Alternative Settings: Unintended Consequences: In Reply

In Reply: Hubbeling and Chang raise important issues and highlight the fact that changes in one area of mental health care have an impact on other parts of the system. The mental health care system provides a continuum of services of treatment and support. Ideally, clients are able to move between levels of service according to changes in their symptoms and well-being; the aim is to provide care in the least restrictive environment. For example, both Australia (1) and the United Kingdom (2) have such a system.

The flow-on effects of changes in available services and client movements within a system are difficult to determine. Doing so requires a systemwide focus rather than evaluation of unique service types within a system, which was the type of review we undertook. Collateral effects of changes in provision of mental health services were not reported in any of the research articles that were included in our systematic review.

We acknowledge that a skilled workforce is essential to the effectiveness of mental health care and that staff movements within the continuum of services—or staff movements out of the mental health care system—will have an impact on the quality of services provided.