 150–200)

• individual maximum of 30 per full-time care coordinator

(part-timers pro rata). in practice this figure is rapidly

shrinking to 1:25 or 1:20

• individual caseloads should reflect skill-mix and patient needs

• standard and enhanced CPa tiers require local agreement

(e.g. enhanced CPa for long-term problems involving more

than one team member)

• enhanced CPa patients should comprise over half the

caseload and have a named care coordinator

• Care coordinators are generally any trained professional on

the team but not usually medical staff (limited availability),

support workers or trainees

• Psychiatrists’ personal caseloads of standard CPa patients

whom they manage with the gP should be limited

• trainees should not hand on long-term patients to other

trainees

• Consultants should have regular, scheduled face-to-face

contact with long-term patients

• structured assessments improve the management of the

long-term caseload (e.g. BPRs, honos)

• Care coordinators maintain involvement with their admitted

patients

BPRs, Brief Psychiatric Rating scale; honos, health of the nation outcome scales.

Table 2



The role of the care coordinator‘Care coordinator’ is now the preferred term for what used to be described as a ‘key-worker’, ‘case manager’ or ‘care manager’. It is a somewhat misleading term as they are also care providers. Care coordinators are responsible for ensuring that a treatment plan is worked out in collaboration with individual patients (and carers, if relevant) and that it is delivered, monitored and reviewed regularly. They must also ensure there are arrangements to cover sickness and annual leave and for ensuring that documentation (CPA, risk assess-ment, contingency plans, carer’s assessment, GP letters, etc.) is up to date. While not responsible for delivering all this care (though often the bulk of it), the care coordinator must ensure it is provided.

CMHTs should have a regular scheduled meeting at least once a week in which all patients can have a multidisciplinary review. Patients on enhanced CPA require reviews that are regular and scheduled, not driven purely by crises.

Note-keeping and time managementCareful time management is essential in an acute CMHT to reserve capacity for emergencies and varying demand. High-quality note-keeping and completion of essential documentation requires supervision and monitoring. Staff need scheduled time in the week to manage paperwork. If staff fill the whole day with direct patient contact they forfeit multidisciplinary input to the care they offer and risk early burn-out. Teams need to agree sensible norms for non-contact times.

Hours of operationMost CMHTs operate 9 am–5 pm, Monday to Friday, with flex-ible working (e.g. evening work with family groups managed by taking time back). An increasing number, however, are providing an extended service (8 am–7 pm), and a very small number have experimented with some skeletal service at weekends. The increas-ing availability of crisis resolution/home treatment teams has tended to reinforce the ‘office hours’ approach of traditional CMHTs.

Liaison with other agencies

The geographical base of CMHTs permits liaison links with local voluntary and community agencies (e.g. MIND, Rethink, housing services, police); these links need regular review. The NHS has recently taken responsibility for patients admitted to prison, which will require development of effective liaison and provision.

GP liaisonCMHTs have long-established links with the GP practices they serve.8 Various approaches have been tried, from Balint groups (in which difficult patients are discussed but not assessed), ‘shifted outpatients’ and link workers, to timetabled liaison meet-ings to discuss common patients.9 Time spent in such liaison is generally cost-effective for establishing referral practices, devel-oping shared-care for complex individuals and simply avoiding conflict. Effective GP liaison has been helped by the growth of group practices and also by the increasingly common policy of defining catchment areas around GP lists.

Coterminosity with borough boundariesWhen GP practices serve more than one borough or dis-trict, CMHTs have to decide on which alignment to base their

PsyChiatRy 6:8 32

responsibilities. The MHPIG clearly states that GP alignment should prevail, but this is problematical, particularly where bor-oughs relate to differing NHS Trusts. As problems usually arise about urgent compulsory admissions or responsibility for funding of long-term care with long-term and severely ill patients, clinical experience suggests that social services boundaries should take precedence.

Assessment and treatment

CMHTs must offer prompt and qualified assessment of patients referred to them – a comprehensive initial assessment is the basis of effective care. Table 3 summarizes current thinking about assessments.

