Abstract
Major changes have occurred over the last three decades in the delivery of psychiatric care, changes greater than in any other part of the health system. The large mental hospitals, for decades the loci of care, have been dramatically reduced in size or closed. Across Australia this reduction has been from 400 to less than 50 psychiatric in-patients per 100 000 population. Accompanying this reduction in hospital care has been a somewhat haphazard growth in community mental health services.
Despite the major changes that have occurred, it is clear that in Australia as throughout the developed world, mental health care does not yet adequately meet the needs of people with mental illness. Countries with health service structures as diverse as Italy, the UK, the USA and Australia all share the problems of under-funding, and neglect of individuals with severe mental illness, comorbidities and/or homelessness.
Community-based alternatives to hospital-centred care have been researched for over two decades beginning with Stein and Test [1] in the USA and Hoult et al. [2], [3] in Australia. Since then a significant number of innovative projects have provided further support for more effective forms of treatment than standard hospitalcentred care [4], [5]. Case management was seen as the answer to the haphazard delivery of services and it has been implemented in many countries to help individuals co-ordinate services and manage the complexities of psychiatric care.
Typology and evidence for case management
Typologies of case management
‘Case management’ is not a unitary concept: it is a heterogenous concept used both in mental health, as well as in other health welfare and service sectors. Case management is defined in an Australian mental health service context [6] as the role of drawing together into one coherent system all services necessary to meet the needs of the service user, whether in the community or in hospital. This includes meeting the needs for psychiatric or physical treatment, family and social relationships, basic survival needs like food, safe accommodation, employment, leisure, cultural and spiritual needs. [6]
There are several models of case management within contemporary mental health services (see Table 1) [7], [65]). Another typology by Thornicroft [8] defines case management at the levels of individual co-ordination of services, project or team organization and programme or system management. It uses 12 axes to describe variants of case management in practice. These typologies cover the spectrum from active-response mobile intensive ‘in vivo’ case management to passive-response more sedentary brokerage style case management. Diamond and Kantor [9] have referred to the varieties as travel agent model – where the professional just sits behind a desk offering advice; travel companion model – where someone goes with you but without any special expertise or training; and thirdly as travel guide model – where a person who will not only be there and do things with you, rather than doing things to you, but also has appropriate training, experience and expertise to know the most scenic routes, how to take short cuts without getting lost, how to reliably avoid the pitfalls, and to arrive reliably at the desired destination.
Australasian mental health case management teams draw on all these models, but have most in common with the more assertive clinical, networking and travel guide models, particularly in the higher level of professional training and the more active mobile response to needs required.
Genealogy and fidelity of case management
While the roots of case management lie in social case work, within mental health services, the concept was introduced to provide a system to co-ordinate the often fragmentary community services available to individuals with severe mental illness, once discharged from hospital [8]. In mental health, the more passive brokerage models of case management have gradually given way to the more professional active case management models. Earlier controlled studies of 24-h community alternatives to hospital-based care, proved only moderately effective in the long term for high-intensity users of services with severe and prolonged psychiatric disabilities [1]. This was particularly the case when caseloads remained high or intensity of team effort could only be sustained during periods of crisis. The innovation of Assertive Community Treatment (ACT) teams provided for greater stability in the community for this subpopulation resulting in less revolving door admissions, less hospital days, and improved quality of life [10], [11].
Assertive Community Treatment team intervention is generally limited to a 1:10 (average) provider: service user ratio (ensuring continuity of team case management, mobility, 7 day operation, capability of responding to crises of all service users, professionally skilled multidisciplinary staff, adept at psychosocial as well as pharmacological interventions) serving a highly and continuously disabled subpopulation of psychiatric service users [12].
While there is no gold standard, and no perfect service meeting all criteria, there is a growing consensus regarding the components of assertive case management (ACT) which consistently result in improved outcomes for service users and their families. Fidelity checking methodologies are increasingly being employed [13–15]. These are summarized in Table 2, column 1.
Case management: does it work?
There are three major types of evidence we must examine. These have been clearly defined using rigorous criteria by Chambless & Hollon [16]:
(1) Efficacy is proven when clearly specified interventions have been shown to be beneficial in controlled research with a delineated population. A treatment manual or equivalent must be available and used, the results replicated and valid outcome measures and appropriate data analysis conducted.
