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Over the past ten years, the National Health Service in England has introduced home treatment teams throughout the country. Despite this, and the fact that England now has the fourth lowest number of beds per capita in Europe, no mental health service has been able to dispense with acute admission beds altogether. One unintended consequence of new investment in community alternatives to inpatient care is that the threshold for admission has risen and acute wards now accommodate a patient group that is more severe with regard to levels of disturbance and social disadvantage. This has compounded the challenge of providing high quality inpatient care and repeated national surveys suggest that acute admission wards are the weakest link in the English mental healthcare system. In response to this, the Royal College of Psychiatrists has established an accreditation scheme for acute admission wards. Only 22 of the first 132 wards to have completed the review process so far are considered to be excellent. Although 59 wards (45% of the total) failed to meet one or more essential standard, 43 of these were able to rectify the problem.
The Royal Colleges and other professional bodies could use their clinical expertise, authority and influence with clinicians to improve the quality of regulation of healthcare services. At present, their contribution to regulation in England is ad hoc and informal. Better engagement could increase the impact that professional bodies have on patient care and create a new role for them as arbiters of quality in the organisation and delivery of care. the requirement for healthcare provider organisations to register with the Care Quality Commission from April 2010 and the National Health Service Next Stage Review have created an opportunity for closer collaboration. However, there are problems that must be overcome. These include the ownership of information about the quality of care and the uses to which this is put. It would be self-defeating if closer working with the regulator undermined the trust that clinicians have in quality improvement work led by the professional bodies.
Mental illness is now the leading cause of both sickness absence and
incapacity benefits in most high-income countries. The rising economic and
social costs make health and work an increasing priority for policy makers.
We discuss the findings from Dame Carol Black's recent review of the health
of Britain's working-age population and examine how her recommendations may
impact and challenge mental health services.
Expert clinical judgement combines technical proficiency with humanistic qualities.
To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback.
Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients.
Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbach's alpha > 0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Eρ2) of 0.75.
Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.
Clinical guidelines recommend the routine use of a single antipsychotic
drug in a standard dose, but prescriptions for high-dose and combined
antipsychotics are common in clinical practice.
To evaluate the effectiveness of a quality improvement programme in
reducing the prevalence of high-dose and combined antipsychotic
prescribing in acute adult in-patient wards in the UK.
Baseline audit was followed by feedback of benchmarked data and delivery
of a range of bespoke change interventions, and then by a further audit 1
Thirty-two services participated, submitting data for 3942 patients at
baseline and 3271 patients at the 1-year audit. There was little change
in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined
antipsychotic prescribing (baseline 43%; re-audit 39%). As required
(‘p.r.n.’) prescriptions were the principal cause of both high-dose and
combined antipsychotic prescribing on both occasions.
The quality improvement programme did not have a demonstrable impact on
prescribing practice in the majority of services. Future efforts to align
practice with clinical guidelines need to specifically target the culture
and practice of p.r.n. prescribing.
Workplace-based assessment (WPBA) is becoming a key component of post-graduate medical training in several countries. The various methods of WPBA include: the long case; multisource feedback (MSF); Mini-Clinical Examination (mini-CEX); Direct Observation of Procedural Skills (DOPS); case-based discussion (CbD); and journal club presentation. For each assessment method, we define what the approach practically involves, then consider the key messages and research evidence from the literature regarding their reliability, validity and general usefulness.
The lead consultants of all adolescent in-patient psychiatric units in England and Wales were surveyed in 2000 and again in 2005, to determine whether they could admit young people in an emergency.
In 2000, 51 of 64, and in 2005, 70 of 79 units responded. Although the number of units with dedicated ‘emergency admission beds’ had increased from 6 to 16, 34% of the total could never admit as an emergency in 2005 and 44% could never admit out of hours. The consultants estimated that, in 2005, they turned away 72% of referrals for emergency admission. Although 87% of consultants agreed that there should be emergency access to specialist adolescent psychiatric beds, concern was expressed that services are not configured to accept emergency admissions.
This problem is unlikely to be resolved by requiring units to accept both emergency and planned admissions. These groups have very different needs. Coherent and unified commissioning is needed to achieve equity of access to emergency beds, along with separate planned admission units and a range of alternative emergency services.
In 1999, child and adolescent mental health (CAMH) in-patient provision was unevenly distributed across England. A repeat of a1999 bed count survey was conducted in 2006 to determine whether change had occurred in response to government policy.
Total bed numbers in England were found to have increased by 284; 69% of the increase is due to the independent sector, whose market share has risen from 25% in 1999 to 36% in 2006. Regions with the highest number of beds in 1999 have increased bed numbers more than areas with the lowest number of beds in1999 (8.3 v. 3.6 beds per million population). In units that admit only children under the age of 14, there has been a 30% reduction in beds available (123 to 86).
Inequity in provision of CAMH inpatient services has increased despite government policy to the contrary. We speculate that this might be partly due to fragmented and local commissioning, and the effects of market forces operating as a result of increasing privatisation.
