Various models have evolved in the face of these demands. These are mostly based on variations of ‘case management’, in which mental health workers take responsibility for the planning, co-ordination, review, and to varying extents the delivery of care ‘packages’ to individual patients. In practise, most services organized on these principles have developed eclectic and pragmatic ways of working, which have proved at least as effective as more hospital-based models of clinical care10. The formal models differ in their specifics, for example in the precise role of the keyworker, caseload, organizational philosophy, and specialist functions, such as assertive outreach and crisis intervention. The benefit of one approach over any other remains a matter of debate (see for example reference 11). In any event, such organizational models should not be confused with treatments, and their clinical impact on specific symptoms is likely to be indirect and less pronounced than their effect on more general social variables such as housing stability. Comparisons between different approaches to the organization of community psychiatric care are made more difficult by wide variations internationally in clinical practice and in resources, and there are wide international differences in the extent to which community care is regarded as a successful policy (Figure 5.8)14.

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