A charity that reaches out to troubled rural workers shows community mental health teams at their best, but elsewhere they appear to be in crisis. Mark Gould reports
'We have literally taken weapons out of farmers' mouths or talked people out of trees where they were going to hang themselves,' says Tom Dodd, referring to a remarkable charity which he thinks can provide a model for the rejuvenation of community mental health teams.
Mr Dodd, Care Services Improvement Partnership national lead for community teams, is talking about an organisation that he chairs called Rest (Rural Emotional Support Team). The community mental health charity supports farmers and agricultural workers in Staffordshire.
Rest's support is intensive and intimate. A client is likely to ask to see a Rest worker's hands to check they are capable of doing heavy-duty farm work before they will talk to them. The workers can be called on to do anything from helping with the mucking out or milking to more conventional counselling.
The service was recently commended as an example of good practice by the National Institute for Mental Health in England and the team has built an enviable reputation for its hands-on approach to helping those in severe distress and contemplating suicide.
CMHTs evolved as part of a shift from hospital-based to community-based care, and are made up of nurses, psychologists, psychotherapists and specialist occupational therapists and social workers. For many people, the teams are the first point of contact with mental health services after referral from a GP. Initial screening and assessment may result in referral back to the GP for treatment. People with more complex and difficult cases are taken on by the continuing care team and appointed a care co-ordinator.
But for several years now CMHTs have lived in the shadow of their more glamorous new relations - assertive outreach and crisis resolution/home treatment teams.
While these new teams offer care to hard-to-reach groups and those in crisis, some critics feel community teams are in stasis - failing to engage with the local people who really need their help and not doing enough to drive innovation. It is particularly felt they should be offering more talking therapies than they do currently.
Mr Dodd says some CMHTs need to re-engage with their community to find what the NHS should be providing locally.
'When I qualified in 1991 the thing to aspire to was working in a CMHT but they never actually worked properly together. It wasn't a team but rather a group of individuals sitting in the same office with no notion of team working. There are still pockets of this going on.'
He adds that where teams have good leadership, there is also good engagement with clients. Which is why he wants to see them develop a cadre of leaders rather than just managers.
Steve Onyett, senior development consultant at NIMHE and visiting professor at the faculty of health and social care at the University of the West of England, agrees there is a problem with community teams. 'There is a real danger that with all these new teams being formed, CMHTs are regarded as what's left rather than what they should be seen as: the cornerstone of the national mental health implementation plan,' he says.
'There are people who say that CMHTs are dead; that they are an anachronism. But most mental health systems need the capacity to deal with the iterative care for people that do not require assertive outreach or are not in crisis and requiring emergency home treatment.'
What is needed, he says, is a real assessment of demand and capacity at local level. An example of unmet demand came when Mr Onyett carried out a survey of crisis resolution teams. 'Crisis resolution teams said that when the patient's crisis was resolved, the CMHTs did not have the capacity to take back the work.'
Strong criticism of CMHTs came in September last year with the Healthcare Commission's national review of access to talking therapies, out-of-hours crisis care and information for people who use community mental health services.
The review assessed all 174 local implementation teams (LIT) in England, bringing together local NHS organisations including CMHTs, plus local authorities, voluntary and independent sector organisations, community groups, people who use services and carers.
While national guidance states that all people with schizophrenia or suspected schizophrenia should be offered appropriate talking therapies, the review found that only 50 per cent of people sampled had access to talking therapies and in 20 per cent of LIT areas this figure was significantly lower. It also found that in almost a third of LITs, the frequency or need for physical health checks was not recorded on care plans.
Around the same amount scored poorly when it came to telling patients the name of their care co-ordinator. Yet care co-ordinators are the lynchpin of such a team - overseeing the whole of the care package. This can include liaising with welfare agencies, housing, helping patients understand their condition, developing relapse prevention techniques and keeping an eye on a client's physical health and problems such as addiction.
Significantly, CMHT clients are not getting help with staying in or getting back into employment. Only half who said they needed help with finding employment received it and in 96 per cent of LITs the figure was the same or less than this.
Professor Tom Craig from the Institute of Psychiatry, based at the Maudsley hospital in South London, agrees that access to talking therapies needs to improve.
He says that at any one time there are about 70 people on each of South London and the Maudsley trust's community mental health teams' books that meet the criteria for cognitive behavioural therapy (CBT) or family therapy, but just five in each receive such therapies.
'It's quite a low uptake; we want to go up to around 10 per cent. In terms of results we are looking to reduce readmission rates and reduce the rate of relapse into a crisis or deterioration in their conditions,' he says.
Professor Craig says that using the right sort of therapy for the right amount of sessions does work but integrating into mainstream CMHT work means changing the culture of their very busy teams. 'We have to manage risk and we have to ensure they have the space and time for training and dedicated time to carry out these therapies.'
He also stresses the importance of good leaders and team members having a genuine enthusiasm and interest in the subject.
'It's about better training and better techniques but it's also about better awareness on the part of service managers.'
