Survey of patients from an inner-London health authority in medium secure psychiatric care.

BACKGROUND: Underprovision by the National Health Service (NHS) has led to an increase in medium secure psychiatric beds managed by the independent sector. Black people are overrepresented in medium secure care. AIMS: To describe those people from an inner-London health authority occupying all forms of medium secure provision. To compare those in NHS provision with those in the independent sector, and Black patients with White patients. METHOD: A census of those in medium secure care in August 1997. RESULTS: The 90 patients in independent-sector units were similar to the 93 patients in NHS units except that they were more likely to have been referred from general psychiatric services (48% v. 19%) and less likely to have been referred from the criminal justice system or a high-security hospital (37% v. 63%). There were few differences between Black and White patients. CONCLUSIONS: The NHS meets only part of the need for medium secure care of the population of this London health authority. This comparison of the characteristics of Black and White patients does not help to explain why Black people are overrepresented in medium secure settings.

A delphi approach to characterising "relapse" as used in UK clinical practice.

BACKGROUND: 'Relapse' is a common outcome indicator in intervention studies in schizophrenia. In community studies it is frequently equated with hospitalisation and in psychopharmacological studies with predetermined symptom scores. Its clinical meaning, however, remains undefined. METHOD: Consensus on the defining features of 'relapse' in schizophrenia used by academic and clinical schizophrenia experts in the UK, was investigated using a four stage Delphi process. A two panel, four stage, Delphi based methodology was used to investigate the implicit meanings of 'relapse' in clinical practice. A multidisciplinary panel of twelve members each listed anonymously ten indicators of relapse. A second panel, of ten experienced psychiatrists, rated the 188 submitted indicators from essential-unimportant (1-5). This panel completed a one day workshop during the remaining Delphi rounds ending with a structured discussion of the results. RESULTS: Very strong consensus was achieved on the relative importance of potential relapse indicators. There was complete agreement about some aspects of a definition of relapse (such as recurrence of positive symptoms) and a number of the complex issues underlying the concept were clearly articulated. CONCLUSIONS: This four stage Delphi process achieved consensus on core features of relapse. The elucidation of the "softer" features at the threshold between normal fluctuations in functioning and the start of relapse require continuing investigations.

Home-based versus hospital-based care for serious mental illness. Controlled cost-effectiveness study over four years.

BACKGROUND: The Daily Living Programme (DLP) offered intensive home-based care with problem-centred case management for seriously mentally ill people facing crisis admission to the Maudsley Hospital, London. The cost-effectiveness of the DLP was examined over four years. METHOD: A randomised controlled study examined cost-effectiveness of DLP versus standard in/out-patient hospital care over 20 months, followed by a randomised controlled withdrawal of half the DLP patients into standard care. Three patient groups were compared over 45 months: DLP throughout the period, DLP for 20 months followed by standard care, and standard care throughout. Bivariate and multivariate analyses were conducted (the latter to standardise for possible inter-sample differences stemming from sample attrition and to explore sources of within-sample variation). RESULTS: The DLP was more cost-effective than control care over months 1-20, and also over the full 45-month period, but the difference between groups may have disappeared by the end of month 45. CONCLUSIONS: The reduction of the cost-effectiveness advantage for home-based care was perhaps partly due to the attenuation of DLP care, although sample attrition left some comparisons under-powered.

Does a hostel's managing agency determine the access to psychiatric services of its residents?

This study examines the effect of managing agency (local authority, private or voluntary) on the use of other health and social care services by residents in mental health hostels and group homes with different levels of staffing in England and Wales. The sample comprised 1323 residents in 275 facilities in eight districts. The measures of service use were number of days in hospital and number of other service contacts. There were highly significant differences between facilities with similar levels of staffing managed by different agencies. Residents in the voluntary sector used fewer community services overall; residents in low-staffed local authority facilities used more services than those in similar facilities managed by other agencies. These differences were not easily explained by differences in the social or clinical characteristics of residents. This suggests that there may be organisational factors, e.g. hostel staff, knowledge of services, which influence access to and use of community services.

Public, private and voluntary residential mental health care: is there a cost difference?

