MENTAL HEALTH: By 2003 there should be 220 specialist assertive outreach teams for people with serious mental illness. It is vital they are incorporated into the existing spectrum of care services, say Iain Ryrie and Angela Greatley

Increasing the number of specialist assertive outreach teams for people with serious mental illness has been endorsed by the NHS plan, which said 220 such teams would be in place across the country by 2003, providing services to an estimated 20,000 people.

The authors are involved in several assertive outreach service developments and research projects throughout London. A recent survey of research on assertive outreach teams identified six studies in London that might produce findings that could be of general interest.

1These were categorised as 'effectiveness', 'implementation' and 'naturalistic follow-up' studies. Effectiveness studies, of which there are three in London, are randomised controlled trials designed to compare assertive outreach provision with standard care across a range of cost, service use, health and social care outcomes. These trials are taking place in a team that targets young people who are experiencing a first episode of psychosis as well as in teams that work with those aged 18-65.

The pan-London assertive outreach study is working with all 22 dedicated services to describe their team, staff and client characteristics and to explore any associations that exist between them.

The study also includes a comparison group of community mental health teams, to examine whether and how assertive outreach provision differs from standard care.

The Working Together in London study is examining the partnership arrangements and social inclusion activities of teams within their local community context. Three teams are included, two of which are also research sites for randomised controlled trials and one of which targets young people from the local black African and Caribbean communities. An important question this study seeks to answer is what elements of an assertive outreach service work best for whom and in which circumstances?

The findings from these studies will emerge throughout the next three years and beyond.

Collectively, they will provide the most comprehensive picture to date of assertive outreach service provision in the capital.

A striking feature of the capital's provision is its size. Twenty-two dedicated teams currently provide care to over 1,100 people with serious mental illness who are of adult working age (18-65). This figure excludes other specialist teams that incorporate assertive outreach into their practice such as homelessness teams, those dedicated to mentally disordered offenders, and those who provide rehabilitation services. It also excludes those generic community mental health teams within which a limited number of assertive outreach posts are subsumed.

A further characteristic of these services is their diversity. There appear to be key differences in the way these teams have been implemented and in their current operations. The service sector to which the teams are aligned is an immediately apparent difference. London has at least six dedicated teams operating from within the voluntary/non-statutory sector. Other differences are more complex.

Some teams report their purpose as primarily being the treatment of a medical condition in the community. They focus their interventions on medication administration, adherence and symptom management. Others, while acknowledging the importance of medication, emphasise the social debilitation incurred by serious mental illness and focus their interventions on accompanying psychosocial needs. There is some evidence to suggest that the relative importance given to these different approaches within a single team can generate interdisciplinary conflict. The sustainability of these teams may therefore be related to their clarity of purpose and the quality of their leadership.

Those charged with implementing mental health care policy might find it helpful to consider some emerging findings from the Working Together in London study. A central theme within the data is the integration and linkage of teams within complex environments.

This complexity can partly be understood in relation to the different areas in which integration needs to take place.

One such area is the wider mental health and social care culture within which the team exists.

Typically, this will include generic community mental health teams, inpatient units and other local treatment and care providers. These local systems need to be examined and balanced in order to achieve the right range and intensity of inputs, according to local need.

This is a necessary prerequisite so that functional teams focus on those who can derive most benefit from their carefully targeted services. It will also allow users to move within the system as their needs change. This approach is challenging for many teams and further analysis of the Working Together in London study data aims to show how this challenge is being met.

There is also a need for open discussion between staff of different services within any locality. Their respective roles and responsibilities for the assessment and management of a range of people with serious mental illness must be made explicit and agreed.

Specific issues that warrant attention include management of the key worker role across teams, integrating the contribution of the approved social worker, and working more collaboratively with housing agencies.

Clearly, these types of agreement are essential for managing the type of system integration described above. They also present opportunities for the crossfertilisation of ideas and learning between staff to ensure that people with serious mental health problems are supported and treated in ways that they find acceptable. There is no longer scope for the kind of isolationism and lack of openness that has characterised some mental health services.

Teams in the Working Together in London study are also developing links with services that have not traditionally been identified with mental health care. We have begun to see real success, particularly for younger people, in work with colleges and other education and training providers. Links have also been made with potential employers, and collaborative working is evident with police and probation services. These approaches may be of help to other teams.

The use of a 'recovery'model to help users achieve their own aspirations is another theme to emerge. The implications of this in practice are best understood when compared to the more traditional medical model of diagnosis and treatment. 'Recovery' is rather more concerned with an individual's ability to function as a citizen in their local communities, according to their own desires, and with a minimisation of the stigma and isolation that often accompany serious mental illness.

We are undertaking detailed qualitative interviews with a small group of clients from each team. Mental health service users who have been trained for the task conduct these interviews. Since the intensity of team provision may lead some users to feel that their freedom, creativity and capacity for recovery are stifled, these data will generate valuable insights into how a central plank of contemporary mental healthcare policy is viewed by those it is intended to benefit.

Future directions The pan-London study specifically intends to examine inner city UK practices against US fidelity criteria for assertive community treatment. Initial team-sampling for this study and preliminary findings from Working Together in London suggest a spectrum of assertive outreach provision that may be different from the more narrowly defined US models. This is of particular interest since the panLondon study has sampled all teams, the majority of which were not developed as model services for the purpose of clinical trials. Description of the key dimensions by which they differ is an anticipated outcome of current research. It is further hoped that by examining these differences in relation to client outcomes, we will learn something of the critical components of assertive outreach provision within the British context.

An important implication of the work to date is the need for a 'whole systems' approach to the development and operation of teams. We would contend that while assertive outreach teams are necessary components of contemporary care, the sufficient condition is their place and integrated function within a complex environment of health and social care provision.

A specific emergent challenge is the interface between the main clinical priorities within the NHS plan, assertive outreach, crisis resolution and early intervention teams.

Despite the wealth of London research, many questions will remain unanswered. Given the spectrum of provision, different combinations of client and programme characteristics will probably be associated with different outcomes. So, for example, teams that target young people might employ family interventions as a first line of treatment, in combination with medication.

Key points

The NHS plan proposed the establishment of 220 specialist assertive outreach teams for people with serious mental illness by 2003.

Research on the development of these teams in London shows that diverse models are in operation.

Some focus on medication administration, others on psychosocial needs.

It is important that these teams are incorporated into the spectrum of care services.