Inclusion criteria

Inclusion criteria are detailed in Box 11. Only empirical studies were included. Objective 1 references were restricted to the UK. For objective 2, literature had to measure at least one service user, staff or process outcome, and compare different CMHTOP approaches. The last of these criteria excluded studies which compared the work of CMHTsOP with other service models (e.g. single-discipline nurse interventions).

BOX 11

Inclusion and exclusion criteria UK only

Two reviewers undertook the data extraction process using a standardised electronic form. The first 10 were completed together to ensure reliability. Data were extracted on team attributes indicative of structures and processes and, where available, outcomes and relevant findings (see Appendix 18). A full list of data items can be found in Appendix 19. Studies were subjected to a three-stage screening process (Figure 10). Retained references were read in full by one of two reviewers with the final decision on inclusion being made via discussion between them. The main reasons for excluding references can be found in Appendix 20. The extent to which publications provided detailed and relevant information about how teams were organised, as well as evaluations of their effectiveness, were captured in a bespoke centrality tool (see Appendices 21 and 22). An existing quality appraisal tool,¹⁸⁶ covering sampling, measurement, analysis and the interpretation of results, was used to assess the quality of studies addressing objective 2 (see Appendix 23).

FIGURE 10

Study selection process. Adapted from figure 2, Abendstern M, Harrington V, Brand C, Tucker S, Wilberforce M, Challis D. Variations in structure, processes and outcomes of community mental health teams for older people: a systematic review of the literature. (more...)

The review follows a narrative synthesis style^84,187 with findings divided into key areas of the research questions relating to structure, process and outcomes, as well as service user characteristics. Data from individual teams identified within the studies were compared to explore characteristics across teams. Where possible, results were compared with national level data reported in other studies. Consideration was given to the heterogeneous nature of the literature in assessing possible bias when synthesising results.

Details of included and excluded literature

Forty-five studies were included in the review: just over 1% of those initially identified. Most references were excluded from objective 1 because they were not UK based and from objective 2 because they did not relate to older people or did not contain comparisons to determine the impact of a CMHTOP process on user outcomes.

Included studies were heterogeneous in relation to both publication type and the nature of what was reported with a shift visible in the latter over time. Pre-2000 publications, for example, were predominantly reports of local teams with a focus on their aims, philosophy and key features. In comparison, almost half (10 of 24) of post-2000 publications were large-scale surveys or audits which documented and compared the range and variation of provision across the country, implicitly or explicitly determining overall progress towards pre-determined indicators of good practice. Over 75% of studies had a local focus, covering 57 teams. Ten publications^25,188–196 related to just three of these teams which can be regarded as ‘exemplars’: early well-resourced teams, established by research active consultants, wanting to test new service delivery approaches. Local studies offered a level of detail not available in the broader national/regional literature. Depth and breadth of reporting overall was highly variable whereas data were geographically skewed towards London. A description of the studies included in objective 1 alone can be found in Table 37; those included in both objective 1 and objective 2 in Table 38; and the study only included in objective 2 in Table 39.

TABLE 37

Description of included studies (objective 1 only)

TABLE 38

Description of included studies (objective 1 and objective 2)

TABLE 39

Description of included studies (objective 2 only)

Findings/descriptive synthesis

Team membership was available from 30 studies. Less than one-third (n = 13) of teams described contained staff from each of the five disciplines commonly recommended, although there was some evidence this was increasing over time.^{47,48,73,209,210} The nature of the work of core team members was considered by 11 publications, in particular, how profession-specific or blurred these roles were. A range of practices were reported, ranging from strict adherence to discrete professional roles to far greater flexibility in the range of responsibilities across team members. Role blurring was particularly indicated where assessment and care planning was open to community psychiatric nurses (CPNs), occupational therapists (OTs) and social services personnel, and where health professionals could commission social care services.

Ten papers reported on team management, with the most common arrangements being (a) one overall manager, accountable for all core team members, irrespective of discipline;⁴⁸ (b) two team managers; one for health staff and one for social care staff;^179,219 and (c) those without a formal team manager²¹⁷ (cited only in the pre-2000 literature). Three national surveys suggested an increase in joint management arrangements (type a) over time, from just under one-third to 47%.^50,163,179 The changing role of consultants within teams is considered by 11 studies.^{19,46–48,180,190,202–204,209,210} They suggested a shift from leadership to membership over time, ranging from 40% at the turn of the century to 93% more recently^46,47,73 reflecting policy guidance.¹¹

Consultant engagement with teams through support and supervision and involvement in team meetings was a second aspect of their role considered in the literature which indicated a variety of input, although attendance at multidisciplinary meetings was found to be the norm. Finally, the question of whether some of the work traditionally undertaken by consultants could be competently done by others was considered by a number of articles, particularly those reporting on teams in Lewisham and Cambridge.^{48,188,203,204,209} This related particularly to initial assessments, one of the few aspects to have been evaluated, and, as such, is considered further in the next section.

