Published: 06/02/2003, Volume II3, No. 5841 Page 14 15
As the number of assertive outreach teams approaches the government target, do they genuinely provide an improved service for those in greatest need, or might they be a rebranding of old, failed services? Mark Gould reports
'I do assessments in crack houses, police cells and prisons. The client group I deal with have chaotic lives, they have forensic psychiatric histories, crack cocaine addiction, are single parents, are homeless, or have a history of crime. 'They are difficult to engage with and do not comply with treatment. They are rightly suspicious of the conventional medical model of mental healthcare. Listen, darling, I could go on...' By anyone's standards Michelle Simmonds, team leader with Antenna Outreach Services in Tottenham, north London, has a tough brief: bringing mental health services to young African and Afro-Caribbeans with every social and medical problem in the lexicon and a deep suspicion of authority figures of any sort.
Achieving 220 assertive outreach teams across the country by the end of March next year is the government's key target for mental health services. With 191 already in place that target looks set to be hit with ease, so expect the subsequent fanfare of publicity.
The Tottenham service seems to be a resounding success, taking the message out to individuals, their families, churches and local radio stations that help with mental health problems does not mean medication, white coats and locked wards. Heavy Mental, a video (pictured above) produced by Antenna's young people's group, has just won an award in the media section of the national mental health awards. Its message to young people is that there is no shame in asking for help with mental health problems.
'We have to use a social model here. We want to allow people to have a better quality of life and come away from us with something useful like an NVQ. We do not want people isolated from the community, so we do that by using community resources like churches and radio to engage them, 'Ms Simmons says.
Mike Sobanja, chief executive of the NHS Alliance, which represents primary care trusts, says the provision of 191 assertive outreach teams more than a year ahead of deadline is 'better than expected'.
Ted Worthington, team leader of the Sheffield outreach teams, believes the target of 220 will easily be met: 'I think they are well on their way if Trent is seen as typical of the rest of the country.'
Mr Worthington says it costs around£1.2m to run an assertive outreach team of 10, made up of nurses, social workers and occupational therapists plus admin and support staff. But he believes it is money well spent. In his area, it has led to more efficient use of beds and shorter length of stay: 'And we get a very positive feedback from clients and families.'
One fear that Mr Sobanja has is that some of the teams are 'assertive outreach teams' in name only. He worries that some may not be doing the job for which they are intended: 'My impression was that people have been struggling to cope as money is being spent in other areas.What I would be worried about is whether these teams are able to provide comprehensive 24-hour cover, because if they can't then they are not really meeting the target. But I am a very great fan of assertive outreach teams. They are one of the key ways of creating services that are focused on the patient.'
Mental health charities are also concerned that some teams have been 'invented' as a result of renaming old community mental health teams (CMHTs). Cliff Prior, chief executive of mental health charity Rethink, says:
'Whether targets will be met depends largely on how assertive outreach is defined.We know that some brand new teams have been set up, but in other areas established teams that were poorly resourced have used new money to transform themselves into assertive outreach teams.'
King's Fund fellow in health policy Angela Greately says it is hardly surprising that the 220 target will be reached, considering that 100 of these organisations already existed when the NHS plan was published.
And she agrees that the teams must do what they are meant to: 'Assertive outreach teams will do the job they are designed to if they are set up and managed strictly along the lines of the model in the NHS plan. If they are simply old CMHTs with a couple of people who are 'assertive' bolted on, it wouldn't work and would be a simple case of rebranding to meet a target.'
Mr Prior wants to see more focus on developing early intervention services (another of the targets in the national service framework for mental health) that would reduce the strain on crisis mental health services.
And Ms Greately is more concerned about two other mental health targets with April 2004 deadlines: the creation of 50 earlyintervention psychosis teams for people with long-term problems and a poor history of engagement with services, and the creation of 335 crisis resolution teams.
'The NHS plan says that by 2004 all young people with their first experience of psychosis will be able to access early intervention teams and that all people who have had contact with mental health services will have access to crisis resolution teams. I am concerned that they will not meet these deadlines because they are starting from scratch.'
Nasa Begum, policy officer with mental health charity Mind, says the charity wants assertive outreach to be broader in its scope.
'We would support treatment at home for people who might otherwise be hospitalised, but the people that can access it have to show quite high levels of need.
'People with personality disorder or with mental health problems related to family and relationship issues do not seem to be eligible. These people need services like this so they have to be of a broad spectrum so that more people are included.
'We do not want assertive outreach and early onset to be just a way of providing hospitals in the community or to be a gatekeeper denying services to some people.
We want these services to be available to all. To do that Mind wants to see more services to which users can have open access.'
Robert Nesbitt, locality manager for Local Health Partnerships trust, Ipswich, runs the only assertive outreach and early intervention service in Suffolk. He agrees that assertive outreach is all about providing a high-quality, broad-spectrum service and not about saving money or cutting hospital bed use.
'We have never talked about assertive outreach as a way of cutting costs. It targets people whose needs are most complex and intervenes very much earlier.
We have a higher proportion of people in hospital at any one time.'
However, he disagrees with Ms Greately's theory about renaming old organisations. 'I do not think that the Department of Health would allow anyone to get away with bolting a few extra services onto an old CMHT, or if they have they will not last long because their cover will be blown.'
Although mental health trusts may seem to be sailing towards their outreach target, one concern is that although urban areas and big cities are well served there have been problems finding the right model for rural areas.
'Suffolk is made up of a lot of isolated small villages where there might be one person in each who needs assertive outreach.
'We haven't really developed an effective way of tackling it yet, ' says Mr Nesbitt.
Mr Worthington agrees: 'Most of the old Trent region has got an assertive outreach team in place, except for rural Leicestershire where a project manager coordinator is looking at setting up a service.'
Another problem Mr Worthington identifies is that although outreach teams appear to be a resounding success, the age-old problem of competition for money with the acute psychiatric sector is still there: 'We have one team looking after about 100 clients but we estimate that there are around 200 clients in the Sheffield area who need an assertive outreach team.
'We put in a bid last year but were not successful.We have put in a second bid for this service and financial framework round but we are still waiting to hear if we have been successful.'
Mr Worthington says the first bid was unsuccessful because there was just not enough money.
'It had been spent on extra consultant sessions and other things.
'Assertive outreach is our priority, but in terms of finance It is only 50:50 with other services.
'The way that the money is filtering down doesn't seem to be earmarked for the jobs that need to be done. So It is a huge financial juggling act.