Như vậy, trong các lĩnh vực ép cứng, chẳng hạn như nội tâm London, quá trình giảm giường cấp và thay thế các lựa chọn thay thế dựa vào cộng đồng có thể được thực hiện như xa như là khả thi, và có lẽ hơn nữa. Tuy nhiên, có là một đối số truy cập. CMHTs ít có khả năng thăm các bệnh nhân bị bệnh cấp tính | 142 PSYCHIATRY IN SOCIETY results in an inefficient and profligate service with heavy use made of acute beds outside the catchment area a resulting breakdown in continuity of care and a further rise in admission rates. Thus in hard-pressed areas such as inner London the process of reducing acute beds and substituting community-based alternatives may now have been taken as far as is feasible and perhaps further. However there is a counter-argument. Few CMHTs have the capacity to visit acutely ill patients at home on a daily basis 58 . It seems inherently unlikely that community-based care of this low intensity is an adequate substitute for the acute ward for many patients. However more focused and intensive community-based service could effectively take on this emergency function at least for some acutely ill people. Certainly there are good reasons for seeking alternatives to the acute ward. In addition to being an expensive form of service inpatient care suffers from widespread unpopularity with service users 59 and inner city psychiatric wards are characterised by very high levels of compulsory detention and of violent incidents . 56 . Apart from a few small-scale descriptions of crisis houses most of the research on substitutes for inpatient care has focused on home treatment programmes. In these specialist teams generally available for 24 hours or at least over extended hours assess and manage acutely ill patients in their homes. Visits may even be made more than once a day and team professionals are accessible by telephone to patients and their carers. Pioneering examples of this service model were established and evaluated by Stein and Test 32 in Madison Wisconsin USA and by Hoult el al. 37 in Australia it is interesting that these services have been used as models for both ACT and crisis intervention . The results were promising with evidence of effective substitution of community for hospital-based care for at least some patients an overall reduction in
