New Ways of Working: implications for patients in adult psychiatry

We read with interest the article by Mehta et al (Psychiatric Bulletin, December 2007, 31, 381–384). Community mental health teams’ case-loads comprise a variety of service users such as stable patients requiring ‘routine follow-ups’, long-term patients caught in the system, ‘revolving door’ patients (who tend to slip through the net), patients requiring social care and newly referred individuals. There is a tendency for the ‘status quo’ service users on standard Care Programme Approach to remain in the mental health system for routine out-patients.

It is difficult to define a ‘complex patient’ as their and the carer's opinions may differ from the objective. However, we think the authors’ parameter of defining a ‘complex patient’ based on time elapsed since the last appointment, level of Care Programme Approach and lack of objective clinical activity are a good measure of complexity.

The New Ways of Working emphasises the role of a consultant psychiatrist in complex cases. However, after more than 2 years from its introduction the actual initiative is still patchily distributed within organisations and all its main principles are not fully accepted. We agree with the authors that once the New Ways of Working is implemented, routine follow-ups would be expected to be eliminated from consultant's care.

The consultants and the multidisciplinary teams should change the current practice, laying more emphasis on the brief short-term interventions, promoting recovery, self-dependence and timely discharge to primary care. Stable patients can be effectively managed in primary care and an initiative to improve liaison with general practitioners can facilitate such people to be followed-up.

However, it would be interesting to see how the new breed of consultants who start their career under New Ways of Working would function in the long-term. In trying to use the skills of a consultant psychiatrist more effectively to deliver their expertise more ‘timely’ than ‘routinely’, there is a danger that they may end up in dealing with ‘complex patients’ only. Consultants may also lose the skills to manage ‘routine patients’, who are far more common than ‘complex patients’ in a psychiatric practice.