Case Summary; Assertive Outreach Team

The assertive outreach community team worked with service users who experience psychosis. They aimed to develop therapeutic

relationships with service users who have been identified as ‘difficult to engage’ (organisation website). Service users were often isolated

from communities and may have other complex problems such as contact with the criminal justice system or drug and alcohol dependency. They are likely to have had multiple previous admissions to hospital and been cared for under the Mental Health Act. Alongside supporting people with their mental health problems the service offered practical help, input with benefits, access to training and help with housing (organisation leaflet)

The assertive outreach team was located in a large community base in a city in the Midlands. The building provided a base for a number of

126 other community mental health teams as well as offices for Consultant Psychiatrists.

The assertive outreach service in the city was divided into two sub teams. There were two team managers that oversee both of these teams, a social worker and a nurse. The sub teams were divided

according to the geographical location of the service users GP’s in the

city. This governs the allocation of referrals to each team once accepted into the service.

4.1.4.1 Team A

There were six nurses in the team, five of these were band six and one was band five. There was one social worker in the team who undertook a care coordinator role. Four community support workers were also employed. One consultant psychiatrist was linked with the ward and one specialist registrar who rotated out of the team during the time of study.

The team identified that they adopted a pure assertive outreach model. Service users had an allocated care coordinator but were visited

regularly by several team members. This ‘team approach’ is

characteristic of the original US assertive community treatment model (Bond, Drake, Mueser and Latimer 2001). Team A shared one office with communal meeting space at one end and desks at the other end of the room. A large white board in the room listed all the people that the team support, their location, section status, date of next visit, date

of last visit and ‘dot’ status. The dot system was used to identify

service users in accordance with a level of concern, with a red dot being severe concern that would require action and, green denoting the need to be more vigilant. The team was supported by an administrator, part of their role involved taking calls that came into the team.

The team supported 74 service users. Of these six people were on CTOs and six were in acute in patient care. Between eight and ten

127 were identified with a dot against their name during the period of observations.

4.1.4.2 Contextual Issues

There was a proposal to replace a band six post with a band four post, which was causing concern amongst the team, particularly the qualified members. There was a feeling that this devalued the role of the qualified staff, as well as increasing their level of responsibility, as they would be accountable for supervising the conduct of the support worker.

Changes to the meeting structures had fairly recently been introduced, as a result of an ongoing homicide inquiry in another assertive outreach team in the organisation. This inquiry was continuing which appeared to cause some frustration in the team and a feeling that they were under a microscope.

Recovery is an important agenda for the organisation that the teams worked for (see organisational context). Whilst this was not necessarily shared by all members of the team, a meeting observed to

discuss the team’s targets for recovery revealed in some members a

feeling that this agenda had been forced upon them.

4.1.4.3 Team B

Team B was made up of seven nurses, six of whom were band six and one was band five. The team had five community support workers and was managed by the same social worker and nurse as Team A. Two consultant psychiatrists were linked with the team.

The team had adopted a case management model where individual nurses acted as care co-ordinators. With the assistance of specific community support workers, it was their care co-ordinator that a service user would have the majority of their contact with. They continued the intensive input of assertive outreach but had departed from the traditional team approach (Bond et al 2001). Caseloads for

128 some of the nurses were around 14 clients, although it was suggested the caseload maximum should have been ten. Team B were based in a large office opposite Team A, with workbenches against the wall and computers and telephones located on these. There was a large white board at one end containing details for all the service users the team support, with information regarding care co-ordinator, date of next appointment, date last seen, section status and medication due date. Dots were placed against names on the board. Similar to Team A they were also supported by an administrator.

Fifteen of the team’s clients were in acute wards during the time of

the study. Of these eight were under a section and two had been

recalled on a CTO. A further two of the clients were under CTO’s in

the community. Three were in prison and two were in homeless hostels. Ten had dots recorded against their name during the period of observation, though the majority of these were green. The team supported 75 service users.

4.1.4.4 Contextual Issues

Team B raised the ongoing homicide inquiry. Impacting on both teams, during the study, was the announcement by the team manager that commissioning arrangements were under review. The period of compulsory commissioning of assertive outreach services established following the National Service Framework for Mental Health (DH 1999b) had now finished. There was no longer an obligation to fund this type of service. Assertive outreach input could therefore be incorporated into community mental health teams. No decisions as to the future structure of the service had been made but the options were being reviewed.

Another member of Team A was due to leave the team soon and it was unclear whether they would be replaced due to cost saving imperatives in the organisation. Staff in both teams expressed concerns regarding the impact on the service users and well-being of the team members.

129