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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! .
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The rise and fall of ACT in England: lessons learned from a centrally driven programme of 250 ACT teams set up in EnglandMike Firn
Overview • Case study of ACT implementation in England “the rise and fall” • The adoption of a FACT approach in South West London
Gordon Brown: March 2007 “We will not return to the old boom and bust”
The NHS must plan for huge savings £15-20bn productivity challenge Illustrative figures only
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 Benefits of ACT are no greater than with normal community care, but patients prefer it
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 ACTBurns 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.
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,)
Dismantling ACT to no model (Richmond) 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)
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
CMHT CMHT-FACT hierarchyindicative numbers only
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 • HoNOS score (baseline and annual) • Housing status and stability (independent living) • Competitive employment • Educational involvement
