INTRODUCTION Writing about UK psychiatric services is difficult, because one is essentially trying to hit a moving target. There is constant change, and increasing differences between England, Wales, Scotland and Northern Ireland. Recently, ìmodernisationî seems to have been viewed by government as the same thing as improvement. There has been a tendency for ìgood ideasî to be introduced into practice without proper trial, and without adequate resources.

In spite of these continuing difficulties in the system, psychiatry remains an enthralling specialty. Surviving in it depends on a continuing interest in patients as individuals, and also on the ability to work as part of a team- because it is through teams that psychiatry is now generally practiced.

These teams are largely based in the community rather than in inpatient units. I will start with a description of the community mental health team, as this seems likely- at any rate, for the time being- to remain the foundation stone of psychiatric services.

However it is first necessary to say a few words about the historical background, as otherwise it is difficult to understand the rather convoluted and curious pattern of existing mental health services.

BACKGROUND AND HISTORY Psychiatric disorders require rather different systems of care from physical ones. This is because many psychiatric disorders are chronic; impair patientsí ability to meet their own practical and social needs; and often evoke rejection or ridicule from other people, rather than understanding and sympathy.

Until the ìasylum movementî of the eighteenth and nineteenth centuries, most mentally ill and mentally handicapped people were looked after by their relatives, with private nursing at home (see Jane Eyre, 1847) or in a private ìmadhouseî for the minority who could afford it. Some were rejected by their families to become ìvagrantsî and be put in the workhouse, or possibly taken in by religious or charitable institutions.

Asylums (hospitals for the mentally ill and mentally handicapped), set up with the help of charitable support amid much initial enthusiasm, were large impressive buildings usually sited in the countryside with their own gardens and farms. However, in the absence of any really effective treatments for psychiatric illness until the mid-twentieth century, their wards soon became overcrowded, and standards and morale declined. Long-stay patients, including many who would not have been considered to merit even a brief psychiatric hospitalisation nowadays, became apathetic and lacking in simple skills of daily living (ìinstitutionalisedî). A major stigma was attached to admission.

The gradual closure of asylum beds began in the 1950s, was accelerated in the 1960s and 1970s by several scandals and a fashionable ìanti-psychiatryî movement, and has continued to the present day under government policy of ìcommunity careî.

In the 1970s, many modern inpatient units attached to district general hospitals (DGH units) were built to replace the old mental hospitals. DGH units offered the advantages of enabling psychiatric services to be integrated with medical and surgical ones, close to main centres of population. However the typical DGH unit environment, with its compact unlocked wards, proved unsuitable for certain patients such as the behaviourally disturbed, and accumulation of ìnew long-stayî cases soon caused blocked beds.

The more recent trend has been development of community mental health centres, plus crisis teams, and assertive outreach teams, with the aim of reducing inpatient admissions further still.

In the context of managerial reorganisation of the NHS as a whole, profound organisational changes to psychiatric services have been introduced. Debate continues as to which model is best, and what future policy should be.

COMMUNITY CARE Community care involves treating patients as far as possible in their own homes, with an emphasis on a prompt and individualised multidisciplinary response to problems. Community care is recommended on the grounds that it is as effective as hospital care, preferred by patients and their families, minimises the stigma of mental illness and prevents institutionalisation. These are real advantages provided the systems are well organised, and adequately funded; good community care is not necessarily cheaper than hospital care.

Proper funding and good collaboration between the different professional groups is essential for good community mental health care. Unfortunately, staff shortages and vacancies and morale problems are frequently reported, especially in deprived urban areas with high morbidity. Introduction of the Care Programme Approach (see below) was partly to try to make sure that the care of individual patients was properly organised so as to withstand such difficulties.

Community care for patients with long-term mental illness used to be the responsibility of local authority social services departments- though these have now to a greater or lesser extent, been merged into community mental health teams in many areas. Each patient must have an individual needs assessment, and then appropriate services are arranged, though clients with sufficient financial means may have contribute to the cost of these.

Social workers and CPNs now work in similar ways (ìgenericallyî) as care-co-ordinators. As well as general support and advocacy, the care co-ordinator will provide advice about:

• Financial benefit entitlements.
• Employment: for example, sheltered employment, or a gradual return to the work routine through activities in the voluntary sector.
• Accommodation: residential and nursing homes care for numbers of people with mental health problems, not only the elderly. Supported accomodation includes group homes, hostels and other forms of accommodation may be provided by health, social services or the voluntary sector, with varying degrees of resident or non-resident supervision. For example, this might be a group of self-contained flats, with a warden present during the day, and telephone support during the night. The supported lodgings scheme allows for social services to pay landlords extra in exchange for some care of their tenants. Private rented accommodation is home to many with chronic mental illness; some of the landlords involved may be open to criticism, but their tenants might otherwise be homeless.
• Day centres provide a focus for regular supervision, activities and rehabilitation.
  

