Transcript Slide 1

The rise and fall of ACT in England:
lessons learned from a centrally driven programme
of 250 ACT teams set up in England
Mike Firn
Overview
 Case study of ACT implementation in
England “the rise and fall”
 The adoption of a FACT approach in
South West London
Real new money!
Gordon Brown: March 2007
“We will not return to the
old boom and bust”
The NHS must plan for huge savings
NHS expenditure by year
130,000
120,000
£15-20bn
productivity
challenge
100,000
demand, pay & price
pressures
scenario with "flat cash"
from 2011/12
actual and planned spend
90,000
80,000
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13
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70,000
20
£millions
110,000
Optimism / Faith
Doubt / Denial
Confirmation
Benefits of ACT are no
greater than with normal
community care, but
patients prefer it
ACT n=127
standard CMHT care n=124.
18 month follow up
spanning 1999-2004.
Negative study makes front
page of BMJ
No difference found in any
measure of in-patient bed
use.
Better engaged, little loss
to follow up
better satisfaction.
Similar rates adverse events
ACT is now undeniably in decline -several
reasons cited in team closure business cases:
 English ‘hard’ evidence has shown that ACT
does not reduce bed usage (killaspy 2006/2009,
Glover 2006)
 mixed results with local pre-post analyses.(Few
areas collected routine outcome measures or
carried out local evaluations)
 It is more expensive unless it reduces bed
usage.
 We need to make savings (recession)
A local business case (NW England).
“The local evidence reflects the national picture. There is
no evidence to show that ACT Teams have an impact on
hospital admissions or lengths of stay. Assertive
Outreach Teams are however more costly that
Community Mental Health Teams
……..Due to the lack of evidence, CWP proposes to stop
providing intensive case management by separate ACT
teams. Instead we propose to provide intensive case
management and assertive outreach function by
enhancing community mental health teams with extra
staffing. “
NFAO position
The imperative now is to make sure that
dismantling and integration is done
intelligently preserving what is best in ACT
and taking it into the standard locality team.
Can the standard team operate more like an
ACT team with shared care and high levels of
coordination
The FACT model is the best articulated model
for achieving this.
The Rise and Fall of ACT
Burns T. International Review of Psychiatry April 2010
RCTs only show a positive effect on bed use for ACT
where standard care has long lengths of stay
Standard care has improved and in fact benefited from
the intense research scrutiny and experience of ACT
Low caseloads (expensive) do not correlate with
reduced bed use in meta regression analysis
Organisational aspects of ACT team working such as
multi disciplinary teams, regular meetings and home
visiting account for almost all the gains.
These are no longer exclusive to ACT but found in
standard community mental health care
Helen Killaspy conclusions:
lack of effectiveness of ACT
 ACT in England have not been able to impact on
admission rates for “difficult to engage” clients beyond the
effect of crisis & HTT plus standard CMHT care
 CMHTs able to prevent admissions as effectively as ACT
using fewer face to face contacts and higher case loads
 No advantage of ACT over standard CMHTs on any
measure of clinical outcome except satisfaction
 ACT not been shown to be cost-effective
 ACT style is more acceptable to “difficult to engage”
clients and less coercive than standard approaches
Ghosh and Killasy :
Staffing of ACT teams in England in 2007
 36% had no consultant psychiatrist (rest 0.5 FTE)
 22% had no Dr
 52% had psychologist (0.4 FTE)
 65% had OT (0.9 FTE)
 92% had social worker (1.7 FTE)
 99% had support workers (2.7 FTE)
 100% had nurses (4.6 FTE)
 16% employed service users
 29% had substance misuse specialist
 49% had vocational rehabilitation specialist.
service configurations in decreasing
fidelity to the orthodox model that
are now found.
1. Dedicated ACT team with own medical responsibility,
and good model fidelity
2. Dedicated as above but low fidelity e.g. no extended
hours / weekend provision/ medical input
3. Integrated model with more generic CMHT according
to Dutch FACT model- (flexible in and out ACT)
4. Integrated model but case managers placed in CMHTs
without clear guiding model beyond reduced caseload
Lessons Learned
Standard care is better than we thought at managing
long term serious mental illness outside hospital
(Provides real competition for ACT teams)
The trouble with central targets: They distort
behaviour. Mandatory to have a team in each area
servicing a prescribed number of patients. BUT in
practice many teams lacked full implementation in
some important aspects.
