The Core Study



Chisholm & Ford (2004) Transforming Mental Health Care 

Eligibility criteria - who is the service for?

Although the criteria should reflect the local situation, the starting point should be the criteria set

by the MH-PIG. These are based on evidence of effectiveness and cost-effectiveness.

The MH-PIG states that AO should be targeted at adults between the ages of 18 and approximately

65 who have one or more of the following:

• a severe and persistent mental disorder (e.g. schizophrenia, major affective disorders) associated with a high level of disability;

• a history of high inpatient or intensive home-based care (e.g. more than two admissions or more than six months' inpatient care in the past two years);

• difficulty in maintaining lasting and consenting contact with services;

• multiple and complex problems including one or more of the following:

• history of violence or persistent offending;

• significant risk of personal self-harm or neglect;

• poor response to previous treatment;

• dual diagnosis of substance misuse and serious mental illness;

• detention under the Mental Health Act (1983) on at least one occasion in the past two years;

• unstable accommodation or homelessness.

Most of the teams that we visited had attempted to adhere to these criteria, although in some cases they had modified them. From a sample of ten AOTs, most specified severe mental illness and difficulty with engagement as inclusion criteria, whereas only half specified high use of inpatient beds (see Figure 1). There was some evidence that eligibility criteria are adjusted according to the level of local need. For example, in an area of relatively low need there might be a lower threshold for acceptance into the service than in an area of high need. This runs the risk of providing people with an intensive service from which they do not derive great benefit.

Common exclusion criteria are:

• sole diagnosis of substance misuse;

• sole diagnosis of personality disorder.

Other teams do not exclude specific groups but deal with referrals on a case-by-case basis. Hemming et al. (2002) state that services should not be offered or declined on the basis of diagnostic category alone. For example, an individual with a personality disorder, with chaotic engagement and use of services, together with many complex social care problems, may well respond to the intensive support that AO can provide. The Norwich Intensive Support Team reports some success with people with borderline personality disorder, who make up around ten per cent of the caseload. (p.5-6)

Eligibility criteria - who is the service for?

The MH-PIG states that CR/home treatment should be targeted at adults aged 16-65 years old with severe mental illness (e.g. schizophrenia, manic depressive disorders) who are undergoing an acute crisis of such severity that, without the involvement of a CR/home treatment team, hospitalisation would be necessary. In every locality there should be the flexibility to decide to treat those who fall outside this age group, where appropriate.

The guidance further states that the service is not usually appropriate for individuals with:

• mild anxiety disorders;

• primary diagnosis of alcohol or other substance misuse;

• brain damage or other organic disorders, including dementia;

• learning disabilities;

• exclusive diagnosis of personality disorder;

• recent history of self-harm but not suffering from a psychotic illness or severe depressive illness;

• crisis related solely to relationship issues.

In practice, rather than focusing on people with severe mental illness, teams are concentrating on whether the alternative would be hospital admission. This means that thresholds for accepting people may be affected by the availability of other alternatives to hospital admission, including services more appropriate than hospital, to which people with less severe problems can be diverted. (p.22)