THE PSYCHIATRIC MULTIDISCIPLINARY TEAM The multidisciplinary team consists of one or more members of each professional group involved in psychiatric patient care: doctors, nurses, clinical psychologists, social workers and occupational therapists. Much good work is also done by less qualified support workers, who are cheaper to employ and who can therefore have more time to forge enduring relationships with individual patients than other disciplines.

Teams for general adult psychiatry are usually responsible for a given sector, defined geographically (for example by postcode) or by GP. Other teams, often covering a wider area, deal with specialties such as old age psychiatry, child psychiatry, learning disability, substance misuse, forensic psychiatry, psychotherapy and rehabilitation.

A community mental health team may be based in a hospital, a health centre, a converted house or a purpose-built unit within the community served. Each team member is involved in assessment and management of referred patients, contributing both from their professional viewpoint and from their personal knowledge of the patient. It is usual to have a weekly team meeting, at which new referrals are discussed and progress or problems with existing patients are shared and reviewed.

It used to be the case that social workers in the teams were employed and managed by local authority departments of social services, which did lead to potential problems as most of the rest of the team will be employed by health services. Recently, there have been moves to bring all staff under the same management.

Each team may have up to 500 patients on the books at any one time; day-to-day clinical management of most of them is carried out by non-medical team members. Ultimate responsibility for patient care remains with the consultant, if the patient is seeing a psychiatrist. If the patient is only seeing a member of the team, and is not seeing a psychiatrist, responsibility lies with the team manager and/or the referring GP.

The role of the psychiatrist in the team is not only to have a caseload, but also to be a resource for the rest of the team: he must be approachable and available for advice and discussion, and able to work flexibly. Fitting in patients for consultation as soon as problems start to develop is particularly appreciated, and probably reduces everyoneís workload in the long run.

In some areas, community mental ìresource centresî have been set up by social service departments with input from the voluntary sector, especially mental health charities.

PSYCHIATRY IN PRIMARY CARE A quarter or more of consultations in primary care (general practice) appear to have a substantial psychological component, although the patientís presenting complaint is usually a somatic one and the underlying emotional disturbance may not be recognised by the doctor. Mixed neurotic symptoms, often accompanied by social or interpersonal problems, predominate. About 90% of patients with psychiatric disorder are managed solely in primary care, and many episodes resolve quickly without specific treatment, or with brief counselling; some general practices employ their own counsellors.

Some patients require psychotropic drug therapy. Antidepressants, though often prescribed in lower doses and for shorter courses than most psychiatrists would recommend, are effective, though probably in many milder cases, they are acting as placebos. Benzodiazepines are recommended for short periods only, but many GPs now avoid prescribing them at all.

General practitioners (GPs) are also involved, in collaboration with psychiatric and social services, in the ongoing care of those with more severe illnesses such as schizophrenia and affective disorder, which require long-term medication and supervision.

Besides being providers of primary mental health care, GPs are involved in shaping local psychiatric services.

ìFundholding GPsî were introduced in the 1990s; the idea was that they would have a budget to purchase the services they considered necessary for their patients. They considered necessary, including mental health services, for their patients. Political changes caused fundholding to be jettisoned, though, as it is the way with the NHS, it now seems to be coming back under a different name, practice-based commissioning.

At the time of writing, it is difficult to predict the real impact of these changes. In principle, any move to build up primary care, which provides 90% of NHS care, but only gets 10% of the budget, has the potential to benefit low-tech specialties such as mental health care.

It will be likely to accelerate the trend towards community psychiatric nurses (CPNs) and other mental health care staff being based at least partly in GP health centres.

There is a dynamic tension here between probable benefits of such changes, and the real concern about such specialist resources being directed towards the ìworried wellî, and away from patients with severe chronic psychiatric illness.

One problem, which is unlikely to be solved completely by the changes proposed, is the apparently unlimited demand for ìcounsellingî. Some areas are trying out ìgraduate mental health care workersî, that is, graduates who have received a modicum of training in CBT, as a way of trying to satisfy this demand.