(2) Effectiveness is proven when a specific intervention, when used under ordinary clinical circumstances, does what it is intended to do. Effectiveness studies answer the question ‘is the intervention useful in applied clinical settings and if so, with what patients and under what circumstances?
(3) Finally, cost effectiveness determines the economic benefit of an intervention. There are two major types of cost – first, direct health costs (e.g. hospital costs) and second, indirect costs (e.g. unemployment or sickness benefits). Most studies concentrate on the former – or even use ‘inpatient days’ as a proxy for them as indirect costs are difficult to measure [17].
What is the result if we apply evidence based assessment to case management?
Efficacy… The first challenge is to establish whether case management has been shown to be beneficial in controlled research studies. A Cochrane review by Marshall et al. of seven randomised controlled trials (RCTs) found that case management models (not including ACT) were efficacious in maintaining service user contact, but failed to have an impact on quality of life, social functioning or mental state [18], [19]. Further, they increased hospital admissions and durations and therefore costs.
More recently, the UK 700 case management trial [20], [21], [22] compared the cost effectiveness of intensive versus standard case management for people with severe psychotic illnesses. Patients with psychosis and a history of repeated hospitalization were randomly allocated to standard (case loads of 30–35) or intensive (caseloads of 10–15) case management. The reduced caseloads showed no clear benefits in terms of costs, clinical outcome or cost effectiveness. From what can be gleaned from the published methodology [20–22] the intensive case management in this study was not ACT and did not adhere closely to the fidelity criteria in Table 2.
The above examples are drawn from studies where case-management is less developed (see Table 5). The evidence for the efficacy of case management is strongest with more fully developed assertive community treatment teams. A review by Mueser et al. [23] of 75 randomised controlled trials, quasi-experimental and prepost designs, found that compared with ‘usual care’, ACT teams: increased and maintained contact with care, decreased the use of hospital based care, improved patient outcomes (including quality of life), reduced symptoms experienced and increased housing stability. More recent independent, randomised controlled trials [4], [24] further support the findings from this review. The Cochrane and PORT reviews of ACT came to similar conclusions [25], [26].
In 1999, the results of the first RCT of ACT in Australia were published [27]. While this study was an RCT it was conducted within the constraints of existing services and service resources with all accompanying long-term demands. The results are supportive of the tenet that ACT makes a difference, even in the initial phase of operation, but they are not miraculous changes. Seventy-three severely disabled service users of an existing clinical mental health service were randomly allocated to either ACT (caseload 10 clients per clinician), or standard case management (up to 30 clients per clinician) and followed for 12 months. Service users who received ACT showed improved social functioning, fewer psychiatric hospital admissions involving police and were more likely to engage and stay in treatment. Service users receiving ACT did not show reductions in hospitalization. However this study was completed on the first year of operation of an ongoing ACT in a well-established Area mental health service. Funding to continue the RCT for two further years was applied for but not granted.
There is now also emerging, consistent RCT evidence that ACT is a highly efficacious method for achieving and maintaining competitive employment for individuals with severe and persistent mental illnesses [28–30], by having work specialists in the team, carefully matching the service user to the job, and supporting both employer and employee at the workplace.
The Australian National Health & Medical Research Council [31] provides ratings for the level of evidence supporting interventions. The level of evidence supporting ACT is at the highest level, Level 1: Evidence obtained from a systematic review of all relevant randomised controlled trials. Further, ACT meets the Chambless and Hollon [16] criteria for quality in that measures of fidelity are available and used, the results of trials have been replicated, valid outcome measures, and appropriate data analysis conducted.
Effectiveness… The second challenge is to demonstrate that these interventions are useful when applied to routine clinical settings. This is important for several reasons. First, these initiatives must be considered in their differing organizational, health and welfare contexts. Case management systems may be essential but alone are no panacea for these populations, unless restricted to reasonable caseloads, are well supported by psychiatrists, other mental health professionals and facilities and complemented by an adequate range of other services. As recently found in some large cities in the USA the linkage role of case managers means little when there are no other services in the city to be linked, like housing, vocational rehabilitation, and high quality clinical services. Goldman et al. equate the psychiatric case manager in the USA to a shopping guide in a shopping centre or mall [32]. There is no point in a case manager leading a service user to the shopping mall when there are no shops open in the mall, or to more accurately capture the current American experience, no shops that he or she can afford. In many settings the response to the lack of basic services for clients has been to ‘let them eat case-management’.