For talking therapies to flourish, adds Professor Craig, the NHS needs 'product champions' such as Sarah Dilks, a consultant psychologist who works with one of the Maudsley's community teams providing cognitive therapy for adults with psychoses and other complex conditions related to schizophrenia. She also offers family intervention therapies to the families of service users. However, Dr Dilks says there can be a six-month waiting-list after initial assessment - and even once therapy has started there are problems.
'Given their complex conditions we do have problems with people dropping out mid-therapy or their conditions fluctuating so they can't continue.'
There are also problems with integrating therapy services into the care co-ordinators' role. Care co-ordinators need training, supervision and an interest in providing therapies and that means they also need more protected time for their own development and training.
Dr Dilks is also worried that there is too much emphasis on dealing with less serious cases, which might look good in terms of success rates.
'Then there is a danger that the people with more serious diseases lose out,' she says.
There is also a question of which talking therapies should be emphasised by community teams. UK Council for Psychotherapy chair Lisa Wake says there is 'major concern among psychotherapists employed in the NHS that the government's drive towards CBT as the only therapy of choice will result in no choice and raise levels of risk for patients currently cared for within the CMHT'.
Annette Newton, director for adult, older people's and specialist services at Cambridgeshire and Peterborough Mental Health Partnership trust, is a clinical psychologist by training and agrees more choice would be good.
'We should be offering a wider range of interventions but there is a lot more evidence about the effectiveness of CBT than any of the other interventions.'
Cambridgeshire and Peterborough is working on redesigning services so they can be delivered in different ways to fit care pathways.
Central to these new ways of working are 'gateway workers'. Based in CMHTs they manage services in both directions - to improve access to secondary services and provide triage care for clients who may need contact with specialist services in primary care.
'We know there is a whole group out there sort of sitting in the middle, who may need some short-term six to 12-month work that might stress psychological treatment needs but should also look at social inclusion, employment, education and so on.'
Ms Newton feels it is important for CMHTs to link up with crisis resolution/home treatment teams so they can step in to provide the right support and services when the home treatment team has finished supporting a patient.
'Mental health services are a complex network. You can't change one thing without an impact somewhere else,' she says.
Countryside alliance: how rest helps troubled workers
Farmers and agricultural workers have high levels of mental health problems and suicide rates. Exacerbated by the foot and mouth epidemic of 2000, the earlier BSE crisis, long working hours, falling produce prices and the precarious financial position of many farmers makes it a high-risk group. Easy access to shotguns and poisons is also a factor in the high suicide rates.
Community mental health charity Rest (Rural Emotional Support Team) has been working with this group in Staffordshire since 2002, providing free support to anyone over 16. It is funded by Barclays Bank and the Big Lottery Fund.
'When we go to people's homes, we are there on their terms and we need to be able to offer useful support such as mucking out or being able to milk a cow,' says chair Tom Dodd. 'During the foot and mouth epidemic we would be with farmers when their cattle were being slaughtered.'
Being comfortable with firearms is vital: 'There can't be many CMHTs that need shotgun licences. It's the sort of thing that you have to know about; it is part of farm life and farmers are known to kill themselves with shotguns,' he says.
The team has four workers who are paid the equivalent of what a member of a CMHT would earn. Some are qualified mental health nurses but the job is 'more about having the right qualities and capabilities', says Mr Dodd.
It also includes going out and meeting the people and organisations that could be a factor in the ill health of clients. Rest has worked with the Forestry Commission, which employs a large number of rural workers, on awareness of the connection between bullying, absenteeism and mental illness among employees.
It has also worked with local authority trading standards officers to help them gain insight into how mental health problems manifest themselves, for instance in the neglect of animals or crops.
Rest says this work has cut the number of farmers and rural workers sent to jail, prosecuted or bullied by employers.
Mr Dodd, who is also the team's clinical supervisor, says that before its launch, conventional NHS agencies found it difficult to engage with farmers and agricultural workers who had mental health problems. So before
Rest started work, it spent 18 months asking farm workers which services they thought valuable.
'They said primary care, GPs, benefits and employment services were not valuable because they were not part of the things that made up their lives, therefore they were not engaging,' says Mr Dodd.
Farm workers also said they would be more inclined to ask for help if they were certain any source, be it the police, accident and emergency, community mental health workers, parish priests or trade union representatives, could provide a consistent response.
Being able to engage with people means the group can bring primary care to an alienated group, says Mr Dodd..
He believes conventional CMHTs should use the Rest model to engage with other isolated clients, be it black or minority ethnic groups, refugees or the unemployed. Rest has been in talks with politicians in Wales who want to set up a service to work with former mining communities.
- Respond quickly - always take a request or attempt seriously.
- Risk-assess issues that are raised at that point, being open about where those risks lie, and whom they affect.
- Involve the family and take time to understand their fears and burdens. Keep everyone informed.
- Share responsibility and be there for as long as it takes.
- Be flexible, spending as much time as required by the client in a place conducive to their well-being.
- Work together where possible.