We read with interest the findings of the UK700 Group (2000) and were particularly struck by the presentation of the results. The authors start with a premise that intensive case management was thought to be of benefit in terms of quality but was considered an expensive form of care delivery. However, their findings suggest otherwise, that intensive case management can be justified in terms of cost.
That the patients who were part of smaller case-loads did not fair better may reflect the criteria for entry to the study. Having a psychotic illness of at least 2 years with two admissions to hospital could be described as representing a fairly typical cohort of general psychiatry patients, who would not meet criteria for acceptance by most current assertive outreach teams. By being more selective and focusing on a more disabled group, our service has significantly reduced local bed usage. Many of the patients' difficulties previously centred around engagement with services and it is in this area that the team had to work hardest. We have found that it is often only after 2 years of working with patients that many begin to be able to cope with the transition to independent living and to reduce their use of resources, including hospital admissions.
At a time when community mental health teams nationwide are struggling to provide a reasonable standard of care for their patients, assertive outreach can also provide satisfaction and opportunities for learning for all team members. In our experience, the knowledge that patients are receiving an acceptable standard of care rather than just ‘fire-fighting’ can lead to a maintenance of staff moral — a factor which does not come cheap but which the UK700 study shows can be no more expensive.
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