Second, funding and motivation are usually high in research studies [33] and this does not easily generalize to nonresearch settings. Lastly, the long-term demands placed on regular services cannot be replicated in a timelimited research project. Deci et al. [12] in a survey of 303 ACT teams in the USA, identified six characteristics essential to favourable outcomes. These included shared case loads, a case manager to client ratio of no more than 1–20 (with 1–10 usually considered to be more standard), daily delivery of medication if needed, inclusion of medical personnel on the team, and a direct clinical rather than brokerage model of care. All of these features were the features of the teams evaluated above. (See Table 2, column 2.)
The preceeding observations are based on UK and USA findings. What do we know about case management in Australasia? Deinstitutionalization occurred in Australia as fast as anywhere else in the world, with less adverse social consequences than were expected. In 1988 a study was conducted in NSW of the 208 psychiatric patients who had been placed and case managed in supported housing under NSW government reforms to mental health care [34]. The patients had been in the community for between 3 and 40 months before the survey. For 172 patients, measurements were obtained on satisfaction with their current accommodation, and principle carers rated the patients’ impairment and management difficulty. Most patients were considered to be functioning well. Twenty-two of the more impaired patients were rehospitalized at the time of the study. Thirteen of the patients had died, three by suicide, one from a surfing accident and nine from natural causes. Seventy-eight percent of the patients preferred living in the community, and only 7%% preferred a hospital setting.
By the early 1980s case management services were in place in NSW. One of the first studies to be completed in Australia compared the impact of assertive community treatment (ACT), working in a routine service basis in two different parts of Sydney [35], the inner city catchment of King's Cross, with the highest concentration of the homeless in Australia, and a more mixed urban/suburban catchment on the Lower North Shore, demonstrated important differences. The former had its greatest effect on stabilizing accommodation so that these individuals could be kept in better contact with services, including inpatient services when necessary, whereas the latter had a much greater effect in lowering bed-day usage (by 62%%). Meanwhile, both resulted in significant improvements in functioning and basic care, as measured by the Life Skills Profile [36]. In the inner city with the formerly homeless, though admissions initially rose, probably due to being better able to locate people in exacerbation, from year 2–4 there was a highly significant lowering of admissions [35], [37]. In the Lower North Shore it was also demonstrated that the amount of medication prescribed was reduced without any significant increase of symptoms over the same period, which preceded the availability of atypical antipsychosis medications, including Clozapine [38]. These were quasi-experimental implementation studies.
Cost effectiveness… The third challenge is to demonstrate the economic benefit of implementing case management. A cost effectiveness analysis was completed alongside the Australian RCT outcome study [17]. The cost effectiveness study found that in Australia, it cost $7745 extra per service user to provide ACT, over the first year, but that this small extra expenditure resulted in 10 additional service users improved over 12 months in the ACT team compared with standard case management. A recent international review of cost-effectiveness of case management [39] found ACT teams to be costeffective. At the same time, these authors state that there is clearly still room for more work on both costefficiency and cost-effectiveness regarding case management. Despite the consistency of positive findings for ACT case management systems, reservations about their generalisability in the UK remain [57]. The doubts will remain as most of the randomised controlled trials in the UK were developed to meet large deficits in local community care for individuals with mental illness. They did not offer integrated inpatient and assertive community based care.
Case management in practice: translating efficacy into effectiveness
Given the evidence for the efficacy of some forms of case management are there guidelines for its implementation in everyday practice.
While there are comprehensive practice guideline manuals in the USA [11], [40], [41], in Australia the AIMHS Standard Indicators on Case Manager System Maintenance [6] provide such guidelines.
They emphasize that the pivotal role and primary responsibility of the case manager should be formally recognized within both community and hospital components of the mental health service, including recognition of the legitimacy of this role by psychiatrists and other health professionals. Whenever possible, the case manager should be involved when the psychiatrist interviews the service user or family.
The case manager has responsibility for the care of the service user at every stage of care. For example, the case manager is expected to be part of and included in the inpatient team when any of their service users are in hospital.
Emphasis is also given to supervision, mentorship, continual training, team support and debriefing, and involvement in service evaluation.
