New joints, same moves: the ossification of community psychiatry

Community psychiatry is at a crossroads and Peter Tyrer's critique ¹ is timely and welcome. Although problems in community care were developing before the economic downturn, the present financial climate has sharpened the issues and makes finding a solution more pressing than ever.

There have been significant investments in community care over recent years. Mandated by central policy this has resulted in an increased subspecialism, with the development of new community teams focusing on early intervention, crisis work and assertive outreach. The clinical effectiveness of these new teams is hotly debated but an undeniable consequence has been to diminish continuity of care and to create a more fragmented service, with multiple interfaces, each time-consuming and risky to negotiate. The residual community teams have been overwhelmed by the volume and complexity of demand, over-burdened by bureaucracy, and sometimes treated as little more than the handmaidens to specialist services.

The newly formed specialist community teams have had the advantage of defining their place in the system; facilitating the delivery of evidence-based interventions and fidelity to models of care. Tyrer argues for the re-establishment of ‘completely comprehensive’ teams, but the tensions that have challenged community teams will survive a structural reconfiguration. Community teams need to deliver care which is individually formulated but not at the expense of evidence-based treatments. Care needs to be responsive and holistic but this approach has to be balanced with the need to deliver planned treatments. How can these tensions be resolved?

Community teams cannot and should not provide every intervention for patients under their care – to do so creates dependency and a new form of institutionalisation. We need to move from providing holistic care to facilitating holistic care, working with the community, not just in it. We need to establish and formalise robust pathways that facilitate timely access to outside agencies, where patients can receive support for issues such as housing and benefits advice. We need to define the boundaries of unplanned, responsive care delivered by the community team. Should this be available to all patients or restricted to those most disabled by their illness? What unplanned interventions are the task of the team and which sit with other external providers? How do we create systems to deliver a flexible and timely response to need while retaining capacity for clinicians to deliver planned interventions?

Finally, we need to deconstruct care coordination, retaining the important clinical functions but removing the unnecessary bureaucracy that adds little to patient care. On a practical level, these are the issues which challenge community teams and they need to be addressed along with any structural reorganisation.