Psychological Medicine

Original Article

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough

P.  HARRISON-READ  a1 c1, B.  LUCAS  a1, P.  TYRER  a1, J.  RAY  a1, K.  SHIPLEY  a1, S.  SIMMONDS  a1, M.  KNAPP  a1, A.  LOWIN  a1, A.  PATEL  a1 and M.  HICKMAN  a1
a1 From Park Royal Centre for Mental Health, Department of Public Mental Health and Department of Social Science and Medicine, Imperial College School of Medicine and Centre for the Economics of Mental Health, London; and Mead House, Hayes End, Middlesex


Background. Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group.

Methods. The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6·5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years.

Results. Despite a 2·4 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups.

Conclusions. Providing additional intensive community – focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.

c1 Address for correspondence: Dr Phil Harrison-Read, Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG.