The history of the care programme approach in England: where did it go wrong?

Background: The Care Programme Approach (CPA) was introduced in England in 1991 as a form of case management to improve community care for people with severe mental illness. It helped services maintain contact with users but failed to provide comprehensive, co-ordinated care and is associated with increased bed use Aim: To describe and evaluate the introduction, implementation and development of the CPA and identify reasons for its relative failure. Method: A critical review of key events, audits, reports, research and policies that shaped the CPA. Results: Reasons for the relative failure of the CPA included the socio-political and financial context, clinicians' resistance to political and managerial interference, and the bureaucratic, complex and time-consuming nature of the policy. This reduced face-to-face contact whilst contributing to an emergent 'blame culture' and defensive psychiatric practice. The CPA also presumed levels of community resources and interprofessional teamwork that were frequently absent Conclusions: The CPA was a flawed policy introduced insensitively into an inhospitable environment. It was destined to fail and after more than a decade remains ineffectively implemented. Changes introduced recently may have contradictory influences on the ability of services to provide effective case management but remain to be evaluated.