"Reasonable adjustments" under the UK's Equality Act 2010: An enquiry into the care and treatment to patients with intellectual disabilities in acute hospital settings.

OBJECTIVES: To understand the views of qualified medical practitioners regarding "reasonable adjustments" and the quality of the care and treatment provided to adults with intellectual disabilities when admitted to acute hospitals as inpatients. METHODS: Semi-structured interviews took place with 14 medical practitioners, seven from each of two acute hospitals, with a thematic analysis of the resulting data. RESULTS: All 14 medical practitioners reported problems in the diagnosis and treatment of patients with intellectual disabilities. Most participants attributed these difficulties to communication problems and/or behaviours that, in the context of a hospital ward, were non-conforming. However, a minority reported that, because they were likely to have multiple comorbid health conditions, patients with intellectual disabilities were more complex. In addition, half of all these respondents reported making little use of "reasonable adjustments" introduced to improve the quality of the care received by this group of patients. CONCLUSIONS: Medical practitioners should make better use of the "reasonable adjustments" introduced in the UK to address inequities in care and treatment received by patients with intellectual disabilities. However, training should also focus on the biomedical complexities often presented by these men and women.

Mortality of People with Intellectual Disabilities in England: A Comparison of Data from Existing Sources.

BACKGROUND: At present, there is limited statistical information about mortality of people with intellectual disabilities in England. This study explores the data that are currently available. MATERIALS AND METHODS: Four recent sources of data about mortality of people with intellectual disabilities in England are reviewed: the Confidential Inquiry into Premature Deaths of People with intellectual disabilities (CIPOLD); the 2013 Joint Health and Social Care Intellectual Disability Self-assessment Exercise; local registers of people with intellectual disability; and analysis of Cause of Death certificates. RESULTS: Available data confirm that people with intellectual disability have a shorter lifespan and increased risk of early death when compared with the general population. The standardized mortality rate for people with intellectual disabilities is approximately twice that of the general population in England, with little indication of any reduction in this over time. CONCLUSIONS: Comprehensive data about mortality of people with intellectual disabilities that take account of the age and sex distribution of the population are currently lacking in England. Existing data suggest persistent inequalities between people with intellectual disabilities and the general population. There is an urgent need for better monitoring mechanisms and actions to address these.

Numbers and policy in care for people with intellectual disability in the United Kingdom.

BACKGROUND: Statements or commitments making use of numbers have an important place in government policy. They appear at all stages of the policy process: campaigning, formulation, monitoring and evaluation. Many types of source are involved including research studies, national survey information, routine operational data collections and special systems devised to monitor particular initiatives. METHOD: The paper presents examples of policy uses of numerical evidence, and some sources of data that have been used to support them in the field of care for people with intellectual developmental disability in England. CONCLUSIONS: Different levels of precision or coverage are required at different stages of the process. Different types of numerical data are appropriate at the various stages of the policy process.

Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study.

BACKGROUND: People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. METHODS: We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. FINDINGS: We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47-2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10-8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5-49·9, p<0·0001), and medication reviews (2·23, 1·68-2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41-26·9, p=0·0156) and secondary care referrals (1·47, 1·05-2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09-6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03-3·65, p=0·0390), and obesity (2·49, 1·76-3·53, p<0·0001). INTERPRETATION: Targeted annual health checks for people with ID in primary care could reduce health inequities. FUNDING: National Institute for Health Research.

How to select representative geographical areas in mental health service research: a method to combine different selection criteria.

BACKGROUND: Mental health service research can require the selection of representative geographical areas for data collection. This study designed and tested a new method of combining different relevant selection criteria within the context of a survey of housing services for people with mental health disorders in England. METHODS: Six criteria were considered relevant to select areas for the survey: deprivation, urban-ness, provision of community mental health care, residential care provision, total mental health care spend and pressure on housing generally. A measure was identified for each criterion and established for each of 166 local areas. Variables were converted to standardised scores and multi-dimensional scaling undertaken to produce a single axis representing all six variables. Study sites were chosen from this. Identifying the spread of the constituent variables among the finally selected areas we established how successfully the resulting selection represented each of the selection criteria. Reliability analyses were performed on the rank positions of each area. RESULTS: The measures were converted into one axis, and all areas were ranked according to the score on that specifically developed new axis. The scores on the axis showed good reliability when single criteria were eliminated from the equation. The finally selected six areas demonstrated a reasonable spread of scores of each of the constituent variables. CONCLUSION: Converting several relevant criteria into one score is a feasible approach to ranking geographical areas to assist in identifying small samples that are arguably representative. The method may be used widely in similar research, but requires the availability of reliable data on relevant selection criteria.

Developing mental health indicators in England.

