Assertive outreach is widely acknowledged as
the way forward to improve quality of life for people in the
community with mental health problems. So what progress has it made
in the UK, asks Ruth Winchester, while Isabel Schwarz Travel
Fellowship winner and Carmarthenshire mental health worker Ken
Lloyd describes how outreach teams work in the US.
Until relatively recently, anyone with serious
mental health problems who failed to keep clinic appointments
couldn’t expect a great deal of assistance from statutory
But the advent of assertive outreach,
pioneered in the US and now being developed over here, has changed
all that. This highly client-focused approach to mental health
sends workers out into the community to contact people in their own
environment, wherever that may be – at home, in a caf‚, on
the street, or in the park.
Assertive outreach workers break down barriers
by maintaining frequent contact – at least four times per week –
and by offering a broad range of support services, from advice to
help with shopping. The contact is maintained and built over the
long term – often between three and five years – and is not
The model has been developing in the US for
more than 30 years and research suggests it has had significant
success in preventing crisis situations, reducing hospital
admissions and avoiding eviction, controlling drug abuse, and
cutting offending rates.
When the National Service Framework for Mental
Health included a commitment to invest in assertive outreach in
England and Wales it was warmly welcomed. Core to that commitment
was the creation of 50 new assertive outreach teams by 2003, on top
of 170 teams that were in place by April 2001. The NHS Plan backed
the framework with the statement that the estimated 20,000 people
who need assertive outreach should be receiving it by 2003.
We are now less than 18 months away from the
deadline for the creation of these teams. The bulk of the money
allocated – some £10m – will be distributed this year. The
Department of Health appears to believe that this target will be
met, although there have been mutterings from some health
authorities and trusts about whether the allocated cash is real
money or “spun money”. Authorities who fail to set up assertive
outreach teams will undoubtedly face “penalties”.
But there have also been some suggestions that
assertive outreach is not enjoying the same success here as it has
in the US. According to Matt Muijen, director of the Sainsbury
Centre for Mental Health: “There are a few teams here that are
sticking to the original model, but there is a lot of reinvention
going on too.”
Muijen describes two distinct forms of the
model developing – one a predominantly medical model which focuses
on keeping in contact with people, ensuring compliance with
medication, and reducing hospital admissions. The other relies on
looking at client’s social circumstances and focusing on their
quality of life, social interactions, leisure and occupation.
Muijen suspects that these “reinventions” are not necessarily
better or worse than the original, but does feel that there needs
to be a greater focus on targeting clients from ethnic
Brent’s assertive outreach team was set up
three years ago in the north west London borough specifically to
cater for black men with serious mental health problems. According
to team manager Martin Warwick: “Brent is one of the poorest areas
in the country, and places like Harlesden and Willesden have a very
high percentage of people with mental health problems. We’re
definitely one of the ‘social inclusion model’ teams – the medical
model has failed these clients already, and most of them are very
suspicious of that.”
The Sainsbury Centre is jointly working on a
two-year evaluation of assertive outreach across London, which will
look at the diverse forms assertive outreach can take, and what the
outcomes are for clients. More information on what works and why
will prove extremely valuable as the next 50 teams are set up.
The government’s strategy for mental health
revolves around two key themes: public safety, and sound and
supportive services, writes Ken Lloyd, winner of an Isabel Schwarz
Travel Fellowship. This strategy will involve a radical
re-appraisal of community mental health teams (CMHTs) and
substantial retraining programmes for staff. One approach that has
the potential to realise the government’s aims – if properly
implemented – is assertive community treatment (ACT).
During the first two weeks of December 2001 I
visited Madison, Wisconsin where ACT was pioneered and continues to
be practised. The purpose of my visit was to investigate a modern
programme that still closely resembles the original ACT model, to
look at the programme’s philosophy and principles, and to consider
what aspects would be relevant to CMHTs in Wales when developing
their own ACT programmes.
Wisconsin began developing its assertive
outreach, treatment and rehabilitation programme in 1972. After
three decades of development, the service focuses on working
together to build on clients’ strengths. The focus not simply on
providing treatment, but also on improving each client’s quality of
life and standard of living, and improving community awareness and
I spent two weeks observing two different ACT
programmes. The first week was with the Programme of Assertive
Community Treatment team (Pact) – staffed by professionals – which
still adheres to the exact philosophy and principles of the
original ACT programme pioneered in the city in 1972.
I spent the second week with a community
programme called Soar (Services, Outreach, Assessment,
Rehabilitation). Eighty per cent of this programmes’ staff are
themselves service users. Both teams were working with people
needing multiple services at a high level of intensity, and both
sets of workers possessed a wide range of aptitudes and skills.
The Pact team has a ratio of one worker to
every 10 clients, but both teams run a system whereby all team
members are responsible for all clients. To this end team meetings
are organised in such a way that all workers get to know something
about all clients.
Service intensity varies to meet changing
needs, to support clients in normal community settings and to
reduce hospitalisation. Low intensity contact would be three
contacts weekly; moderate intensity contact would be six contacts
weekly by five or six staff members. High intensity contact would
be 14 plus contacts weekly by up to 12 staff.
Pact offers continuity and breadth in the
level of services. It was described to me as a kind of one-stop
shop with workers from different disciplines involved in all
aspects of care, including assisting with benefits, housing or
shopping and delivering medication.
There are about 140 clients on the Pact
programme. Coverage is 24 hours a day, 365 a year, and although the
job is very consuming, people really enjoy their work, with an
enviably low staff turnover rate. Clients and workers get to know
each other very well. The model is suitable for rural and urban
settings and during my stay I spent one day in a rural setting
accompanying the team psychiatrist and medical director as he
visited clients in their homes.
My lasting impression from the visit was the
total commitment given by the people delivering these programmes.
They have developed some of the most innovative and humane services
for people with mental illness in the US and have amassed extensive
knowledge and skills in the process. The assertive community
treatment pioneers remain committed to the model and were delighted
to have someone from the UK observing their methods, and were keen
for me to continue their work over here.
The model requires providers to leave behind
traditional service delivery methods, such as individual care
management. Change will be challenging and will involve a new focus
on staff-to-client ratio, staff mix and qualifications, and
detailed outlines of required treatment, rehabilitation and
support. Clinical staff – including psychiatrists – must look at
vocational rehabilitation as legitimate work, and vocational
counselling is crucial.
Despite the impressive nature of Wisconsin’s
assertive community treatment programmes, I was concerned that the
structures were not in place back in Carmarthenshire to replicate
it. But according to David LeCount, Madison’s mental health
co-ordinator, while the right structures are essential, more
important is the willingness of staff to commit themselves to the
model. He emphasised that the model has been thoroughly researched
and proven (over 30 years) to enhance the quality of lives of those
who suffer from mental illness.