Effective case management relies on adequate infrastructure support – including secretarial support and modern office technology. Availability of cars is essential to ensure a pro-active response mobile service, rather than a passive response ‘outpatient clinic’ style of service. Regarding professional mix and balance, Australasian guidelines [6], [42] do not support the development of a generic mental health case-manager role, either by merging professions or on a non-professional basis. Cooperative effort between professionals of diverse tertiary training and backgrounds, brings many more up-to-date skills to bear on shared challenges, enhances peer support, strengthens hybrid vigour, while also encouraging maintenance of professional ethical standards and continuing learning [43].
Regarding job satisfaction versus burn-out, Onyet et al. [44] reported, using a standardized measure with 57 community mental health teams across the UK, that the staff who have the highest job satisfaction and lowest burnout are those who have high identification both with the team and their profession, and who are both clear about the role of their team and their own role within it.
Hemming and Yellowlees [45] compared the ratings and responses of service users and their case managers to whether the indicators of the AIMHS Case Management Standard were being met. With few exceptions, they found a fairly strong correlation between service users and case managers’ perceptions of what case management services were delivered by staff and received by service users. Such a correlation may be enhanced by jointly negotiating an Individual Care Plan stating what both service user and case manager will be expected to do, which becomes a formal statement of reciprocal obligations.
Conclusion regarding typology and evidence for case management
In summary, case management is a key innovation in the care of individuals with mental illness and their families. The research, at Levels of Evidence 1 to 3 [31], underscores the efficacy of certain case management models under operationally well-defined conditions. It is one of the better-researched treatment options in psychiatry. Evidence of effectiveness and cost effectiveness, and guidelines for implementation and fidelity monitoring are well established. Persistence of the unfounded belief that case management is a ‘dubious practice’ in mental health services [46] may be based on undue deviation from rigorous definitions and well-researched practice models of case management, research funding and studies which are far too short-term, lack of clinical and organizational support, and possibly undeclared bias.
Case management studies and their abuse
In the second part of this paper, we will discuss the ways in which the evidence regarding case management has been used. Examples abound throughout the history of science of sound evidence being rejected if it does not conform to prevailing assumptions [e.g. [47]. Our case example will be the recent UK psychiatric literature in the 1990s for two reasons: first, it is the freshest example, for while community-based services began there in the early 1970s, the UK mental health services have only over the last decade experienced widely a fundamental challenge to traditional hospital-centred and less active community psychiatric service delivery systems – otherwise we could have reported on similar debates in Australia or the USA in the 1970s and 1980s; second, the reaction within the UK, to innovative studies informing such proposals for system change invoked the seemingly novel approach and vocabulary of evidencebased medicine (EBM).
1992–94 home-based care
A series of papers by Marks, Muijen et al. were published in the British Journal of Psychiatry [48], [49], regarding home-based versus hospital-based care for people with serious mental illness, attempting to replicate similar studies in Madison, Wisconsin [1] and Sydney, NSW [3]. The UK outcomes were clearly superior to controls with home-based care and additionally mildly superior with an associated daily living program. Over 20 months in the cohort of 189, five died from self-harm: three deaths in the experimental group and two of the controls. Additionally, one murder occurred in the experimental group, without prior offence or warning, and despite close monitoring. This resulted in adverse media immediately in the local press, but then also 14 months later in four national daily papers and TV news programs, and the project was then threatened with closure. The experimental teams lost responsibility for any crisis in-patient care and subsequently lost morale, key skilled staff and weekend staffing [50]. Support and funding was then withdrawn despite the finding of no significant difference in mortality. The irony was not lost on the authors that no similar fuss was made of suicides in hospitalized patients, or would have been made of a murder by any similarly quietly paranoid patient who may have discharged himself and was allowed to drop out of care by less assertive services over the same period.
Marks et al. conclude, ‘Sound community care is a fragile plant. It withers quickly if policies do not ensure secure funding which counters perverse incentives that impair good care’ [49], presumably including the incentive to play safe and admit, even if outcomes on the whole were worse. This initiative was dismantled over a 15-month controlled withdrawal phase, and the benefits gradually disappeared, except consumer satisfaction.
The Cochrane collaboration/library: reviews relevant to case management
The initial Cochrane review of ‘Case management for people with severe mental disorders’ was published on the UK based Cochrane website in February, 1996 [18]. In this review only nine studies were found to meet the review criteria. The authors concluded that ‘Case management moderately increases a severely mentally ill person's chance of being followed up in the community’, but ‘… it approximately doubles the number of hospital admissions’, though with large heterogeneity between studies, ‘with little evidence of causing an improvement in mental state, social functioning or quality of care.’ Costs increased for direct health care, but decreased in costs to society.