OBJECTIVES: This paper reports on the construction of a set of indicators for mental health and the publication of a report for England's Chief Medical Officer. The report was the seventh in a series of reports aimed at initiating public health action to improve health at a regional level in England. STUDY DESIGN: Observational study using routine data. METHODS: A set of over 80 indicators was constructed by an expert group. These indicators were then populated from routine datasets. Commentary was provided on each indicator in the report. RESULTS: A small team compiled this large set of indicators from routine data working in a public health observatory in one region of England. CONCLUSIONS: It is possible to produce a large array of indicators about mental health. The conclusion from examining these indicators is that there are many unexplained differences in mental health across the regions of England. Many of these indicators are closely linked to deprivation. Some indicators show a lack of difference across the country, and in many instances, service provision is inconsistent and does not always relate to need. In some cases, there was a worrying absence of data, e.g. data on ethnicity and the mental health of offenders.

Adult mental health care in England.

The policy background and current overall provision of mental health services for working age and older adults in England are described. Following the introduction of a new National Service Framework in 1999, an annual service mapping exercise was introduced. Data presented draw heavily on the mapping for 2003. This is supplemented by hospital admission statistics data from the new patient-based mental health minimum data set, introduced from April 2003, and a number of other corroborative sources. Data about services for older people are more restricted in scope and detail. Close attention is given to the extent to which data from these routine sources can be considered accurate.

From commitment to reality: early intervention in psychosis services in England.

AIM: To evaluate the extent to which Government plans for early intervention in psychosis services have been realized in England, the UK. METHODS: Data from the Mental Health Mapping Exercise and Department of Health quarterly performance monitoring were used. Semi-structured interviews were also conducted with the nine regional early intervention in psychosis Leads from the National Institute for Mental Health in England in order to ascertain their views and experiences regarding early intervention in psychosis service development. RESULTS: By 2006 118 teams were operating. However, the staffing and skill mix of each varied considerably with only half reporting that they met all the criteria set out in the original policy guidance. CONCLUSION: Although an impressive number of services have been developed, concerns remain regarding their size, configuration and functional capacity.

[Social deprivation and mental health. Replicability and applicability in the Italian context of the resource allocation methods developed in the United Kingdom]. / Deprivazione sociale e salute mentale. Le esperienze di ricerca e di allocazione delle risorse sanitarie nel Regno Unito e la loro possibilità di "traduzione" nel contesto italiano.

AIMS: Most of the available evidence on the relationship between socioeconomic indicators of social deprivation and patterns of use of mental health services has been produced in the United Kingdom, where the Ministry of Health has developed a resource allocation formula based upon the results of those studies. The main aim of the paper is to evaluate the replicability in the Italian context of such research, and of the resulting allocation strategies. METHODS: Detailed description of the resource allocation method currently adopted in the United Kingdom, whose main purpose consists in reaching the best balance between available funding and patterns of need. Detailed description of resource allocation processes in Italy; discussion of the main methodological and statistical limitations restraining the replicability of the British formula in the Italian context. CONCLUSIONS: There is a growing interest in Italy towards the introduction of evidence-based methods in health decision making, in order to correct the overwhelming influence of political issues. What is needed is a better understanding of the relationship between higher levels of equity in health services access, and their effects in terms of better outcomes.

Crisis resolution/home treatment teams and psychiatric admission rates in England.

BACKGROUND: Introduction of crisis resolution/home treatment teams has been associated with a reduction in hospital admissions in trials. Between 2001 and 2004 there was a rapid expansion in the numbers of these teams in England. AIMS: To examine whether national implementation of these teams was associated with comparable reductions in admissions. METHOD: Observational study using routine data covering working age adult patients in 229 of the 303 local health areas in England from 1998/9 to 2003/4. RESULTS: Admissions fell generally throughout the period, particularly for younger working age adults. Introduction of crisis resolution teams was associated with greater reductions for older working age women (35-64 years); teams always on call were associated with additional reductions for older men and younger women. By the end of the study admissions had fallen by 10% more in the 34 areas with crisis resolution teams in place since 2001, and by 23% more in the 12 of these on call around the clock than in the 130 areas without such teams by 2003/4. Reductions in bed use were smaller. Introduction of assertive outreach teams was not associated with overall reductions in admissions. CONCLUSIONS: Introduction of crisis resolution teams has been associated with reductions in admissions.

Quality indicators for international benchmarking of mental health care.

OBJECTIVE: To identify quality measures for international benchmarking of mental health care that assess important processes and outcomes of care, are scientifically sound, and are feasible to construct from preexisting data. DESIGN: An international expert panel employed a consensus development process to select important, sound, and feasible measures based on a framework that balances these priorities with the additional goal of assessing the breadth of mental health care across key dimensions. PARTICIPANTS: Six countries and one international organization nominated seven panelists consisting of mental health administrators, clinicians, and services researchers with expertise in quality of care, epidemiology, public health, and public policy. Measures. Measures with a final median score of at least 7.0 for both importance and soundness, and data availability rated as 'possible' or better in at least half of participating countries, were included in the final set. Measures with median scores

A needs index for mental health care in England based on updatable data.