Other aspects of assessment were its setting, with general agreement that domiciliary assessments were vital to gathering accurate information on people’s needs;^{19,46,47,179,189,190,199,217} and the extent of multidisciplinary involvement.^{19,46,47,179,208,218} National reports suggested that such practice occurred in only a minority of teams, varied greatly, and most frequently involved doctors and nurses only.^46,47,179 It was harder to draw conclusions from local team data which did not always provide such information. Only two local studies reported that initial assessments were conducted by two or more professionals,^208,218 in one case a social worker and a nurse.²⁰⁸

A range of practices in referral and access arrangements were identified. Although the majority described open referral systems, half represented exemplar teams, whereas the most recent publication,²⁰⁵ claimed that most UK CMHTsOP only accepted referrals from doctors. Evidence on how teams were accessed, in particular the prevalence of a SPA, proved inconclusive.^{19,179,197,211} Reference to the importance of sharing information was common in the literature. However, reports of the type of record system used, and whether or not shared, were rare and only present in the post 2000 literature.^{46,47,50,73,197,199} Electronic systems were the exception.⁷³ Nowhere were information systems fully compatible between health and social care agencies. A recent study found that social workers within CMHTs often had to enter data twice.⁵⁰

Core staff location was reported by seven papers^{43,47,197,211,216,217,219} with a minority reporting colocation of all core members. Joint funding was reported in seven papers; either in the form of pooled budgets for individual care packages, or whether or not health and social care staff had easy access to each others’ services.^{46,48,50,163,210,216,217} Pooled budgets were rare in 2000⁴⁶ whereas ‘some’ instances were reported by 2009.⁴⁶

Evidence of effectiveness

Seven papers^{43,47,197,211,216,217,219} reported outcome data that compared different CMHTOP approaches. All were local studies, four^{188,190–192} referring to exemplar teams. Three examined referral/access arrangements, three others considered assessment or immediate post-assessment issues, and one focused on longer term support. Measures were largely process related, for example the number, appropriateness and timeliness of referrals or the content and accuracy of assessments, diagnoses and post-assessment decisions. Only one study considered outcomes from the perspective of the service user,¹⁷⁹ measuring QoL following intensive care management. None considered consequences for staff.

Three papers described work aiming to widen access for new referrals to CMHTsOP.^191,205,221 Two^191,205 were set in the UK. The third represented the only study outside the UK in this review.²²¹ The earliest¹⁹¹ assessed whether or not open-access systems improved the accessibility of the team to people who might not otherwise have been referred to them without leading to inappropriate referrals. It concluded that such concerns were not realised and that had there only been a traditional referral route available, many people would have faced delays and some may not have been referred at all. It did not, however, consider how operating the two systems simultaneously might change how they worked. The second paper considered the characteristics of social services referrals to a CMHTOP 1 year after the introduction of an ‘open’ referral system as well as the total number of referrals with those of the previous year. They found that 90% of referrals from social workers (n = 36) had a mental illness, demonstrating that social services referred appropriately. No increase in the overall number of referrals following the introduction of the new system was found.²⁰⁵ The non-UK study compared the numbers and characteristics of new referrals, following the introduction of a triage system; finding this led to a large increase in referrals although only a minority appeared to need specialist mental health input. These articles provide conflicting evidence on whether systems introduced to widen access result in more inappropriate referrals.

In relation to assessment, one article evaluated the introduction of a new structured tool, comparing the quality of recording and communication with GPs before and after its introduction. Significant improvements were reported in the collection of medical and social history, and documentation of clinical information from GPs. Two other papers were closely linked, relating to the same service (Lewisham) and the same sample of service users. The first compared the psychiatric diagnoses of 100 service users made by MDT members against an assessment and diagnosis undertaken by research psychiatrists, revealing a high degree of diagnostic accuracy by CMHT members and a very high level of agreement between the team and research psychiatrist assessments.¹⁹⁰ Length of community experience was more significant than the profession of the assessor. The second considered post-assessment decision-making and reported a high degree of agreement in relation to antidepressant use; satisfactory agreement regarding the use of neuroleptic drugs; but less agreement with regard to psychological interventions.¹⁸⁸ The authors concluded that this did not suggest that assessments by non-doctors resulted in either ‘substantial under-use or inappropriate use of psychiatric interventions’ (p. 80). A possible weakness of these two studies, acknowledged by the authors, was that where psychiatric assessment and diagnosis was conducted by a non-clinician, recognised medical classifications could not be used. Non-medical staff used broad classifications which were not comparable with other studies of diagnoses, limiting the comparability of these data. Use of research psychiatrists as proxies for real decision makers, also potentially limited generalisability.^188,190

One paper evaluated the impact of intensive care management (involving a designated case manager with a flexible budget) for older people with dementia and their carers in comparison with those provided with ‘usual’ support from the CMHT.¹⁹² Findings after 2 years revealed that, at an increased cost to social care budgets, just over half of those receiving the intensive service remained at home compared with 35% of the control group.

Table 40 summarises the studies on team attributes and evidence of their effectiveness, listing potential design features of a CMHTOP.

TABLE 40

Towards an evidence based model of effective CMHTsOP design: review findings