Professor Burns rightly reminds us that, unlike specialist teams, community mental health teams (CMHTs) have never had strong advocates and have not been actively researched. His point about the wide variation in CMHT outcomes as comparators in trials illustrates this: lacking a clear role, responsibilities and remit, CMHTs have struggled to delineate what they do well, shed what they do not, and ensure that their staff keep up with the changing evidence base for therapeutic interventions. Specialist teams do not do anything special which is out of CMHT reach. Specialist teams are simply better placed to engage patients and deliver high-quality interventions because of the specialist focus that allows clinicians to develop and hone specialist skills. This is the history of improvements in medicine, where specialisation is both an outcome of academic advance and a vehicle for service improvement. It is in the nature of generic teams to deliver generic care; there is no evidence that pouring extra resources into CMHTs would turn them into specialist equivalents.
The latest National Institute for Health and Clinical Excellence (NICE) guidelines on schizophrenia reviewed the clinical and cost-effectiveness of CMHTs and concluded:
‘Despite the fact that CMHTs remain the mainstay of community mental healthcare, there is surprisingly little evidence to show that they are an effective way of organising services. As such, evidence for or against the effectiveness of CMHTs in the management of schizophrenia is insufficient to make any evidence-based recommendations’ (p. 336). 1
The health economic review adds:
‘The available evidence on health economics is unclear. The non-significant differences between standard care and CMHTs, and between pre-intervention period and intervention period, suggest that CMHTs provide no real cost savings or extra costs’ (p. 337). 1
Reluctant as I am to disagree with an esteemed colleague, there is little evidence to support the superiority of CMHTs over specialised teams.
Our understanding of mental disorders and the complexity of treatment has moved on considerably from the time when CMHTs were originally established. In this rapidly changing world, it is difficult to see how generic teams can deliver all the recommendations of the 22 NICE guidelines in mental health. The ‘conflict’ between generalism and specialism is not restricted to psychiatry, it is writ large in the historical development of 20th-century medicine. Reference Huddle, Centor and Heudebert2 In the 21st century, CMHTs need to evolve and innovate and carve out a niche where the generalist can flourish, either in primary care or in high-quality, rapid assessment teams that complement specialist services, rather than compete with them.
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