BACKGROUND: Mathematical models relating rates of mental health care use to population characteristics such as social deprivation are widely used in both planning and researching mental health services. The models currently in wide use in England are based on data mostly derived from the 10-yearly population censuses. These are perceived to be out of date many years before new census data are available for their replacement. A new set of government deprivation monitoring statistics based mainly on annually updatable data has recently been developed. This study set out to produce a mental illness needs index based on these new data. METHODS: A series of regression models were tested using individual domain scores from the DETR Index of Multiple Deprivation and the Office of National Statistics area-type classification as independent variables to predict 1998/9 psychiatric admission rates for broad diagnostic groups for 8251 of the 8414 electoral wards in England as dependent variables. RESULTS: The distribution of admission numbers in wards showed a pattern of over-dispersion with an excessive number of zero values for conventional regression approaches. A two-stage 'hurdle' model was, thus, adopted, predicting first the likelihood that wards would produce any admissions and second the probable number. This produced satisfactory predictive power, with residual variance showing strong geographical patterns associated with administrative areas, probably arising from differential resourcing or idiosyncratic clinical practice. CONCLUSIONS: A website providing data on the various indicators has been provided and its uses are indicated.

Inner London collaborative audit of admissions in two health districts II: Ethnicity and the use of the Mental Health Act

BACKGROUND: Twenty-six per cent of patients in two inner London districts were admitted to acute wards under the provisions of the Mental Health Act. Compared with those not under compulsion, they were young, male, more likely to be of black Caribbean origin, and to have a diagnosis of schizophrenia of short duration. The hypothesis is tested that ethnicity determines rates of compulsory admission independently of the other factors. METHOD: Sampling and data collection methods were described in the first paper. Statistical analyses included a log-linear analysis of six key variables: compulsory admission, challenging behaviour, diagnosis, ethnicity, age, and sex. RESULTS: There were no substantial differences between districts. Analysis provided two similar statistical models. In both, admission under the Act was strongly associated with challenging behaviour and diagnosis of schizoprenia. In the model of best fit there was no significant interaction term for ethnicity and compulsion. In the second model there was a weak association. CONCLUSIONS: Ethnicity did not appear to be of outstanding importance in decisions to use the Mental Health Act. There was a strong link between ethnicity and diagnosis, independent of compulsion. Differences between the districts made no major contribution to the rates of compulsory admission (AU)

Admission of British Caribbeans to mental hospitals: is it a cohort effect?

Work in the 1980s has shown that the high incidence of schizophrenia in British Caribbean men is restricted to those born after 1950. Data from a study of admissions in three London health districts suggested that the greater part of this excess risk may be confined to those born before 1966. This suggests that the group of British Caribbean men experiencing a high frequency of schizophrenia could be a tightly delineated birth cohort. It confirmed in wider studies, this could have important implications for the elucidation of the causes of one type of schizophrenia (AU)

The use of inpatient psychiatric care by immigrants in a London Borough

The prevalence of admission to psychiatric inpatient care in the major immigrant groups in the London Borough of Newham in 1982 is surveyed and results discussed with reference to relevant published literature. High admission rates were found among young West Indian men and older West Indian women, Pakistani men, older Indian women, Irish women and women from the West African new commonwealth. Women from the East African new commonwealth had a low admission rate. The diagnostic mixture found in patients from the various groups is discussed. (AU)

Differences in psychiatric admission patterns between Caribbeans from different islands

Routine DHSS data show that in London, Jamaicans have higher psychiatric admission rates than Barbadians or Trinidadians. A higher proportion of admissions of Jamaican and Barbadian men receive a diagnosis of schizophrenia while a higher proportion of Trinidadians are diagnosed as affective disorders.(AU)

Why is there a high rate of schizophrenia in British Caribbean?

Recent work strongly suggests a high prevalence of schizophrenia in young Caribbean men in the UK. While the aetiology of schizophrenia is not clear, it appears to have an organic basis. The hereditary patterns that have been described do not account for the pattern observed. Alternative explanations, including the possible influence of infectious agents, are being discussed. (AU)

The pattern of psychiatric admissions of Caribbean-born immigrants in London

Data from the mental health enquiry and the 1981 census are used to describe the age/sex specific pattern of first and total admissions of west Indian born patients to psychiatric hospitals in two Thames Regions. By contrast to native Britons, more young men, but not young women, appear to be admitted but the readmission rate for young women, appear to be admitted but the readmission rate for young patients of both sexes is high. Older West Indians of both sexes have a similar first admission rate to the native British. Older men but not older women have a low overall admission rate. Time trends suggest that there is a cohort of young men of whom the oldest are now in their early thirties who are at particular risk.(AU)