How did we let it come to this? A plea for the principle of continuity of care

Abstract

SummaryThe administrative imposition of new models of psychiatric care in the community has led to the fragmentation of services and a deteriorated experience for both service users and professionals. The author makes a plea for psychiatrists to reassert the principle of continuity of care, which has been all but lost from the practice of psychiatry during the past decade. It is possible to meet the clinical objectives of necessary support and treatment for service users within the community without the current multiplicity of team structures seen throughout England.

Specialisation and marginalisation: how the assertive community treatment debate affects individuals with complex mental health needs

“…Protagonists argue that specialisation reflects an evolving evidence base for delivery systems that are most effective, whereas generalists cite the risks of specialisation to continuity of care and therapeutic relationships. [3][4][5][6] In this editorial we use the example of assertive community treatment (ACT) to explore the challenges of importing models of specialist care into different socioeconomic contexts and health systems at the international level.…”

“…The ACT story in the UK has prompted initially healthy but now repetitive debate about whether investment in specialist community mental health services should ever have happened. [3][4][5][6] The result from the only trial of ACT to be carried out in the UK 8 is used to support the case made by protagonists of standard care to stick with the generic CMHT case management model. 3,5 On the other hand, early intervention services, which incorporate similar key components to ACT, are seen as central to current mental health policy in England.…”

“…[3][4][5][6] The result from the only trial of ACT to be carried out in the UK 8 is used to support the case made by protagonists of standard care to stick with the generic CMHT case management model. 3,5 On the other hand, early intervention services, which incorporate similar key components to ACT, are seen as central to current mental health policy in England. 16 This is despite the fact that evidence for their longer-term effectiveness has not yet been clearly established in the UK literature, 17 although encouraging longer-term results are emerging elsewhere in the world.…”

A solution to the ossification of community psychiatry

“…Instead, the product champions of the different service models spend large amounts of unproductive time assaulting each other in increasingly intemperate language, 12,13 forgetting that they are all meant to be fighting on the same side. The growth of specialisation then leads to greater fragmentation of care, 14,15 so that it is now possible for a patient to be under four or five different consultants during the course of a single episode of illness. With greater fragmentation there is the increased bureaucracy of transfer between teams, which also takes up a large proportion of clinical time that would be best spent in clinical contact.…”

“…When admission does take place there is frequent discontinuity, and individual therapeutic relationships are extremely difficult to develop and maintain. 14,15 It needs to be appreciated that it is not the model of care that helps patients -it is the practitioners who provide the treatment. Shoe-horning them into one team structure after another, often increasing their case-loads in the process, does nothing for their morale or performance.…”