Rehabilitation psychiatry in an era of austerity

The credit crunch is putting strain on personal and Governmental finances worldwide. The UK has been the hardest hit of the G20 countries and the outlook for public finances is, to say the least, bleak. So after a decade of investment and expansion of mental health services, which has left them “the best in Europe” (Appleby, 2007), we face an era of ever greater “cost-improvements”, “cash releasing efficiency savings” and perhaps more honestly cuts in services.

During the fat years the English Department of Health (DH) was hyperactive in producing policy documents on mental health care, many of which were published under the rubric of a Mental Health Policy Implementation Guide (PIG). The most influential PIG was the first (DH, 2001) which set out a vision for adult mental health services based on a “functional” model of multiple specialist community teams that replaced the 1990s consensus of the all-singing all-dancing Community Mental Health Team (CMHT) relating to a local inpatient unit. This “functional” model consists of a number of community teams in addition to the CMHT that provide Crisis Resolution/Home Treatment Teams (CRT/HTT) as an alternative to admission, Assertive Outreach Teams (AOT) for difficult to engage patients with severe mental illness and Early Intervention in Psychosis (EIP). Subsequent PIGs addressed a range of topics which included services for people with a personality disorder, women's services, inpatient services and Psychiatric Intensive Care Units and Low Secure care (the latter two perhaps unfortunately conflated in a single document)(DH, 2003a, 2003b, 2002a; 2002b).

The DH has developed policies for almost every aspect of adult mental health services. It has been very active in managing the implementation of these policies through a reporting framework that was enormously detailed (to the extent that the numbers of patient contacts by CRT/HTTs had to be reported and variances explained and the size of the AOT and EIP caseloads were centrally determined whatever the local demand and epidemiology identified as the need). However there is one area that has never received policy attention: rehabilitation and continuing care services.

Why is rehabilitation psychiatry unfashionable?

Rehabilitation and continuing care services have become marginalized in the discourse surrounding mental health care (Holloway, 2005). This is at odds with trends in general medical practice, where rehabilitative inputs are seen as increasingly important in reducing the burden of chronic disease. There are many reasons why this marginalization has occurred.

1. Health economies in England have disinvested in specialist community rehabilitation teams and units in order to implement the policy requirements outlined in the initial PIG document (DH, 2001). Some effective community rehabilitation teams have been rebadged as AOTs (Killaspy et al., 2005; Mountain et al., 2009). This has resulted in discharging their existing caseloads to the care of the local CMHT or merging two rather different client groups, one characterized primarily by difficulties of engagement and the other by severe social disability requiring intensive support to maintain independent living.

2. The “virtual asylum” that has replaced the traditional mental hospital has grown in a largely unplanned fashion (Poole, Ryan, & Pearsall, 2002), lying at least until recently below the radar of policy-makers and local service commissioners. Both health and social care placements have tended to be spot-purchased from independent sector providers, allowing local services to avoid the necessity to make strategic decisions surrounding the treatment and support of those individuals who require the highest levels of care. Huge sums of health service money have been spent in Out of Area Treatments (OATs) that have often not been thought out, may not be effectively monitored and may be of poor quality (Ryan et al.,2004; 2007): OATs cost the NHS £222m in 2005.

3. Inpatient facilities offering rehabilitation, which will generally seek purposefully to have extended lengths of stay, fit badly with a managerial ethos focused on admission-avoidance, ever-shortening length of stay in hospital and bed reductions. There are technical difficulties in defining appropriate care episodes for inpatient rehabilitation and Forensic spells, which will become an urgent necessity should mental health services move from their current block funding into the Payment by Results (actually payment by activity) regime that has funded mainstream health care in recent years (as is due to happen from 2010; Howitt, 2009).

4. More fundamentally, throughout the era of community care there has been a consistent tendency to ignore the disability and social exclusion of people with the most severe disorders. There has been a repeated assumption that advances in service provision and treatment technology have abolished poor social and clinical outcomes for people with psychotic illness. The NICE Schizophrenia Guideline (NICE, 2009) effectively stops when a rather simple menu of treatments and interventions, including Cognitive Behavior Therapy, clozapine and access to work rehabilitation, is exhausted. In fact the evidence suggests that some important outcomes, such as achieving employment, have got very much worse over the past 40 years (Marwaha & Johnson, 2004; Royal College of Psychiatrists, 2002). Failure to respond to treatment remains common amongst people with schizophrenia (see, for example, Robinson et al., 2004) and, even in the short term, a significant proportion of individuals presenting with psychosis fare very badly indeed (Craig et al., 2004).

