Whatever happened to assertive outreach?

Ten years ago community mental health services were still busy setting up assertive outreach teams. This initiative was prompted to a degree by media interest in a few serious crimes committed by people who disengaged from mental health services.

Official reports observed a lack of communication between services and an apparent indifference to clear indicators of risk. Assertive outreach services were commissioned within a national service framework and, although more than 250 teams were set up at that time the majority no longer exist.  

‘In the absence of any government lead programme, the NAFO was set up as a grassroots organisation to disseminate good practice and provide leadership’

In 2014, new GP based commissioning arrangements will require that people who have been served by assertive outreach services are defined within clusters 16 and 17, within a payment by results framework. Healthcare trusts are agreeing care packages in the hope they will continue to receive income for providing these services.

These care packages are designed, however, to show improvements within six months. Although assertive outreach is shown in England to have improved engagement and service user satisfaction, improvements in functioning or recovery are more difficult to demonstrate. Treatments are “assertively” administered, but many people continue to live with severe symptoms and often die young from physical health problems, if not from misadventure.

On the fringe

In the absence of any government lead programme, the National Forum for Assertive Outreach was set up as a grassroots organisation to disseminate good practice and provide leadership. It has been self-funding and has grown in influence through annual conferences. Unfortunately cuts in funding have prevented further development.

A generation of practitioners learnt from each other over the past 10 years and, though many teams have disbanded, these experienced workers have found ways to serve a challenging service user group in a confusion of new service models and local adaptations.

‘With no nationally agreed definition of what assertive outreach involves or how it is measured, England is falling behind international research’

There have always been people who live on the fringes of our communities; people who appear to refuse to be rehabilitated, housed, treated or helped. Commentators seem to fluctuate between blaming these people for their problems or accusing caring professionals of not caring enough. If there is no future leadership in assertive outreach, the next generation of practitioners will not benefit from networking or dissemination and it is a concern that good practice will be lost.

Community mental health teams commonly find reasons not to provide care or treatment to people who do not fit within the bureaucracy of their systems. Commissioners might not invest in the relatively expensive services that are required to engage this reluctant service user group and they might be left to drift into social exclusion and homelessness.

In the past, there was talk of a “long stay” population but this form of inpatient service is now unavailable. So what will happen to the next generation of socially disengaged people who have difficult to treat psychosis?

Missed opportunities

The organisation of community care around fidelity to a recognised model had developed in the US and enabled the use of extensive research in comparing and refining service configurations or interventions. But unfortunately the commissioning of assertive outreach services has not been closely defined in the UK and many opportunities have been missed.

Without the ability to measure or compare models, it is not possible to demonstrate the effectiveness of one kind of service or intervention against another.

With no nationally agreed definition of what assertive outreach involves or how it is measured, England is falling behind international research. The lead in Europe is taken by the Netherlands, where flexible assertive community treatment has been developed. These services are being set up and evaluated in a systematic manner.

‘It would not be helpful if another moral panic were to be triggered, whereby people who are unwell are regularly subject to the stigma of newspaper headlines’

Other countries are taking an interest, including Belgium and Norway, while the UK was poorly represented at a recent European conference. But, against the odds, services in London are evaluating different models. Assertive outreach services have been integrated with other community teams to create flexible assertive community treatment teams − these have been shown to be effective and further research is underway.

The National Forum Assertive Outreach asks that those who are involved in designing and enacting healthcare commissioning systems consider the needs of service users who are unable to advocate for themselves. These reluctant “customers” often avoid treatment and are then subject to detention under mental health law.

This is a form of care and treatment that is not easy to align with notions of consumerism, as popularised in the promotion of market principles in healthcare. It would not be helpful if another period of moral panic were to be triggered, whereby people who are excluded and unwell are regularly subject to the stigma of newspaper headlines. 

Simon Wharne is team leader for assertive outreach at Sussex Partnership Foundation Trust