A good therapeutic alliance between mental health professionals and patients with psychosis can enhance adherence to medication regimens and improve clinical outcome. This article explores how the therapeutic alliance might be developed with respect to decisions to prescribe antipsychotic medication. It does this by presenting the implications for practice that arise from a recent qualitative interview study with consultant psychiatrists. We consider strategies for strengthening the therapeutic alliance, occasions when it might be appropriate to suspend shared decision-making temporarily, techniques used to enable discussion of symptoms and side-effects, and how issues of adherence are uncovered and addressed. Psychiatrists already possess considerable skills in these areas. The dissemination of these to colleagues forms an important opportunity for CPD.
We audited 184 psychiatric wards against clinical practice guidelines for the management of violence. Staff and service users completed anonymous questionnaires. Environmental inspections were performed by two teams.
There were 4460 questionnaires returned. Nurses (78%) were significantly more likely to report the experience of violence than service users (37%). Drugs were reported by 72% of nurses and alcohol by 61% as causing problems. Other standards frequently not met included staffing levels, training, provision of activities, ward design and ambience.
Specific issues are identified that must be addressed by national and local action. A baseline is set against which the impact of this action can be judged. Priorities must include tackling drug and alcohol use in psychiatric wards.
With the development of community care, the number of National Health Service psychiatric beds in England has been reduced to between one-fifth and one-quarter of those provided in the mid-1950s. Psychiatric bed numbers are close to the irreducible minimum if they have not already reached it. The problems facing today's acute psychiatric admission wards include: poor design, maintenance and ambience; a lack of therapeutic and leisure activities for patients leading to inactivity and boredom; frequent incidents of aggression and low-level violence and problems with staffing. It is suggested that there are a number of underlying causes: First, there has been failure to plan inpatient services, or to define their role, as attention has focused on new developments in community care. Second, the reduction in bed numbers has led to a change in the casemix of inpatients with a concentration on admission wards of a more challenging group of patients. Third, admission ward environments are permeable to the adverse effects of local street life, including drug taking. After years of neglect, acute inpatient psychiatric services in England are now high on the UK Government agenda. The paper lists a number of national initiatives designed to improve their quality and safety. A recent review of qualitative research suggests that acute psychiatric wards in other countries face similar problems to those reported in England. It is suggested that there might be a need for joint action which might take the form either of international research about acute inpatient care or the development of international standards and a common quality improvement system.
It is difficult to disagree with Chilvers & Clark that, overall, recent work to bring a more systematic approach to the organisation of mental health research in England has been a good thing. It is also necessary if mental health is to compete for research funding with other branches of healthcare. However, recent changes in the research system have not all been positive and there is a danger that the process of centralisation, which is inherent to the model they describe, will have unintended adverse consequences.
A new fast-track assessment (FTA) clinic was established by a community mental health team (CHMT) in SouthEast London. Previously, those who responded to an opt-in letter were offered an appointment with a duty worker or at an out-patient clinic. In the new system, all routine referrals are booked into a single fortnightly clinic staffed by two doctors and two to three other CMHT staff with post-clinic discussion of all cases (2–6 min per case). A total of 100 consecutive referrals before the introduction of the FTA clinic were compared with 100 following the introduction.
The interval between receipt of referral to first appointment offered was reduced from 55 to 18 days and to actual assessment from 71 to 26 days. Eighty-four referrals to the FTA were offered a first appointment date that was within 21 days of receipt of a referral, compared with four before the introduction of the FTA. These differences were highly significant. There was a trend for more patients to attend for assessment after the FTA clinic was introduced (79 compared with 68).
This simple re-engineering of the assessment process within a CMHT has achieved its objective of reducing waiting times to first assessment appointment. It also appears to have reduced the number of referrals that do not result in an assessment.
The Electroconvulsive Therapy Accreditation Service (ECTAS) was launched in May 2003. Its purpose is to assure and improve the quality of the administration of electroconvulsive therapy. Participating clinics undergo a process of self- and peer-review. The Royal College of Psychiatrists' Court of Electors will award an accreditation rating to clinics that meet essential standards; this accreditation will last for 3 years, subject to annual self-review. Participating clinics will also receive feedback and advice about local strengths and areas for improvement. The accreditation service is endorsed by the Royal College of Nursing and the Royal College of Anaesthetists and has the support of the Healthcare Commission in relation to English services. Clinics that participate in ECTAS will be listed on the College website, with the accreditation rating awarded.
Little is known about the current state of provision of child and adolescent mental health service in-patient units in the UK.
To describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales.
Following identification of units, data were collected by a postal general survey with telephone follow-up.
Eighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions.
A national approach is needed to the planning and commissioning of this specialist service.
This study aimed to examine in-patient child and adolescent consultant psychiatrists' knowledge of and attitude to the Mental Health Act 1983 (MHA), the Children Act 1989 and issues around consent. A questionnaire form was sent to all in-patient consultants in England and Wales.
The consultants who responded (n=51, 67%) reported a desire for more training in legal issues. Knowledge of the MHA was better than for the Children Act 1989; those who used the MHA at least once every 6 months scored more correct answers to questions about the MHA than did those who used it less frequently or never.
Although the study indicates specific gaps in knowledge, the main message is that training should consider the legal framework as a whole, with an emphasis on practical issues about its application in the in-patient setting.