This paper describes the need for commissioners and service providers to consider the development of a whole-system approach to providing rehabilitation services for patients with complex psychosis, in the context of the current economic pressures and emergence of a competitive market in this area of mental health. The practical and organisational arrangements for the management of risk with such services are described, taking into account the varying provision of rehabilitation services across the UK and considering how these can be developed against the care clustering system and interfaces with other mental health services.

Aims and method To build on previous research findings by examining engagement and problematic behaviours of patients in 10 residential rehabilitation units. Two measures were completed on patients in community rehabilitation, longer-term complex care and high-dependency units (109 patients in total). Data were analysed and categorised into higher-engagement ratings across the domains of engagement and behaviour over the past 6 months and lifetime in terms of presence of the behaviour and likelihood of resulting harm.Results Data were available for 73% of patients. All aspects of engagement were consistently low for all units, with highest levels in community rehabilitation units. Levels of problematic behaviours were similar across all units. Socially inappropriate behaviours and failure to complete everyday activities were evident for over half of all patients and higher for lifetime prevalence. Verbal aggression was at significantly lower levels in community units. Lifetime behaviours likely to lead to harm were much more evident in high-dependency units.Clinical implications Despite some benefits of this type of care, patients continue to present challenges in engagement and problematic behaviours that require new approaches and a change in focus.

Aims and method To examine care pathways and characteristics of service users across a range of in-patient rehabilitation settings: community, long-term complex care and high-dependency rehabilitation.Results Significant differences were found for service users in the different units with respect to duration of stay, length of history, number of admissions, community team, physical health, social functioning, history of aggression and perceived risk if discharged.Clinical implications Community service provision may not adequately meet the needs of the most disabled and access to appropriate move-on facilities for rehabilitation in-patients is insufficient. Remedying this requires collaboration between policy makers, commissioners and clinicians to ensure access to a comprehensive range of services.