Barbara Hatfield

Long term care for serious mental illness outside the NHS: A study of out of area placements

Background: Non-forensic placements within the independent sector represent one of the largest parts of the care system for adults with severe and enduring mental illness. Aims: To describe a cohort of patients placed out of area in one voluntary sector and 11 private sector open (non-forensic) facilities by one PCT and Social Service authority. To provide empirical evidence on the care they receive. Method: A purpose-designed survey instrument based on patient and staff interviews and analysis of documentation (casenotes, careplans, risk assessments, prescription cards) examining 70 (100%) adult patients with severe and enduring mental illnesses placed out of area of origin. Results: Significant numbers of patients were not in receipt of CPA (45/70, 64.3%) or multi-disciplinary review (44/70, 62.9%), most were locked within facilities although informal patients (55/70, 78.6%), clinical and treatment histories were absent in half of the cases (35/70, 50.0%) and many needed supported accommodation rather than independent hospital or nursing home care (19/70, 27.1%). Involvement of patients (19/70, 27.1%) and relatives (30/70, 42.9%) in care planning was limited. Placement costs for 2003/04 was £2,160,662 (mean = £30,867). Conclusions: Closer collaboration between NHS providers, service commissioners and the independent sector is required to ensure greater consistency in quality of care and to prevent patients from being lost from the commissioning system. The role of regulators requires review in light of these findings. Declaration of interest: None.

Persuading the persuadable: evaluating compulsory treatment in England using Supervised Discharge Orders

Background: Supervised Discharge Orders (SDOs) were introduced in 1995, as an amendment to the Mental Health Act in England and Wales. They require patients to abide by specific conditions on discharge from hospital, but can not enforce medication compliance. On introduction, SDOs were received with scepticism by the psychiatric profession. The purpose of this study was to describe the use of SDOs in England and the characteristics of patients made subject to these orders, and to evaluate the effectiveness of the order in securing treatment compliance on discharge from hospital. Method: A survey was conducted of 170 mental health provider Trusts in England. Interviews with senior managers in 12 Trusts and associated Local Authorities were subjected to qualitative analysis, and a cohort of patients subject to SDOs in 56 randomly sampled Trusts was described. Results: SDOs were being used for 596 patients (1.2 per 100,000 total population) at the survey date in 1999, and use had been increasing steadily since its introduction. The order is not systematically considered for all potential cases. The majority of the 182 patients in the cohort had complied, if sometimes intermittently, with conditions of the order. Conclusions: For patients compliant with SDOs, the pressures necessary to treat effectively need not involve powers to enforce medication compliance.

A census study of independent mental health sector usage across seven Strategic Health Authorities

Background: Private and voluntary organizations are significant providers of mental health and social care in England. Limited strategic information is available on the range of people placed into independent sector care. Aim: To describe independent sector usage by NHS and local authority commissioners through examining secondary mental health care placements for adults of working age, types of service provision, linkage between agencies and associated costs. Method: A census day study was undertaken across all agencies commissioning mental health services within seven Strategic Health Authority areas (n = 127). A 100% response rate was obtained from data providers consisting of 82 Primary Care Trusts, 42 Local Authority Social Services Departments and three specialist commissioning agencies. Data was obtained for 3,510 cases. Results: A weekly expenditure of over £2.98 M was identified with considerable variation in costs across and within client groups. All illness groups were being supported across the full range of service models. Many people were placed at distance and links with CPA care co-ordinators and commissioners were frequently not robust. Conclusions: Private providers dominate the independent sector and require strategic engagement. Improved co-ordination between the independent sector, NHS provider trusts, CPA care co-ordinators and service commissioners would more effectively utilize this significant resource. Declaration of interest: This work was part of a wider programme of work that was funded through grants from Care Services Improvement Partnership National Institute for Mental Health in England Development Centres in the North West and West Midlands and the County Durham and Tees Valley Strategic Heath Authority.

