Author's response

I agree with Dr MacMillan that unguarded enthusiasm for community services has led us into uncharted waters and that it is important to recognise the value of hospital admission. Every day psychiatric professionals conclude that admission is necessary for hundreds of patients. ¹ In my editorial, I referred to the draconian reduction in psychiatric beds which has occurred in England over the past decade, a reduction driven, as Dr MacMillan says, by the need to fund the new multifarious community teams. In turn, the current focus on preventing hospital admissions is largely driven by bed shortages rather than by the needs of patients. These shortages frequently result in the transient placement of patients far from home, contributing further to the fragmentation of care pathways, distancing patients from family and friends and presenting challenges and delays in liaison. It is ironic that a service model intended to keep patients in their own environment has resulted in many being placed so far from home. A further irony is that it has led to the diversion of huge sums away from the National Health Service (NHS). In 2010/2011, out of the £925 million spent by primary care trusts in England on secure and psychiatric intensive care unit services, 34% was with non-statutory providers. ²

Hospital admission may be the only practical way of keeping the patient or the community safe or the only environment in which the patient can be provided with the care they need. It can take the patient out of an adverse environment in which their mental state is deteriorating. However, it is always right to consider whether hospital care is necessary or whether treatment could be safely and effectively provided in the community. Hospital is an alien environment. Many will recognise the wish to be home and that long periods in hospital risk habituation, institutionalisation and disempowerment.

Though accused by Dr Killaspy of nostalgia and looking back through rose-tinted spectacles, I can assure her that, having worked in both acute and rehabilitation psychiatry, I do not need convincing of the benefits of community treatment and developments in treatment approaches for schizophrenia. However, all doctors should engage in reflective practice, carefully evaluating developments and modifying practice accordingly.

Dr Killaspy quotes the 2009 National Institute for Health and Clinical Excellence guideline, ³ but she has been selective in her quotations. The guideline also says: ‘Continuity of care from professionals capable of communicating warmth, concern and empathy is important, and frequent changes of key personnel threaten to undermine this process’ (p. 24). On crisis and home treatment teams, it says: ‘While such teams can offer a responsive service, they can at times struggle to maintain continuity of care’ (p. 24). Also, ‘Other service changes have seen the development in some areas of separate teams for inpatients and community-based individuals. These service changes present further potential seams and discontinuities’ (p. 24). The NHS Institute for Innovation and Improvement observes: ‘As patients pass through boundaries within and between organisations on their healthcare journey, there is often duplication, inefficiency and waste’. ⁴

Dr Killaspy also cites Parker et al, ⁵ but does so extraordinarily selectively. The more complete quote is ‘For people with severe mental illness, flexibility and longitudinal continuity are the most important aspects’ (p. 102). Flexibility is defined as ‘to be flexible and adjust to the needs of the individual over time’ and longitudinal flexibility as ‘care from as few professionals as possible’, a key element of the continuity which I value. A more careful reading of this 140-page review and re-interpretation of 10 studies, of which only 2 relate to mental health, reveals more evidence in support of my case. Interestingly, ‘the most striking thing to emerge’ from questionnaires from professionals was ‘the relative lack of enthusiasm for specialist teams such as home treatment (crisis resolution) teams or assertive community treatment (assertive outreach) teams’ (p. 68).

It is a truism that specialists tend to do what they do better than generalists. However, against this should be balanced the impact of the short duration of contact these specialists will have with a patient, something unlikely to foster the good relationships the Parker et al study says patients and carers value. Patients’ experience ‘was often that repeated staff changes led to feelings of helplessness and isolation. Having continually to retell their story to new staff was experienced as devaluing the story’ (p. 43). ⁵ The result can be that the story is never fully told or recorded, thus reducing the chances of an effective patient-centred care package.

Dr Killaspy expresses the concern that it is ‘unrealistic’ for every psychiatrist to ‘remain fully informed and competent to treat all mental health conditions in accordance with the best available evidence’. However, in my experience, teamwork can provide specialists from within the team or specialists can be called in from outside, when needed, without having to change the whole team.

I have made it clear that I support the principles of helping patients to remain at home, of psychoeducation and family interventions. What I object to is the disjointed way in which services are typically provided today, which, in my experience, is inefficient and often ineffective.