INPATIENT SERVICES Despite the national reduction in psychiatric bed numbers, there still remains a need for some inpatient facilities, whether in a mental hospital, or a DGH unit, or a community unit. Separate wards usually exist for:

• Acute admissions in general adult psychiatry (usually patients aged 18ñ65). Sometimes there is a separate intensive care unit for severely disturbed patients.
• Acute admissions in old age psychiatry (patients over 65, or 75). There may be separate wards for functional illness, and for assessment of dementia cases.
• Other facilities are required such as residential / long-stay rehabilitation, but this may not always be provided by the NHS ìin-houseî. Facilities vary from area to area; some rehabilitation hostels and schemes are run by local authorities, or by charitable organisations. It follows in these cases that admission to them is by assessment, and this can lead to delay. In the same way that the psychiatrist does not have direct authority over the non-medical members of the community mental health team, so the health service cannot direct outside agencies to accept patients, for example for rehabilitation.
• various types of supported accommodation are provided by social services and other organisations such as charities and housing associations. They allow patients to be discharged from hospital, who would otherwise be unable to cope on their own.
• The NHS still seems to suffer from the fond delusion that the need for longstay beds has somehow been abolished, with the closure of the old psychiatric hospitals. There is a small number of patients in each area who do require this. At the moment, at any rate in England, the need is met by the patient generally being placed in private nursing homes or hospitals.
• More specialised inpatient units exist to cover a wider population, such as a health region. These deal with, for example, forensic cases (secure units), drug and alcohol misuse, adolescent psychiatry, mother and baby care, eating disorders.
  

OUTPATIENT CLINICS Psychiatric outpatient clinics, mainly conducted by the medical members of the team, exist for assessment and treatment of new referrals, and for follow-up of recent discharges from inpatient care. Many milder patients do not require indefinite clinic follow-up, but can be discharged to GP care with recommendations for future management. Patients who have had psychosis or bipolar affective disorder, amongst others, should remain in long-term follow-up.

Some clinic sessions, often supervised by specialist nurses, are dedicated to particular patient groups, for example those on long-term medication with lithium or depot antipsychotics or clozapine.

Computer registers to monitor the frequency of patient attendance, prescribing activity and performance of relevant laboratory tests are a useful aid to managing such clinics and reviewing their performance.

CRISIS AND HOME TREATMENT Home treatment has been developed as an alternative to inpatient care for acute cases (1). This involves a ìcrisis interventionî model in which members of the multidisciplinary team visit the patient, and family, at frequent intervals sometimes several times per day. clinical experience is that such crisis teams can reduce hospital admissions, and that they can be popular with patients. However, they do depend on having adequate staffing, good morale, and good relations with other parts of the service such as community mental health teams and inpatient units.

Crisis teams can screen new admissions, to see if they can be avoided, can attend Mental Health Act assessments, to see if a potential ìsectionî can be handled in a different way, and can attend inpatient ward rounds, to see if patients can be given early discharge into their care.

This represents another step in the general shift towards providing interventions in patientsí homes, for example domiciliary assessment of new referrals, and regular visits by community psychiatric nurses (CPNs) to monitor patients who need long-term care.

DAY HOSPITALS Many acutely ill patients can be managed in a Day Hospital as an alternative to admission, and Day Hospitals can also provide a useful period of follow-up care for those recently discharged but still needing intensive support. They offer medical and nursing care, occupational therapy, psychological treatments and social work. The day hospital is regarded as an essential part of a fully developed mental health service, but the work it does is to some extent overlapping with the currently more fashionable crisis team.

RESOURCE CENTRES AND DAY CENTRES Mental health services have been slimmed down to the most efficient and effective service models in treatment of acute illness, but there is still a need for a proportion of chronically ill or recovering patients to have somewhere to go for social contact, for meals, and for other activities such as rehabilitation and education.

This is often provided by resource centres, which may or may not be linked, geographically and organisationally, to mental health services.

RECOVERY AND REHABILITATION The modern idea of rehabilitation is to do with helping patients in the community who have had any kind of mental health problem gradually return to normal functioning. The currently fashionable recovery model emphasises positive aspects of the individual patient, building strengths, so that they get back to their full potential even though they need continuing support from mental health services.

This stands in complete contrast to the old idea of rehabilitation, which was restricted to severely affected psychotic patients. Such conjures up pictures of the longstay ìback wardsî of the old psychiatric hospitals, where deteriorated patients with schizophrenia would be rewarded with cigarettes, in return for performing simple tasks such as self-care. Such programmes of ìtoken economyî would of course now be regarded as unethical.