Specialist teams


Create new problems with fragmentations in services
and new rivalries
keep hold of patients beyond their requirement for
the specialism
My basic rules of service
development
 Pool what you can and specialise
where you must
 Context is king -England is not USA,
Australia or the Netherlands. Services must be
adapted to their environment (political, financial,
structural,)
The local adoption of a
FACT approach in South
West London
Dismantling ACT to no model (Richmond)
N=43
ACT team care
Nov ‘05-Nov ‘06
CMHT care Nov
06 –Nov ‘07
Admissions
36
33
Average
LOS
107
128
LOS average is influenced by a small number of lengthy admissions eg
between 301-365 days (7.3% in AO care and 22% in CMHT care.) Both
groups had the majority of patients staying between 0-50 days (53% in
both groups)
Services in the adult care pathway popn 390,000
56 General
Practices. 11
Health Centres
Community Visit - out patient clinics
2x Assertive
Outreach Teams
(ACT)
Caseload 151
5 x Community Mental Health Team
(caseload 1586)
72 acute
Hospital beds
+ 5 intensive
care
2x Early Intervention Team
Caseload 170
ACUITY OR SEVERITY OF NEED
In patient
Primary Care
Psychological therapy in
primary care
referrals=5,000 per annum
2 x Crisis and
Home Treatment
Teams
(episodes 756)
Reduced by 19%
from 2008
through closing
beds and Home
treatment teams
Merton & Sutton helped to choose the
FACT model – anticipated benefits of FACT
 Equitable use of limited resource
 Recognition that AO population is not static
 Ability to titrate care between intensive case
management and standard very easily (fewer
interfaces /delays/referrals)
 A properly manualised service with clear measures
and standards (compared to CMHT)
 CMHTs becoming more like ACT rather than other
way round.
 Most errors arise from poor co-ordination and
communication
HTT
FACT n=25±
Care Programme Approach
for complex / multi-agency
(CPA)
Care co-ordination n=150±
Non CPA (simple out patient
care from one professional)
Intake (assessment and brief
treatment n=120±)
CMHT-FACT hierarchy
indicative numbers only
Sutton & Merton experience to
date?
Team
Wallington
Carshalton
Cheam
FACT
ratio / %
31/306
(10%)
30 / 286
(10%)
21 /246
(8.5%)
Wimbledon/ 10 / 567
Merton
(2%)
Mitcham
East/ West
25/267
(10%)
Notes
Embraced the Model , daily FACT
meeting.
Overcame scepticism about daily
meeting . Would not return to twice
a week ‘zoning’
FACT and ‘Fiction’ for target
attainment (40). Expect people to go
through FACT before Home
Treatment team referral
Key findings +ve
Target population. Of the original clients from
ACT teams only 50% are now on FACT board
(proves that ACT had stagnated and was not
caring for the most intensive clients, demonstrates
churn )
Absorb in the team what would have gone to a
duty system (continuity of care)
Team approach -supportive model “I can sleep at
night now”
Coordination and communication- Supports
effective risk management
Key findings +ve
Audit trail of team decisions
Know who is doing what and when for
FACT clients
Cross cover improved with team culture
Shared knowledge of whole caseload and
team scrutiny
Key findings –ve
Frequency of contact down post-ACT
Less direct supervision of medication
Not enough support workers (typically 1-2
per team) to fully support shared FACT
caseload (too many professionals with high
caseloads)
The dismantling study
The power of a dismantling study is that it
avoids the common limitation of traditional
pre-post studies where improved outcomes
can be attributed to wider improvements in
health and social care such as the
background trend of falling admission rates
and bed closures, rather than the service
change being evaluated.
Methodology
Differences pre and post AOT will be
calculated statistically with individuals
on the caseload of the assertive
outreach teams acting as their own
controls. Evaluation areas are taken
from the SAMHSA toolkit evaluating
your ACT team
publication may be
downloaded or ordered at
www.samhsa.gov/shin.
The primary outcomes will be hospital admissions (or
equivalent) and bed use.
 Number of admissions / Number of HTT episodes
 Number of days in hospital (including and excluding
leave)
 Use of Mental Health Act (including CTOs).
 Prison days
Secondary outcomes
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HoNOS score (baseline and annual)
Housing status and stability (independent living)
Competitive employment
Educational involvement