There were updates or ‘substantive amendments’ to this review in December 1997 and February 1998 [19], [25]. In the latter update one more study was included, and an improvement in compliance with case management was conceded as significant. In 1999 a further update includes 10 studies.
The initial review was followed by an editorial in the BMJ proclaiming case management ‘a dubious practice’ [46] but what does the review really tell us about casemanagement? We examined the review with ‘The Well-Built Clinical Question’ method to determine quality and sources of bias (American College of Physicians Journal Club, see Table 3 [52]). The question asks: in the population or problem being addressed does the intervention or exposure considered, compared with a standard intervention or exposure, change the outcomes(s) of interest?
Table 3 summarize the assessment of the 1996 and 1997 versions of this Cochrane review of Case Management using the well-built clinical question methodology.
In summary, in selecting studies, the Cochrane review utilized a very narrow definition and set of principles of case management [53] which often amounted to no more than brokerage, a model which was vulnerable to be gestural, sedentary, less professional and sometimes devoid of intervention content, except for ‘monitoring and maintaining contact with the person’. It may have been that this superficial model was of particular interest at the time in the UK because a somewhat enhanced version of it was being nationally implemented (the Care Programme Approach [70], [71]). This policy tried to pull together the severly fragmented services then available to most people severely affected by mental illness in the UK. It was partially provided by NHS Area Health Authorities and partially by Local Authority Social Services.
The review explicitly excluded all RCTs involving consistently active assertive mobile clinical and/or professional case management as practised in studies of ACT and 24-h home-based psychiatric care on the pretext that the former was not case management, though it was a ‘superficially similar approach which developed at the same time’ and that the latter was often too shortterm and ‘deals with patients who are acutely ill but usually not chronically ill’.
The exclusion of all studies of assertive community treatment types of case management is like taking the dopamine or serotinergic blocking ingredients out of antipsychosis medications and pitting them as the active drugs against placebos, or worse, against mildly active neuroleptics. In fact, ACT and home-based care are both recognized important subsets of case management, and if all RCTs of authentic case management were being reviewed as suggested by the title and conclusions, these significantly positive outcomes should have been included in the analysis.
The review, in excluding all RCT studies of acute patients who were case managed, introduces another bias, DOES CASE MANAGEMENT WORK? 738 in studying only the most chronically unchangeable patients, who are least likely to elicit different outcomes with any difference of intervention. Again, studies of acute care utilizing case management constitute a subset of studies of continuity of community-based care, with ongoing case management being available in many service systems if symptoms or dysfunction persist or recur.
The review conceded that most disabled subjects tended to stay or pool in experimental groups, and drop out of control groups. Yet data was excluded when more than 30%% of subjects were lost to follow-up except for the outcome of ‘number staying in contact’, so potentially favourable results for experimental (case management) groups were lost.
For an international, evidence-based Cochrane review, the conclusions were astoundingly passionate and parochial. The 1996 review stated that in the UK case management had been ‘triply unfortunate’, railing in essence against case management, as ‘an unproven intervention’, with which the UK government had saddled services on an ‘obligatory basis’, based on the ‘political motives’ of ‘vested interests’ [18].
This conclusion tarred all case management worldwide with the same brush, when it was really referring solely to a passive sedentary office-hours brokerage model being implemented in the UK. Further, it questioned whether there is ‘any case for further research on the case management models in this review’. Yet earlier it had defined other models as being something other than case management. In the 1997 revision, this statement is made even more boldly: ‘It is questionable whether further original research on case management is justified; the weight of evidence is sufficient to suggest that this intervention is not worth pursuing further [19].’ This was a very biased conclusion considering such limited evidence. At the same time, conflict of interest was stated as ‘none’.
Similarly, some senior clinicians in the UK have accused advocates of case-management of being imbued with ‘religious fervour’ or ‘missionary zeal’ [54]. However, no side in a debate, whether about science or policy, has a monopoly on ‘political vested interests’, ideology, or personal bias.
In the 1997 Cochrane update [19], the conclusion was amended to ‘doubly unfortunate’, quietly dropping the highly subjective and intemperate statement that ‘Third, … the intervention has become a political policy and hence has acquired a degree of support from vested interests whose motives for continuing to support the intervention are political rather than scientific.’
