The PRiSM papers (Reference Becker, Holloway and McCroneBecker et al, 1998) and subsequent editorial (Reference Marshall, Bond and SteinMarshall et al, 1999) on assertive community treatment (ACT) highlight the quest by mental health professionals to provide appropriate and effective services to vulnerable individuals with severe mental illness. The design, implementation and model fidelity of ACT have been a widely researched aspect of community mental health care (Reference Mueser, Bond and DrakeMueser et al, 1998).

Interestingly, the studies and editorials animatedly examine research carried out between 1992 and 1994, the inception and teething stage of the Nunhead psychiatric assertive community care team (PACT). Crucially, this period was characterised by staff and client recruitment, site relocation, and resource allocation while imbibing the tenets of ACT. Designers of ACT fidelity measures (Reference McGrew, Bond and DietzenMcGrew et al, 1994) sound a note of caution that “implementation and fidelity are developmental” and this “natural temporal evolution in service” if not accounted for in research, can be a potential source of unexplained error.

The Nunhead PACT team has shown considerable development over the 1990s derived from tailoring a service to suit its own unique client population. Community mental health services are not identical as they cover unique geographical and socio-economic areas, with diverse ethnic, demographic and psychopathological characteristics. However, numerous studies of ACT facilities (mainly outside the UK) stress that model fidelity is fundamental to effective ACT service provision (Reference Teague, Bond and DrakeTeague et al, 1998).

We present here an updated description of the Nunhead PACT team. The multi-cultural client population (55% male, 45% female), with a mean age of 46 years, has a predominant diagnosis of schizophrenia (80%) and the remainder affective psychoses. With a mean duration of illness of 17 years, characterised by multiple hospitalisations, admissions are currently one-sixth pre-ACT intervention levels.

The team comprises staff with diverse backgrounds namely psychiatrists, clinical psychologist, psychiatric nurses, social workers, a community forensic psychiatric nurse, an occupational therapist and support workers, with a staff (keyworker) : client ratio of 1 : 12. Furthermore, regular input from a benefits/welfare adviser, chaplain and community pharmacist has proven beneficial to clients and their carers. Dual diagnosis/substance misuse expertise is also being developed. The mean core staff duration in the team is 4.5 years. Patient input through client-led weekly community meetings and newsletters has been found to be invaluable. A variety of work rehabilitation activities (e.g. computer skills, tool workshop, photography and college courses) are being taken up by clients. Multi-sectoral collaboration with voluntary and statutory housing befriending, and ethnic and religious agencies has also facilitated engaging clients in the community. With its current resource and near total programme fidelity, is it likely that the service is actually more advanced than many other ACT services? What intervals and outcome measures reliably assess ACT interventions? In our opinion, two years is a relatively short period to adequately engage, treat and initiate significant rehabilitation of a person with severe mental illness. We owe it to our clients to enhance their quality of life by sustaining the merits of PACT into the 21st century. Prospective longitudinal research may still identify elements crucial to advancing lessons of the past to the future.