Authors' reply

Dodwell raises three important questions in his letter. How intense is intense? Can levels of contact be related to outcome? What are the staff doing with the rest of their time?

Before addressing these, we would like to reiterate the purpose of our paper. We set out to determine whether the ICM teams really did achieve a different way of working and make more frequent patient contact than standard treatment (SCM) teams. There has been doubt expressed about this in the past and our study is able forcefully to reject these doubts. Any failure to demonstrate differences of outcome in the UK700 study (UK700 Group, 1999) cannot be attributed to a failure of the ICM staff to establish more intensive contact with their patients. Our paper also confirms that they were more persistent in their follow-up and involved carers more. The St George's group, who were clearly influenced by Stein and Test (Stein & Test, 1980), established a mean contact frequency near to their (St George's) target of two per week.

How intense is intense? We do not know and, as far as we can ascertain from published scientific literature, neither does anyone else. Although there are published quality standards and targets for contact frequency (Teague et al, 1998), we found no publications of prospective data. Our figures appear low and this, in part, reflects the very rigorous and conservative approach we took to data collection. Data were also collected in the early stages of these teams' functioning and would probably underestimate the contact frequency of a mature team. We know from work in other areas, however, that clinicians usually overestimate clinical activity when judged retrospectively. One of us (T.B.) has visited several demonstration ACT teams in the USA and from a clinical impression would not consider the St George's team's current contacts of around 25 per week per case manager to be much below that in good US teams.

Can levels of contact be related to outcome? Our means do conceal considerable variation, with some patients only being seen monthly (often during a prolonged period of engagement) and some being seen daily for long periods. Low contact can as easily represent severe problems with engagement as it can superior adjustment and fewer clinical needs. Some of the patients with the worst outcomes had the most contact because they were so ill. We have not attempted to test this correlation because of the difficulty of developing a convincing hypothesis — we would not hypothesise that there is a linear relationship between contact and outcome.

What are the staff doing with the rest of their time? This is surely a general question rather than one about ICM. The SCM staff recorded about as much time per week if their case-loads are accounted for. Many phone calls were unrecorded because they were short and there is considerable travelling time involved in community mental health work. Staff also attended ward rounds, team meetings, supervision, etc. We had anticipated that mental health staff would spend about 50% of their working time in direct clinical contact. Our study suggests that this may be something of an overestimate.

Virtually all of the major outcome papers from the UK700 study have attracted correspondence implying a partial implementation of good practice (McGovern & Owen, 1999; Gournay & Thornicroft, 2000). Whenever presented at meetings the results generate very strong feelings because they do not bear out what advocates of this approach want to hear. Our critics are confident that they know what goes on in ACT teams and other forms of assertive outreach. However, detailed exploration of the literature in this area for a PhD (M.F.) fails to find evidence for even such basic questions as ‘how intense is intense?’ Numerous policy statements about what is desirable, yes — but evidence of what happens, no. It is the purpose of research to replace conviction with knowledge. In the area of assertive outreach this is sorely needed. The UK700 study overall, and this paper in particular, helps reduce the gap between rhetoric and reality.