Emergency referrals to an acute psychiatric service: Demographic, social and clinical characteristics and comparisons with those receiving continuing services

The characteristics of individuals referred to psychiatric emergency services serve as one indicator of the functioning of the service system as a whole. Evaluations of emergency services have been relatively sparse in the research literature. A two-month cohort of emergency referrals is described and comparisons made with a Community Mental Health Team (CMHT) caseload group. The characteristics of the individual, dimensions of the crisis, and the outcome of the emergency assessment were recorded in each case. Health of the Nation Outcome Scales (HoNOS) and Global Assessment of Functioning scale (GAF) ratings were obtained. Those referred form a heterogeneous group, some of whom have serious mental illnesses and many of whom were identified as having poor coping and psycho-social problems. The comparison group (CMHT caseloads) had significantly greater problems of symptoms and functioning. The study raises the issue of whether prioritising of specialist mental health services to those with severe and enduring mental illnesses serves to exclude other vulnerable groups. While most individuals in the study had a history of episodic psychiatric contact, many would be unlikely to satisfy the criteria for continuing support. Some may only have transient needs related to a life crisis; for others with more chronic difficulties, an emergency response alone cannot be expected to make an impact.

The Mental Health of Residents of Approved Premises in the Greater Manchester probation Area: A Cohort Study:

This article reports on a 12-month cohort study of mental disorder among residents of approved premises within the Greater Manchester probation area which had contracted psychiatric support via the local NHS Trust. Generally high rates of mental health problems were identified, particularly at the premises with psychiatric support and the women’s premises, and also amongst bailees across all premises. Not all of those with mental health problems were receiving mental health services. Implications for service development within the probation service and alongside health and social care agencies are considered.

Managing severe mental illness in the community using the Mental Health Act 1983: A comparison of Supervised Discharge and Guardianship in England

Background Two measures in the English Mental Health Act allow requirements to be imposed upon patients living in the community. These are Guardianship (Section 7) and Supervised Discharge (Section 25A). Aims The paper aims to compare patients with mental illnesses, made subject to Guardianship or Supervised Discharge. Method Data on patient characteristics, impairment, needs and interventions were collected from keyworkers in a random national sample of Trusts and local authorities. Ratings were obtained on standardised measures of disability, impairment and needs. Results Patients placed on Supervised Discharge were more likely to have problems of treatment compliance and drug misuse, whilst those on Guardianship were more likely to have problems of social welfare and higher ratings of disability and impairment. Supervised Discharge has a higher proportion of African-Caribbean patients. Interventions delivered are rated as effective for both measures. Conclusions Legal changes proposed in England include a single power for supervision in the community. This should not mean a focus on risk management to the neglect of social welfare interventions.

Mental health training needs amongst staff of Probation Approved Premises: A comparison with mental health hostel staff in the voluntary sector

The recognition of significant levels of mental health need amongst people in contact with the criminal justice system has led to many new areas of partnership working between mental health and the criminal justice system. The training needs of staff within the criminal justice system in England and Wales is recognized as an important area for service development and has to date been largely unexplored. This article examines many of the issues as identified when comparing the mental health training needs and experiences of staff working in two forms of residential service - Probation Approved Premises and voluntary sector mental health services.

A follow up-study of probation service-approved premises residents in contact with mental health services

Abstract The paper examines the service contact at 6–9-month follow-up of residents of seven probation service-approved premises with a dedicated specialist mental health service. The service is designed to assess, provide brief interventions, and promote appropriate linkage with mainstream mental health services upon discharge. Findings suggest that linkage with mainstream services was robust with a significant proportion in contact at time of follow-up. The high levels of non-psychotic mental health needs suggest services of this type may have an important role in ensuring the needs of mentally disordered offenders are appropriately met and that the engagement of primary care services is essential.

The use of compulsory powers by approved social workers in five local authorities: Some trends over two years

This paper represents the second report of an ongoing collaborative project and charts the activities of social workers undertaking their duties within the framework of the 1983 Mental Health Act for two years. Approved Social Workers are involved in a range of activities under the Act, but most commonly they are involved in assessments with a view to compulsory detention. The paper examines rates of assessments and detentions under the Act, and identifies marked increases over the two years 1990 and 1991. More people are detained under Section 3 of the Act in particular, and more detentions occur from informal in-patient status. Comparisons with an earlier national study confirm these trends. People aged over 75 years are analysed separately, and increases are identified in the rates of referral and detention, particularly for those with mental health problems other than dementia. In the second year, more were identified who were living in staffed accommodation, or with relatives. The findings of the stu...

Changing the Focus of Community Mental Health Teams: A Study in one English Locality

This study of community mental health teams (CMHTs) in Knowsley aimed to provide information about changes to the service user group and the nature of work undertaken in the teams following the implementation of the national service framework for mental health. Clear changes in the balance of work undertaken were identified, reflecting successful implementation of the new policies and appropriate selection of cases. Issues raised by such developments are summarised in view of their relevance to other localities.