Rehabilitation aims to reduce disablement, or better still to prevent this through early intervention; and to improve social functioning and quality of life. This might involve a worthwhile occupation, and a stable social network preferably involving the family, in addition to psychiatric symptom control. Individual programmes take account of each patientís impairments, positive attributes, and likely future environment. Progress towards agreed goals is often achieved gradually. Rehabilitation is part of everyday care, not something to be seen as separate.

Many patients have always done well, and there is the potential to improve outcomes and functioning for most patients through appropriate rehabilitation, in particular, vocational rehabilitation (2), that is, getting patients back to work so that they can benefit from the positive effects of having a routine, social contact and from improved self-esteem and self-confidence (- and improved finances, potentially, though the extremely complex benefit system can provide perverse incentives against paid work).

Old-fashioned ìsheltered employmentî is now uncommon, but there are different schemes in different areas, which seek to encourage people with health problems to get back to work; the Disability Employment Adviser at the Job Centre can help. Doing college courses, and voluntary work, can be very helpful first steps in rehabilitation.

In the case of patients who have an existing job, graduated return to work programmes can be very helpful in helping patients to return to work. In the case of neurotic symptoms such as anxiety and depression, we should be moving towards a presumption that they do not prevent work once the acute stage is passed. Patients do lose confidence, but prolonged absence can result in a vicious cycle and become a self-fulfilling prophecy; the well-known therapeutic benefits of work and the converse risks to health of not working are increasingly recognised.
Patients who are working and become unwell, have legal rights, which may protect their employment, for example, under the Disability Discrimination Act.

Severe prolonged psychiatric illness, notably chronic schizophrenia, may lead to loss of daily living skills and/or socially undesirable behaviour. The result may be breakdown of family relationships, homelessness, poverty and unemployment. However, it is clear that some patients in the past have developed these associated problems at least partly because they coincided with expectations of society and of services.

THE CARE PROGRAMME APPROACH The Care Programme Approach (CPA) aims to improve delivery of services to psychiatric patients. Following a formal assessment of their medical and social needs, patients and carers themselves are invited to take part in drawing up individual written care plans. These might include statements about the frequency of outpatient reviews, medication, home visits by a CPN and/or social work interventions with the family. The resulting document is signed by those responsible. Regular review meetings follow. Although several members of the multidisciplinary team are likely to be involved, the plan must specify a named ìkey workerî who will coordinate the care, and be the first point of contact in a crisis.

Two ìtiersî of the CPA exist, enhanced, where the patient typically will have both psychiatrist and a care-coordinator, typically a social worker or community psychiatric nurse, and standard, where the patient just sees one professional, typically, they just attend psychiatric outpatients. Enhanced cases are more complex and severe; the care coordinator may have approximately 20 at any one time; there are written risk assessments and regular CPA review meetings with care coordinator, consultant psychiatrist, patient, family and other involved parties. Standard cases are less severe, their care is less complex; no special paperwork is required, the risk assessment is held to be implicit in the standard notes and letters.

ASSERTIVE OUTREACH TEAMS Assertive outreach teams practice a type of psychiatric care for clients with multiple complex needs (1). It involves, for example, seeking out someone who fails to attend an appointment, and frequent visits long term. It is more expensive than standard care, but can serve to improve outcomes in ìrevolving doorî patients with poor compliance.

NON-NHS HEALTHCARE FACILITIES Although the most psychiatric services are provided by the NHS, some care is purchased from other providers. Examples include:

Private psychiatric hospitals: including some set up for profit, and some non-profit-making charitable institutions. Services from both types are often purchased by the NHS, in areas where it cannot itself meet demand. ìDifficult to manageî patients, especially the acutely psychotic and potentially violent; those suffering the chronic effects of brain injury; and special groups such as patients with eating disorders or puerperal illnesses, are among those most frequently placed in the private sector. Many private wards offer higher levels of staffing, and tighter physical security, than most modern NHS facilities.

The voluntary sector: this receives public monies to provide services; for example a charity may receive social services or health funds in order to provide ìmeals on wheelsî or a day centre.

Psychological treatments such as counselling, and various forms of alternative or complementary medicine, are frequently purchased by patients directly. The practitioners consulted may or may not be properly trained and accredited, and patients may not reveal this information unless sensitively asked.