After several decades of reduction in the numbers of psychiatric beds, there is now substantial agreement that the great majority of long-stay psychiatric inpatient beds can be replaced with community resources such as supported hostels and CMHTs providing support and treatment at home. Given adequate resources, this can be done without detriment to clients.
However, controversy remains about the extent to which community alternatives can substitute for acute inpatient treatment. The Monitoring Inner London Mental Illness Services (MiLMIS) Project Group  has suggested that, at least in inner London, this process has been pursued well beyond the point supported by current evidence, arguing that service planners have failed to distinguish clearly between the functions served by acute and by long-term beds. The result has been a misplaced assumption that acute beds may be closed as easily as long-stay ones, and that generic CMHTs can provide adequate substitute care. Moreover, Tyrer  has argued that reducing local acute beds beyond a certain minimum number results in an inefficient and profligate service, with heavy use made of acute beds outside the catchment area, a resulting breakdown in continuity of care, and a further rise in admission rates. Thus, in hard-pressed areas, such as inner London, the process of reducing acute beds and substituting community-based alternatives may now have been taken as far as is feasible, and perhaps further.
However, there is a counter-argument. Few CMHTs have the capacity to visit acutely ill patients at home on a daily basis . It seems inherently unlikely that community-based care of this low intensity is an adequate substitute for the acute ward for many patients. However, more focused and intensive community-based service could effectively take on this emergency function, at least for some acutely ill people. Certainly, there are good reasons for seeking alternatives to the acute ward. In addition to being an expensive form of service, inpatient care suffers from widespread unpopularity with service users , and inner city psychiatric wards are characterised by very high levels of compulsory detention and of violent incidents [e.g., 56].
Apart from a few small-scale descriptions of crisis houses, most of the research on substitutes for inpatient care has focused on home treatment programmes. In these, specialist teams, generally available for 24 hours, or at least over extended hours, assess and manage acutely ill patients in their homes. Visits may even be made more than once a day, and team professionals are accessible by telephone to patients and their carers. Pioneering examples of this service model were established and evaluated by Stein and Test  in Madison, Wisconsin, USA, and by Hoult et al.  in Australia (it is interesting that these services have been used as models for both ACT and crisis intervention). The results were promising, with evidence of effective substitution of community for hospital-based care for at least some patients, an overall reduction in bed use, and improved satisfaction among patients and their carers.
In the UK, Merson et al. [40, 60] have recently described a team which aimed to assess and treat patients as far as possible outside hospital, and appeared to achieve lower levels of bed use, lower costs and greater patient satisfaction than the conventional, largely hospital-based service with which the team was compared. Muijen et al. , again in London, carried out a randomized controlled evaluation of a home treatment service based on Stein and Test's model. This also showed evidence of benefit, at least in the early stages of the team's functioning, again with a reduction in bed use and greater patient satisfaction.
Some of these teams have in fact followed hybrid models, combining initial intensive home treatment with subsequent retention of patients on the team's case-loads and use of an ACT approach. While reductions in bed use have often been substantial, most authors agree that an entirely bedless acute psychiatric service is unlikely to be attained: acute hospital admission at least for a brief period continues to be seen as necessary for some of the most acutely disturbed and socially dislocated individuals.
Despite these indications of effective substitution for acute inpatient care, significant weaknesses remain in the evidence on crisis teams. Kluiter  has highlighted several important unanswered questions. These include the small number of studies carried out, the small numbers of subjects within these studies, and the relatively brief periods of follow-up. It is often unclear which patients have been excluded at the outset from home treatment and what the outcome has been for the substantial numbers of study non-responders.
In interpreting the efficacy of crisis teams, we again need to assess how far the services received by the control group resemble current routine practice. In the RCTs so far carried out, the control groups have mainly been served by hospital-based services. However, in many Western countries the preferred model of treatment is now community-based multidisciplinary mental health teams. These may have advantages over crisis teams in managing emergencies: even though they are not specialists, team members will already know many of the patients presenting in emergencies. This will make it easier for them to assess patients' needs, and to judge whether hospital admission is necessary and whether compulsory detention is justified. They may also be better at maintaining engagement and adherence to treatment through a crisis because of their established relationships with patients. A modern CMHT may well be better at managing emergencies than the control services in the experimental studies discussed: we thus still lack evidence of the relative advantage of crisis services in this more modern service context.
A further point: it is easy to reduce admissions in areas where clinicians have previously been relatively ready to admit, and patients relatively willing to go to hospital. However, the situation may be very different in areas where clinicians avoid admission because the demand for beds greatly outstrips supply, where the majority of admissions are compulsory, and where a highly aroused, sometimes threatening atmosphere on the wards makes patients reluctant to stay in hospital. Moreover, crisis teams may not be an effective substitute for admission in areas of low social cohesion and high deprivation. Failure to replicate may occur because home treatment is less feasible in areas where many patients live alone and have no informal carers, and where homelessness and poor living situations are frequent.
Overall, the gains from introducing crisis teams have appeared rather limited. Reduction in costs and in inpatient bed use and some increase in patient satisfaction have several times been reported. However, there has been little evidence of significantly better outcomes on dimensions such as symptoms, social functioning, social networks or quality of life. Ideally, we should be developing forms of acute care that actually do produce better outcomes than conventional inpatient care.
Kluiter  summarised the current state of evidence, stating that there is "not nearly enough information to base general policy on''. In particular, he noted, "Community care alternatives are capable of reducing the need for inpatient treatment. The trouble is that we do not know to what degree. Current scientific knowledge is not sufficient to base a radical reduction in beds on.''
This question of how far the transfer of acute care into the community may be taken is pressing wherever there is a shortfall in acute inpatient bed provision in relation to demand. Should this be met by a pragmatic retreat, with an increase in inpatient bed provision, or should we be developing more effective means of managing crises in the community, following the emphatic wishes of service users? Convincing evidence from high quality research is urgently needed for rational decision-making.
Intensive home treatment generally appears to be preferred by clients and relatives alike. They place a high priority on rapid access to emergency assessment and intervention at home, and on 24-hour intervention. Easily accessible crisis teams are also likely to find favour with primary care physicians. The existence of crisis teams, particularly out of hours, reduces the burden of working in generic CMHTs, in that key workers no longer have to manage acutely ill patients in the community single-handed, and have someone to pass responsibility on to when they go home at 5.00 p.m.
The possible combinations of generic and specific mental health teams are listed in Table 6.1. In our view the jury remains out on the choice of service
Table 6.1 Possible combinations of generic and specific mental health teams
1. All treatments delivered by a generic community mental health team (CMHT) serving a given area
2. One CMHT and one crisis intervention team per area a) Crisis intervention/home treatment team covers catchment areas of more than one CMHT
b) CMHTs provide cover during the day, a crisis team provides out-of-hours cover to a wider area
3. Generic CMHT plus assertive outreach team a) Each sector has both CMHT and an assertive outreach team b) Each sector has CMHT; assertive outreach team covers several sectors
4. CMHT plus assertive outreach plus crisis team
5. Generic CMHTs with specialist crisis and/or assertive outreach functions within them
6. Specialist intervention functions developed by distinct teams (e.g., dual diagnosis, rehabilitation, vocational rehabilitation, family interventions, etc.)
7. Specialist functions developed within teams structure best suited to the management of people with long-standing and severe mental illness.
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