1. Learning from managed care in mental health Dr Richard Ford Director

2. Managed care system Care programme approach for all people in contact with specialist mental health services – originally called case or care management (1991 onwards) –Key worker, care plan and reviews National Service Framework/NHS Plan/LDP Targets –Assertive outreach teams for the most severely ill 20,000 people –Crisis resolution and home treatment for 100,000 people per annum –Early intervention in psychosis for 7,500 people per annum

3. Care programme approach/case management May be necessary component of other models but ineffective on its own Can help to keep people in contact with services Increases use of hospital beds No outcome benefits – clinical or quality of life Unpopular with clinicians and therefore difficult to implement

4. Assertive outreach/assertive community treatment Well validated model (Cochrane review) Can help to keep people in contact with services Decreases use of hospital beds if targeted at high users Clinical and patient satisfaction outcome benefits Popular with clinicians and relatively easy to establish Can be difficult to sustain effective service Lesson – hit target group + assertive + community + treatment

5. Crisis resolution and home treatment Well validated model (Cochrane review) Decreases use of hospital beds if targeted at people at risk of hospital admission Clinical, patient and carer satisfaction outcome benefits Initially unpopular with clinicians and complex to establish Must be multi-disciplinary including medical input, emphasis on intensive home treatment for several weeks and not just assessment, must act as the filter to all potential admissions Lesson – fidelity to model or opposite to intended impact

6. Early intervention in psychosis Similar to assertive outreach but for young people Evidence base for minimising duration of untreated psychosis – better long term prognosis Limited evidence base for service models Popular service but numbers small and difficult to establish to rural and low prevalence areas Lessons – too early

7. Conclusions Case management may be necessary but is not sufficient It is not the model but the effective interventions within it that have impact Must hit the target group – all too easy to miss Fidelity to evidence based models important, but makes implementation more difficult You dont get it right first time and things change all the time – continual review for people and services