OBJECTIVES: To determine how public (NHS or local government), private (for-profit) and voluntary (non-profit) providers of residential mental health care compare. Do they support different clienteles? And do their services cost different amounts? METHODS: Based on a cross-sectional survey of residential care facilities and their residents in eight English and Welsh localities, the characteristics and costs of care in the different sectors (NHS, local government, private, voluntary) were compared. Variations in cost were examined in relation to residents' characteristics using multiple regression analyses, which also allowed standardisation of results before making inter-sectoral comparisons. RESULTS: Private and voluntary providers of residential care support different clienteles from the public sector. The patterns of inter-sectoral cost differences vary between London and non-London localities. In London, voluntary sector facilities may be more cost-efficient than the other sectors, but local government/private sector comparisons show no consistent difference. Outside London, the results suggest clear cost advantages for the private and voluntary sectors over the local government sector. CONCLUSIONS: Private and voluntary providers may have some economic advantages over their public counterparts. However, outcomes for residents were not studied, leaving unanswered the question of comparative cost-effectiveness.

The cost consequences of changing the hospital-community balance: the mental health residential care study.

BACKGROUND: Altering the balance of provision between hospital and community care is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could be supported more appropriately elsewhere, in turn denying in-patient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure. METHODS: Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of today's balance of care were explored. Comprehensive costs were calculated and their associations with resident characteristics examined using multiple regression analyses. RESULTS: On a like-with-like basis, the costs of hospital in-patient treatment for inappropriately placed patients greatly exceeded the costs of community-based care. CONCLUSION: Further reduction of hospital beds, however, is not the panacea for an appropriate balance of mental health care, given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous in-patient bed reductions apparent in the services surveyed. Rather, service providers and purchasers should focus on developing community-based care (including increased provision of 24-hour nursed beds) by ensuring that resources released through earlier closure programmes have been redeployed for their intended use and by accessing additional pump-priming or bridging resources.

The mental health residential care study: predicting costs from resident characteristics.

BACKGROUND: Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary. METHOD: As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs. RESULTS: Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts. CONCLUSIONS: The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.

The mental health residential care study: classification of facilities and description of residents.

BACKGROUND: The NHS is no longer a virtual monopoly provider of mental health residential care. This makes it difficult to assess the volume, range and adequacy of local provision. METHOD: Local data collectors used standard instruments to collect detailed information about 368 facilities (with 1951 residents) providing mental health residential care in eight districts. Because local definitions were inconsistent, facilities were reclassified on the basis of facility size and extent of day and night cover. The eight categories of accommodation are compared on levels of staffing, staff qualifications and the characteristics of their residents. RESULTS: There was a nearly threefold variation between districts in the total number of residential places available per unit of population, and even greater variation in the number of places with 24-hour waking cover. Most residents have long-term, severe mental illness and severe impairment. Long-stay wards accommodate people who pose greater risk of violence than do the two types of non-hospital facility with 24-hour waking cover (P < 0.001). The former also employ a much greater proportion of staff with formal care qualifications and, in particular, nursing qualifications than the latter (49% v. 15%, P < 0.001). CONCLUSIONS: It is suggested that one consequence of the diversification in provision of mental health residential accommodation has been a relative reduction in the proportion of provision available to the most severely disabled. This might apply particularly to those who pose a risk of acting violently.

Home-based versus hospital-based care for people with serious mental illness.

BACKGROUND: A controlled study tested whether the superior outcome of community care for serious mental illness (SMI) in Madison and in Sydney would also be found in inner London. METHOD: Patients from an inner London catchment area who faced emergency admission for SMI (many were violent or suicidal) were randomised to 20 months or more of either home-based care (Daily Living Programme, DLP; n = 92), or standard in-patient and later out-patient care (controls, n = 97). Most DLP patients had brief in-patient stays at some time. Measures included number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction. RESULTS: Outcome was superior with home-based care. Until month 20, DLP care improved symptoms and social adjustment slightly more, and enhanced patients' and relatives' satisfaction. From 3 to 18 months DLP care greatly reduced the number of in-patient bed days as long as the DLP team was responsible for any in-patient phase its patients had. Cost was less. DLP care did not reduce the number of admissions, nor of deaths from self-harm (3 DLP, 2 control). One DLP patient killed a child. Even at 20 months many DLP and control patients still had severe symptoms, poor social adjustment, no job, and need for assertive follow-up and heavy staff input. (Beyond 20 months most gains were lost apart from satisfaction.) CONCLUSIONS: It is unclear how much the gain until 20 months from home-based care was due to its site of care, its being problem-centred, its teaching of daily living skills, its assertive follow-up, the home care team's keeping responsibility for any in-patient phase, its coordination of total care (case management), or to other care components. Home-based care is hard to organise and vulnerable to many factors, and needs careful training and clinical audit if gains are to be sustained.