5. Psychiatric rehabilitation, as a discipline, emerged within the traditional mental hospital. Having served, through the hospital reprovision programmes of the 1980s and 1990s, as the mechanism for closing the mental hospitals rehabilitation came to be seen as a redundant concept, irrelevant in the era of deinstitutionalization. There was a belief that after the successful hospital closure programme the issue of long term need had somehow been dealt with, since these needs were so obviously an iatrogenic phenomenon consequent on the effects of institutionalization.

6. The evidence base for the practices of Rehabilitation Psychiatry is seen to be limited, despite the publication in recent years of several major texts on the subject (Corrigan et al., 2008; Liberman, 2008; Pratt et al., 2007; Roberts et al., 2006).

7. The concept of psychiatric rehabilitation, which implies both long-term disability and long-term commitment from services to address this disability, is simply unfashionable. Historically psychiatric rehabilitation has been predicated on concepts of impairment, disability and handicap (Wing, 1993) that appear to fit badly with a contemporary discourse that embraces strengths, empowerment, involvement, social inclusion and, of course, that currently dominant paradigm, Recovery (Davidson, 2003; Roberts & Wolfson, 2004; Shepherd, Boardman, & Slade, 2008).

Why is rehabilitation psychiatry important?

There are two broad arguments for the continuing importance of rehabilitation psychiatry. One is humanistic: we know that despite advances that have occurred in mental health care over the past few decades major mental illnesses continue to be a cause of enormous distress and social disability for a significant proportion of patients, even where the new service models have been fully implemented.

In the face of this continuing disability and distress it makes sense to invest in rehabilitation services which aspire to “provide a whole system approach to recovery from mental ill health which maximizes an individual's quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and which leads to successful community living through appropriate support” (Killaspy et al., 2005). In practice people get referred to rehabilitation services once the NICE Guideline algorithms for treatment have been exhausted and other approaches have failed (Holloway, 2005). The high proportion of people receiving long-term care in OATs results in people with the most severe and complex problems being excluded from their local communities: quite literally out of sight, out of mind.

The second argument is pragmatic and relates to the scale of resources expended on rehabilitation and long-term care, which may come as a surprise to many. Although the trend in NHS psychiatric bed numbers has continued downwards throughout the past decade, to a new low for England of 23,000 occupied beds in 2008 (National Health Service Information Centre for Health and Social Care, 2009) there has been a massive expansion in certain kinds of NHS provision – medium secure beds and (a rather new concept) low secure beds – which largely lie within the domain of Forensic Psychiatry. In addition there is a large and growing independent sector offering a wide range of longer-term provision including secure care, rehabilitation and continuing care and some niche provision, for example for people with acquired brain injury and co-morbid autistic spectrum disorder. It is surprisingly difficult to be confident about inpatient psychiatric provision in England. Data sources converge on their being approximately 16,000 adult mental health beds, of which 10,000 are designated as acute or psychiatric intensive care, 1300 are low secure, 1700 medium secure and 3000 rehabilitation and continuing care (this excludes people in high secure hospitals) (Mental Health Strategies, 2008). To this need to be added independent sector beds (Commission for Healthcare Audit and Inspection, 2008). Roughly 3000 of these beds are purchased by the NHS to provide long term care, usually in settings that are many miles away from the patient's home and their families. Despite five decades of deinstitutionalization there are therefore almost as many working-age adults in long-stay beds as there are in acute facilities (which also contain a share of people who have become long stay, of course).

For some years the DH has commissioned a mapping exercise for mental health services in England, which has included a financial mapping of expenditure on health and social care. In 2008 some £5.5 bn was spent on adult mental health of which 52% went on budget headings that are providing some form of rehabilitative or long-term care (e.g., secure care, continuing care, housing and residential care, day care and assertive outreach) (Mental Health Strategies, 2008). This is not just an English phenomenon. Contemporary evidence suggests that throughout Western Europe, we are now entering an era of reinstitutionalization. The expansion in secure care has already been noted and as mental hospital beds have declined residential care has expanded to fill the gap (arguably along with the prison population) (Priebe et al., 2005). There are throughout Europe concerns over the quality of long-term care, both within and outside the hospital sector (Taylor et al., 2009).