Assessment: key points

• all referred patients should be assessed: complex referral

criteria or triage rarely help; establishing appropriate

thresholds through dialogue with referrers works better

• CMhts should expect to receive referrals of patients without

obvious mental illness and be willing to advise on their

management

• adequately trained or supervised staff should conduct

assessments; only an agreed minority should be by trainees

• gPs expect 70–80% of assessments of new patients to be

by trained psychiatrists (consultant, staff grade or specialist

registrar), either singly or jointly with other disciplines

• there should be a single point of entry for new referrals

to the team to establish consistent thresholds and enable

adequate monitoring. opinion is divided on the practice of

providing parallel outpatient clinics

• Community (including both gP surgery and patients’ homes)

and multidisciplinary assessments are highly regarded

• new patient assessments should always contain an adequate

assessment of risk and substance abuse

• Carers’ and families’ information should be incorporated into

a comprehensive assessment

• Maximum waiting times for differing categories of assessments

should be agreed locally. the MhPig recommends 1 week as

routine, but this is generally impractical for both patients and

teams. More realistic times are as follows:

• routine assessments within 4 weeks

• urgent assessments within 1 week

• emergency assessment within 1 day

• emergency assessments usually by CMht. same-day

assessment procedures should be agreed locally, including

stipulation about the seniority of the assessor and

requirement that referrer has seen the patient

• Discharged patients should all be assessed as early as

possible within the first week of discharge

• Crisis resolution/home treatment teams target emergencies,

but local arrangements vary markedly

• access to qualified medical and social work assessment must

be available 24 hours a day, 7 days a week within each local

service

Table 3



This contribution has focused on how services are organized. However, it is the treatments provided that make the difference, not team organization. CMHT staff should keep pace with best practice through their own continuing professional development. The MHPIG for CMHTs summarizes the principles (Table 4).

Operational policy and team governance

CMHTs must be clear about their roles, responsibilities and poli-cies. This is best formalized in a written operational policy that is reviewed and agreed at least annually and is known to all staff. It should be short and practical and must cover at a minimum: • the chain of internal authority and responsibility • liaison arrangements (e.g. with primary care, social services,

housing)

Treatment principles for CMHTs

• CMhts should aim to keep abreast of, and apply, evidence-

based practice

• all staff (not just clinical psychologists) need to be trained

in psychological therapies and current psychosocial

interventions (e.g. adherence therapy, relapse signature

planning)

• Psychological therapies (e.g. cognitive–behavioural therapy

(CBt), stress management, brief counselling) should be

offered both for reducing symptoms and increasing coping

and resilience

• CMhts are expected to be able to provide types a and B

of the nhs classification of psychological treatments (a: as

integral component of routine care; B: eclectic psychological

therapy) and some type of C (formal psychotherapy)

• CMhts should provide optimal pharmacotherapy (e.g.

physical health monitoring for use of atypical antipsychotic,

including blood tests for clozapine, and also for lithium) and

structured assessments of drug side effects

• outcome goals should exceed the purely medical and include

social functioning such as vocational and leisure pursuits

• Comprehensive assessment and support with substance

abuse management

• help with ‘survival skills’ (e.g. housing, budgeting)

• Basic monitoring of physical health

• family and carer support and education

(source: Department of health, 2002.5)

Table 4

PsyChiatRy 6:8 32

• transfer arrangements and protocols for crisis resolution/home treatment, assertive outreach and early intervention services

• protocols for discharge to referrer and transfer between services

• safety policy • documentation (CPA, risk assessments, relapse plans, etc.). CMHTs have proved to be a robust approach to providing com-munity care in many parts of the world. Although they have received a bad press in the UK during the last few years, and the National Service Framework implied that they would be replaced by a range of specialized teams,7 they seem to be surviving. Indeed, rather than being replaced they are being supplemented by these specialized teams. The criticism has, however, been beneficial for CMHTs because the model is finally attracting the attention to standards and consistency that has been absent in the past. ◆

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http://www.dh.gov.uk/mentalhealth

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