Service use and costs of home-based versus hospital-based care for people with serious mental illness.

BACKGROUND: The Daily Living Programme (DLP) offered problem-oriented, home-based care for people aged 17-64 with severe mental illness facing emergency admission to the Bethlem-Maudsley Hospital. The multidisciplinary DLP team acted as direct provider and link with other services. Each patient had a key worker. Cost-effectiveness was assessed. METHOD: The comprehensive costs of DLP and standard in-patient care were compared within a randomised controlled trial. Cost measures ranged over all service inputs and living expenses. The costs of informal care and lost employment were also considered. Assessments of service use, costs and outcomes were conducted at referral, 4, 11 and 20 months. RESULTS: The DLP was significantly less costly than standard treatment in both short and medium term (P = 0.000). Cost savings accrued almost exclusively to the NHS, with no other agency's costs being higher. CONCLUSIONS: Coupled with mildly encouraging outcome results over the 20 month period, the DLP was clearly cost-effective in this medium term.

Home-based versus out-patient/in-patient care for people with serious mental illness. Phase II of a controlled study.

BACKGROUND: The effect of a randomised controlled withdrawal of home-based care was studied for half of a sample of seriously mentally ill (SMI) patients from an inner London catchment area, compared with the effects of continuing home-based care. METHOD: Patients, aged 18-64, had entered the trial at month 0 when facing emergency admission for SMI. After at least 20 months home-based care (Phase I), patients were randomised at month 30 into Phase II (months 30-45) to have either further home-based care (DLPII, n = 33) or be transferred to out-/in-patient care (DLP-control, n = 33). They were assessed at 30, 34, and 45 months. Phase I control patients (n = 70) were assessed again at month 45. Measures used were number and duration of in-patient admissions, independent ratings of clinical and social function, and patients' and relatives' satisfaction. RESULTS: The slim clinical and social gains from home-based v. out-/in-patient care during Phase I were largely lost in Phase II. Duration of crisis admissions increased from Phase I to Phase II in both DLPII and DLP-control patients. During Phase II, patients' and relatives' satisfaction remained greater for home-based than out-/in-patient care patients. At 45 months, compared with the Phase I controls, DLPII patients and relatives were more satisfied with care. Such satisfaction was independent of clinical/social gains. CONCLUSIONS: The loss of Phase I gains were perhaps due to attenuation of home-based care quality and to benefits of Phase I home-based care lingering into Phase II in DLP-controls. The Phase II home-based care team suffered from low morale.

The daily living programme. Preliminary comparison of community versus hospital-based treatment for the seriously mentally ill facing emergency admission.

Patients with a serious mental illness requiring admission were randomised to home care or standard hospital care. Over the initial 18 months, 60 patients entered each group and were studied for a mean of 10 months. Home care reduced hospital use by 80%, with patients being admitted for a mean of 14 days, compared with 72 days for the standard group, but this bed-saving made no difference in direct treatment costs. Home care offers individualised treatment, and many patients require continuing support with the emphasis on areas such as finances and housing.

Home based care and standard hospital care for patients with severe mental illness: a randomised controlled trial.

OBJECTIVE: To compare the efficacy of home based care with standard hospital care in treating serious mental illness. DESIGN: Randomised controlled trial. SETTING: South Southwark, London. PATIENTS: 189 patients aged 18-64 living in catchment area. 92 were randomised to home based care (daily living programme) and 97 to standard hospital care. At three months' follow up 68 home care and 60 hospital patients were evaluated. MAIN OUTCOME MEASURES: Use of hospital beds, psychiatric diagnosis, social functioning, patients' and relatives' satisfaction, and activity of daily living programme staff. RESULTS: Home care reduced hospital stay by 80% (median stay six days in home care group, 53 days in hospital group) and did not increase the number of admissions compared with hospital care. On clinical and social outcome there was a non-significant trend in favour of home care, but both groups showed big improvements. On the global adjustment scale home care patients improved by 26.8 points and the hospital group by 21.6 points (difference 5.2; 95% confidence interval -1.5 to 12). Other rating scales showed similar trends. Home care patients required a wide range of support in areas such as housing, finance, and work. Only three patients dropped out from the programme. CONCLUSIONS: Home based care may offer some slight advantages over hospital based care for patients with serious mental illness and their relatives. The care is intensive, but the low drop out rate suggests appreciation. Changes to traditional training for mental health workers are required.