Enabling recovery for people with complex mental health needs. A template for rehabilitation services

In an attempt to plug the policy gap that exists surrounding rehabilitation and complex care the Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists has recently published a report that sets out in brief a template for a comprehensive psychiatric rehabilitation and recovery service (Wolfson, Holloway, & Killaspy, 2009). Enabling recovery for people with complex needs was developed after a consultation exercise involving stakeholders that included users, carers, service commissioners and mental health professionals (Wolfson & Mountain, 2008). This template is deliberately not prescriptive in terms of the numbers of people who will require any particular kind of service in a catchment area. This is because the precise figures will depend on particular local factors relating to the epidemiology of severe mental disorder, local demography and social capital and to an extent on the history of the local services.

The starting point is a simple definition of a psychiatric rehabilitation service as a “recovery-oriented service for people with disabilities associated with longer-term mental health problems”. The aim is to promote personal recovery “whilst accepting and accounting for continuing difficulty and disability” (Roberts et al., 2006). The case is made for proper access to rehabilitation services across the UK in terms of a set of principles that the authors believe to be important: localization of care so that the service is close to its clients, their families and the wider service system; personalization of a local service tailored to the needs of individuals and capable of responding to a change in need; choice; social inclusion and addressing stigma; and promoting mental health and safety. The current culture of throughput that dominates in-patient care pathways can be too optimistic for some service users who become trapped in an aversive and unsafe cycle of revolving door admissions: long-term problems need a long-term strategic approach.

It must never be forgotten that services are not in themselves treatments – merely ways of delivering treatment and care. The main function of a rehabilitation service is to provide specialist treatment in a suitable setting that helps service users gain or regain the skills and confidence to achieve their own goals, be that living independently, getting a job or starting a family. Treatments and interventions will include optimal medication, psychosocial interventions, healthy living, attention to self care and complex living skills and are often but not invariably initiated in a therapeutic living environment.

The core components of a rehabilitation service will include a range of inpatient provision (defined as hospital beds able to care for compulsorily detained patients) that can offer care across a set of dimensions (e.g., site – on a campus or free-standing; expected length of admission; the functional abilities of residents; the capacity of the settings to manage risk; and the degree of specialization in terms of client group). A detailed typology of inpatient settings is provided. This is sufficiently complex to mean that not all dimensions can be provided at a truly local level and independent providers, regional and even national services will form part of the functional network.

The inpatient provision needs to be complemented by a multidisciplinary community rehabilitation team: this should be taking on a role of supporting people in placements and receiving complex packages of care in their homes as well as offering consultation to more generic community mental health teams. Much of the work will be in ensuring that their clients are encouraged to maximize their independence (something that traditionally residential care providers have been poor at). The community rehabilitation team will form part of a “family” of teams that support people with psychosis and other complex conditions: AOT; EIP; community forensic teams; and community mental health teams with a longer-term complex caseload.

The specialized rehabilitation services cannot operate in isolation and must work in partnership with other essential resources that are funded out of mental health and social care budgets, including a spectrum of locally available supported accommodation to meet local needs, agencies working to foster social inclusion, advocacy services and peer support. It goes without saying that the principles of partnership working extend to the patient/client and their carers: identifying goals that the person wants to attain is a core skill that the recover-oriented practitioner needs to have (Davidson, 2003).

Rehabilitation in an era of austerity

It may seem quixotic to be putting forward plans for service development in the coming era of austerity: rehabilitation services with their relatively slow pace of work and high costs per case have long been a target for cost-improvements, service reviews and downsizing (Mountain et al., 2009). In fact investment in ethical and effective rehabilitation programmes set up within a coherent framework that seeks to minimize dependency and maximize autonomy are a way, perhaps the only way, of managing mental health services through the economic downturn.

Declaration of interest: Dr Holloway is a former Chair of the Faculty of Rehabilitation and Social Psychiatry, Royal College of Psychiatrists and one of the authors of Enabling recovery for people with complex mental health needs. A template for rehabilitation services.