Abstract
Kevin Gournay and Graham Thornicroft, Health Services Research Department, Institute of Psychiatry, London, United Kingdom:
Rosen and Teesson's review [1], although intended primarily for an Australasian audience, will, we hope, also provide food for thought in the UK. They raise a variety of issues that have implications for international policy development, research and everyday clinical practice. However, we believe that Rosen and Teesson have not addressed one significant area: that of training.
In the UK and Australasia, millions of dollars are spent every year on training the workforce. However, there is little evidence regarding the efficacy of training ordinary clinical staff in routine clinical settings to deliver interventions which have been tested within research trials. To take one case, there is a great deal of evidence attesting the efficacy of cognitive behaviour therapy for specific neurotic conditions, based on trials which have employed highly skilled therapists working to rigorous manuals and with populations lacking comorbidity. However, there is little evidence of whether these interventions can be applied to staff working in ordinary clinical settings with the populations that one finds in local health services. With regard to assertive community treatment, the majority of studies, which feature in the literature, provide limited accounts of how much training and preparation staff receive. Recently, we provided comment on the UK 700 trial [2] and suggested that the equivocal outcomes could be explained by the fact that the staff in both conditions received a very small amount of training in similar interventions. It is worth drawing attention to the fact that the study, conducted a decade ago in the UK [3], showed that community psychiatric nurses working in case management teams were no more effective than community psychiatric nurses working in generic ways. The results of this study were surely suggestive that merely reconfiguring services without improving staff skills is unlikely to lead to any real benefit. In the UK we now have training programmes, largely targeted towards community psychiatric nurses, which provide fairly comprehensive training in assertive community treatment methods. Within our programme at the Institute of Psychiatry, we also provide additional skills in interventions such as medication management, dealing with the dually diagnosed, using psychological methods of treatment and providing family interventions. We know that these training models are now attracting interest from colleagues in Australia and it thus seems timely for us to make the point about the importance of evaluating such training. Recently, this message has been accepted and we have now had two completed trials of training of the workforce which have involved sufficient numbers of case managers and patients to be able to draw firm conclusions about efficacy of training (papers on these outcomes are currently in preparation). In relation to the Rosen and Teesson paper, to overlook the skills and training needs of the workforce in gathering the information required to decide whether intervention is successful or not, would be a grave omission.