We are not the first to point out the flaws in the Cochrane review of case management. In late 1997, while other UK authors had tried unsuccessfully to get a critical response to this Cochrane report published (Jenkins R: personal communication, 1998), the first article to appear in the research literature to seriously question the scientific rigour of two versions of this Cochrane review was published. Parker [55] argued that: the control condition, ‘standard care’ was ill defined and may have included many of the central ingredients of the experimental condition ‘case-management’. In other words, the control condition was unlikely to be sufficiently different from the experimental intervention to enable scientific comparison.
Second, the ‘case-management’ condition was also ill defined, and third, two of the principle outcome objectives set by the review (contact with psychiatric services and fewer psychiatric hospital admissions), may be ‘underpinned by political and philosophical motives’, not necessarily associated with better qualitative outcomes for individuals with severe mental illness. Why should reduced admissions ‘as against reduced time in hospital – not yet examined by the reviewers’ be a ‘good thing’? In severe exacerbations, conscientious case managers ‘will… seek and ensure hospital admission.’ Teesson and Hambridge (1992) demonstrated this effect, though only in the first year of establishing an ACT [35].
Finally, Parker argued that the third outcome variable ‘improved clinical outcome’ may be inappropriate as individuals with severe mental illness in receipt of community services have substantial mental state deficits which may be ‘immutable’ or at least hard to shift, once the early phases of illness have passed [55].
Parker noted the Cochrane Review's ‘provocative tone’ and sums up the study, as follows: ‘A number of their conclusions illustrate how evidence-based researchers can (once freed of their strict protocols) spring from the bedrock of the evidence base into subjective musings. In this context, it might be of benefit for the Cochrane Collaborators to incorporate another set of variables (i.e. the reviewer's a-priori biases or beliefs: did the evidence change such beliefs; if so, or if not, why?) into their protocols’ [55].
Cochrane on assertive community treatment, 1998
In February 1998, a separate Cochrane review on ACT for people with severe mental disorders was published. Its results were unambiguously positive. The authors concluded, ‘ACT is a clinically effective approach to managing the care of severely mentally ill people in the community. ACT, if correctly targeted on high users of in-patient care, can substantially reduce the costs of hospital care whilst improving outcome and patient satisfaction. Policy makers, clinicians, and consumers should support the setting up ACT teams’ [25]. But it was already too late. The damage had been done. The Cochrane reviewers had already hit the medical press with a piece in the BMJ headlined: ‘Case management: a dubious practice’[46]. The public newspapers took up the issue and the repetitive ‘mentally ill murderer’ enquiries with headlines blazing: ‘Community care for the mentally ill: the experiment that failed’. All case management had become condemned as ineffective.
UK institute of Psychiatry PRiSM Study
The recent UK controversy surrounding case management did not end with the Cochrane reviews. PRiSM is a recent large-scale study of case management in practice in the UK [56]. It compared case management in one suburban catchment area in south London, UK with more ‘intensive’ case management in a neighbouring catchment.
This study attempted to examine the question: does intensive case management work in practice? Intensive case management consisted of providing an additional number of case managing staff to the whole experimental catchment compared with the control catchment. It identified all persons with schizophrenia in two London catchment areas and then provided two different systems of care. It demonstrated mild benefits for the intensive condition, but at greater cost. It was a highly innovative study, examining case management-based systems across two catchment areas. It tells us much about implementation of case management systems.
However, every study has limitations and the PRiSM study is no exception. The interesting question is why commentators are so keen to conclude that case management does not work from this study, in the face of the international weight of evidence of its efficacy.
We summarize the limitations and potential sources of bias of this study in Table 4.
First, PRiSM did not focus on case management of the population in need: it deliberately did not select the more severely psychiatrically disabled clientele for more intensive case management, but spread its staffing over the entire client-base, including some people without one measurable active symptom (25%%) or problematic behaviour or disability (33%%) or any history hospital admissions [57]. The authors attempted to provide comprehensive case management across a whole geographical area.
Second, it did not apply an ACT intervention, even though it was stated explicitly by the editorial accompanying the PRiSM reports that it did [58]. This claim was not intended by the authors (Thornicroft, pers. comm. 2000). Readers could be forgiven for assuming that this was a test of the ACT model, as the more intensively staffed service called their team Psychiatric Assertive Continuing Care Team or PACT [57] and the study purported to meet a number of the fidelity criteria for an ACT [14].
The intensively staffed catchment service did not squarely meet the criteria for an ACT as it divided the work into two teams for acute and continuing care; it did not have a sufficiently low client-to-staff ratio to meet usual ACT criteria; and it employed a mixture of models (crisis, intensive case management, GP shared care) which was not related to any prior RCT of case management. This was a study about the practical application of a hybrid model of case management.
It would appear that the PRiSM Intensive (Nunhead) Sector did not squarely meet the majority of criteria for an ACT team, and that Australasian examples of ACTs, however imperfect, squarely meet more of the fidelity criteria. (Table 2, columns 2,3). Even some Australasian Extended hours Teams (combining crisis and case management functions, with caseloads of 30+) arguably meet more ACT fidelity criteria than did the PRiSM intensive sector (Table 2, column 4). While Thornicroft et al. [14] state that PRiSM did not adopt the ACT fidelity criterion of ‘team case working’, this approach on a day-to-day basis is seen in many Australasian ACT and EHT teams to be entirely compatible with having an individual case manager, negotiating and ensuring the implementation of personal care plans for particular consumers and their families (see Table 2, criterion 2, columns 2–4).
Third, the compared standard community care was not well defined, but was much better established. Accurate comparison of the two catchments may have been affected by other factors including the fact that the control sector had the much more experienced and clinical leadership and consistent staffing, more stable access to hospital admission beds, and more say over what happened when people were admitted to them; and although it is of less major concern, the experimental and control studies were not contemporaneous. It appears, overall, that there was insufficient difference between the intensive intervention and standard clinical care for scientific comparison.
Fourth, in terms of outcomes, this study was by no means the first as claimed, to generate effectiveness results ‘in the real world’ over a 2-year period, including a subgroup with dual disorder with substance abuse. Ten RCTs of ACT have run for 2 years or more [5] and most studies have involved ‘a routine clinical service which is designed to endure’ [57] and most include or select for dual disorder clientele.
The results showed that while there were no changes either in symptoms or social behaviour as a result of the introduction of either model of care in the community, the intensive service helped subjects meet their needs, improved their social networks and their quality of life. The more intensive service cost more than the standard service, but these costs were largely due to accommodation and were less than they would otherwise have been because their bed-use reduced. The authors had recently presented these 2 years of findings in a far more positive and upbeat way, but in a less mass-audience publication [59]. They conclude, referring to the UK experience, that it is a powerful myth that ‘community care has failed’: they state: ‘it hasn't failed because it hasn't yet been fully tried’[59].
The results of the PRiSM study were published in 1999 as 10 articles in the prestigious British Journal of Psychiatry [57],[59–67] with an editorial clearly stating that intensive case management doesn't work [57] (although the thrust of the editorial comment was not what the authors would have intended (Thornicroft pers. comm. 2000). What followed was considerable editorial commentary and protest internationally [5], [67], with a response from Thornicroft et al. [14]. Being given the vast majority of pages and articles and a laudatory editorial in the one journal issue, what psychiatric professionals in the UK could have missed reading the PRiSM study, or the indelible message that they were to conclude that intensive case management doesn't work?
Sashidharan et al. [68] conclude that this is part of a disturbing trend: ‘that having failed to strangle the infant of progressive community care in the UK, psychiatrists in this country appear to be keen to marshal whatever evidence they can in the way of “scientific evaluation” in order to diminish its significance and arrest its progress. It is no wonder that, while we are in the midst of some of the most significant changes to affect mental health care in this country for nearly a hundred years, the psychiatric profession is often accused of heading in the opposite direction.’
The main problem we have with the PRiSM study, is not the science, which was plainly done in good faith, despite our differences regarding biases. It was the British Journal of Psychiatry's presentation, the editorial spin, and how easy it was to assume, mistakenly, that this was a test of ACT. This particular edition has been waved around by various people in Australia to show that ACT case management does not work. So this is the perception we mean to challenge.
UK political, professional and media context in the 1990s
Why was there such a difference in reactions between the UK and Australia to case management?
There is some evidence that the Australian community is more tolerant of people with mental illness in the community [69]. Compared with the Australian studies (apart from [35]) all the UK studies are more inner-urban, with higher expected levels of social morbidity associated with social deprivation factors, apart from their mental illnesses. It may also be that the mental health establishment in the UK are, or were at the time, far more cautious and less open to system change on the basis of new evidence.
