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Continuity of care and clinical outcomes in the community for people with severe mental illness

  • Alastair Macdonald (a1), Dimitrios Adamis (a2), Tom Craig (a3) and Robin Murray (a4)

Abstract

Background

High continuity of care is prized by users of mental health services and lauded in health policy. It is especially important in long-term conditions like schizophrenia. However, it is not routinely measured, and therefore not often evaluated when service reorganisations take place. In addition, the impact of continuity of care on clinical outcomes is unclear.

Aims

We set out to examine continuity of care in people with schizophrenia, and to relate this to demographic variables and clinical outcomes.

Method

Pseudoanonymised community data from 5552 individuals with schizophrenia presenting over 11 years were examined for changes in continuity of care using the numbers of community teams caring for them and the Modified Modified Continuity Index (MMCI). These and demographic variables were related to clinical outcomes measured with the Health of the Nation Outcome Scales (HoNOS). Data were analysed using generalised estimating equations and multivariate marginal models.

Results

There was a significant decline in MMCI and significant worsening of HoNOS total scores over 11 years. Higher (worse) HoNOS scores were significantly and independently related to older age, later years and both lower MMCI and more teams caring for the individual in each year. Most HoNOS scales contributed to the higher total scores.

Conclusions

There is evidence of declining continuity of care in this 11-year study of people with schizophrenia, and of an independent effect of this on worse clinical outcomes. We suggest that this is related to reorganisation of services.

Declaration of interest

None.

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Copyright

Corresponding author

Correspondence: Alastair Macdonald, BRC Nucleus, 16 de Crespigny Park, London SE5 8AF, UK. Email: alastair.macdonald@kcl.ac.uk

References

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Continuity of care and clinical outcomes in the community for people with severe mental illness

  • Alastair Macdonald (a1), Dimitrios Adamis (a2), Tom Craig (a3) and Robin Murray (a4)
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eLetters

Continuity of care: under attack

Anuradha Menon, Consultant Psychiatrist and Medical psychotherapist, RCPsych
17 June 2019

Dear Editor

I read with great interest the interpretations offered in this study. In trying to understand links between lack of continuity of care in the community and poor outcomes for patients with schizophrenia, the authors wonder whether a ‘disrespect of continuity’ manifest in repeated organizational change somehow translates into everyday clinical situations. For me, it is not a reassuring discovery that here is hard evidence for what we as clinicians have always suspected: that repeated organizational change seems driven neither by the best interests of the patient nor an economic imperative. The study beautifully highlights the important idea that what is really being attacked here is continuity.

But why attack continuity? Because of the obvious reason, of course- it is easier to attack it than to offer it. It is easier to create newer, smaller teams and splice the patient temporally into acute vs chronic/ early vs long term/ compliant vs non-complaint / risky vs not risky, rather than to bear that these are all aspects of the same patient and may need to stay in the same place as opposed to being scattered to the four winds!

The great British psychoanalyst Wilfrid Bion (1) writes about his struggles in trying to treat a psychotic patient who experiences him as obstructive and unhelpful. Bion is troubled; and takes this up seriously. He then explains that he discovered he had been trying to impose his own language on the patient, rather than trying to bear the patient’s language of projective identification. Bion’s realization led to a breakthrough. Thus, for coining one of the most popular terms in psychiatric services today- ‘containment’, we owe a debt to him (2). It goes without saying that the need for their anxieties and fears to be contained is something all patients bring to us, and as an example of a serious mental illness, psychosis requires skillful intervention on the part of services.

Schizophrenia (3) is an illness rubric which brings together people with many vulnerabilities, but all with a common theme: patients whose minds struggle to integrate conflicting feelings and thoughts safely, leaving themselves and others connected to them at an ever-present risk of alienation. The harmful effects of failings in continuity are well documented. (4) The chilling conclusions of this study also highlights declining outcomes linked to poor continuity, independent of service reorganization. It raises the obvious question: does ‘poor continuity’ also mean that staff become cut-off from the patient in a cut-off state of mind?

Returning to Bion, what changes his practice is his interest in and concern for his patient. If an organization, claiming to care, conveys ‘disrespect’ as the authors astutely point out, what state of mind does the clinician find themselves in? It is difficult to manage and treat seriously ill patients, and it cannot be done safely by staff who feel alienated all the time, from their own team and from the organization. (5). The authors suggest a more sober approach in the future towards casual change; I think there needs to also be a closer look at the nature and function of organizational attacks on good clinical care in the name of change.

References

1. Bion,W.R. (1958). On Arrogance. Int. J. Psycho-Anal., 39:144-146.

2. Bion, W.R.(1962) Learning from experience. London: Tavistock.

3. 3. L. Postmes, H.N. Sno, S. Goedhart, J. van der Stel, H.D. Heering, L. de Haan (2014) Schizophrenia as a self-disorder due to perceptual incoherence, Schizophrenia Research, Volume 152, Issue 1, Pp 41-50.

4. Sanatinia, R., Cowan, V., Barnicot, K., Zalewska, K., Shiers, D., Cooper, S., & Crawford, M. (2016). Loss of relational continuity of care in schizophrenia: Associations with patient satisfaction and quality of care. BJPsych Open, 2(5), 318-322.

5. Menon, A., Flannigan, C., Tacchi, M. and Johnston, J. (2015). Burnout-or heartburn? A psychoanalytic view on staff Burnout in the context of service transformation in a crisis service in Leeds. Psychoanal. Psychother., 29(4):330-342.

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Conflict of interest: None declared

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