The UK political climate certainly has appeared even more conservative than that in Australia in relation to mental health. The Ministry of Health in the Thatcher and Major governments ensured that there was a major public national enquiry in every instance where a murder was allegedly perpetrated by a person with a mental illness, with the inquiry being publicly named after the perpetrator. These were widely covered in the media in lurid detail with banner headlines, and undoubtedly repeatedly sensitized the UK community to fear of people with mental illness in their midst; a typical example occurred when Jonathon Zeto was killed by Christopher Clunis at Finsbury Park Tube Station in London. Most people in England still remember these names.
In Australia, Mental Health Service reforms have often been supported on a bipartisan political basis, both by state and federal governments, with brief exceptions.
Conclusion
Why hasn't an RCT of ACT been completed in the UK? Three controlled studies, (two of them randomised) in the UK have shown no benefit of more intensive forms of case management in the UK. This is not surprising because the intensive forms of case management did not meet the fidelity criteria for assertive case management. What is surprising is why hasn't a high fidelity trial of ACT been completed in the UK? The model has certainly been tested outside the US (see Table 5 for a full list of studies referred to in this paper), so what makes it so difficult to transport it for research purposes to the UK? The implementation of a trial of ACT requires considerable resources, and the allocation of only 10 clients on average to a case manager, perhaps the current NHS funding mitigates against such a trial. While UK 700 study compared a form of intensive case management with standard care and the PRiSM study compared two ways of organising community mental health teams, a trial of assertive case management is yet to be completed in the UK.
A summary of the studies of types of community care referred to in this paper
Interestingly, and despite the critiques of case management, a comprehensive range of evidence-based community mental health services including ACT in each locality and region has been proposed for the UK [61], [62] and is being implemented nationally there [71–73].
Some British psychiatrists argue that the reason little difference is found between ‘intensive case management’ (ICM) and standard treatment in the UK is the possibility that the control treatments in the UK Studies were superior to most of the US and Australian RCT studies. Those of us who worked in both UK and Australian systems, around the time of the Hoult et al. [3] study (commencing in 1979), would have to say that the community teams in the control condition of the Australian study were far more resourced, coherent and active-response than community provision in the UK at the time. Similarly, the control condition for the Issakidis et al. [27] study in Australia demonstrates more fidelity criteria for ACT than the ICM team of the PRiSM study in the UK (see Table 2, column 4) and yet the experimental ACT intervention was still significantly superior.
The standard NHS community mental health care in the UK has relied over the last decade on the Care Programme Approach [71]. As stated in the above report, until recently, this system has been seen as ‘overbureaucratic’, ‘duplicating information’ between two agencies (Health and Social Services), causing fragmentation and passivity of response, as it could be dominated by brokerage style coordination.
This is just the style of case management the Cochrane reviews of case management implicitly were railing against. Improved CPA care management has not been widely or effectively implemented throughout the UK, and yet this is considered to be the standard care against which ACT is unlikely to show differential superiority. So this is an entirely hypothetical argument about comparison between ACT (which has never been tested in the UK) and a standard which doesn't actually exist yet in the UK. Thus, it is a spurious argument, not supported by evidence.
The role of ACT is affirmed in the National Health Service Framework Implementation Guide [72] in which an entire section is devoted to ACT as an effective vehicle for delivery of services to individuals ‘at risk’ of disengaging and being lost to follow up.
So what is going on? How is it that such important ‘gold standard’ landmark reviews and studies can allow EBM to be used so loosely and commented upon with such apparent bias? What is most puzzling is that many of the participants, are both strong advocates of ethical practice and good community care, and know well how competent case management should be practised.
Are they earnestly trying to make a case for evidencebased community care as opposed to the perceived scourge of superficial case management, or have they been caught up somehow in some wider system political game? No-one is immune to these pressures in the UK or in Australasia.
Unless this potential for abuse is recognized and checked, evidence-based practice in psychiatry is in danger of being discredited at the hand of some of its most prominent proponents. This makes the more rigorous pursuit of evidence-based psychiatry even more important. Whether involved in quantitative studies or the complementary use of qualitative research, we should develop ways of systematically declaring interest or bias in a way which causes us to reflect on its impact on our work.
Footnotes
Acknowledgements
To Jonathon Craig, Andrew Baillie, Vivienne Miller, Rachel Jenkins, Geoff Shepherd, Sylvia Hands, Ainslie Vines, John Gleisner and Graham Thornicroft for assistance with the manuscript.