Helen Gilburt

In-patient and residential alternatives to standard acute psychiatric wards in England

BACKGROUND Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years. AIMS Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations. METHOD National cross-sectional survey of alternatives to standard acute in-patient care. RESULTS We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions. CONCLUSIONS Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study

BackgroundRecovery has become an increasingly prominent concept in mental health policy internationally. However, there is a lack of guidance regarding organisational transformation towards a recovery orientation. This study evaluated the implementation of recovery-orientated practice through training across a system of mental health services.MethodsThe intervention comprised four full-day workshops and an in-team half-day session on supporting recovery. It was offered to 383 staff in 22 multidisciplinary community and rehabilitation teams providing mental health services across two contiguous regions. A quasi-experimental design was used for evaluation, comparing behavioural intent with staff from a third contiguous region. Behavioural intent was rated by coding points of action on the care plans of a random sample of 700 patients (400 intervention, 300 control), before and three months after the intervention. Action points were coded for (a) focus of action, using predetermined categories of care; and (b) responsibility for action. Qualitative inquiry was used to explore staff understanding of recovery, implementation in services and the wider system, and the perceived impact of the intervention. Semi-structured interviews were conducted with 16 intervention group team leaders post-training and an inductive thematic analysis undertaken.ResultsA total of 342 (89%) staff received the intervention. Care plans of patients in the intervention group had significantly more changes with evidence of change in the content of patient’s care plans (OR 10.94. 95% CI 7.01-17.07) and the attributed responsibility for the actions detailed (OR 2.95, 95% CI 1.68-5.18). Nine themes emerged from the qualitative analysis split into two superordinate categories. ‘Recovery, individual and practice’, describes the perception and provision of recovery orientated care by individuals and at a team level. It includes themes on care provision, the role of hope, language of recovery, ownership and multidisciplinarity. ‘Systemic implementation’, describes organizational implementation and includes themes on hierarchy and role definition, training approaches, measures of recovery and resources.ConclusionsTraining can provide an important mechanism for instigating change in promoting recovery-orientated practice. However, the challenge of systemically implementing recovery approaches requires further consideration of the conceptual elements of recovery, its measurement, and maximising and demonstrating organizational commitment.

Alternatives to standard acute in-patient care in England: short-term clinical outcomes and cost-effectiveness

BACKGROUND Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched. AIMS To explore short-term outcomes and costs of admission to alternative and standard services. METHOD Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services. RESULTS All outcomes improved during admission for both types of service (n = 433). Adjusted improvement was greater for standard services in scores on HoNOS (difference 1.99, 95% CI 1.12-2.86), TAG (difference 1.40, 95% CI 0.39-2.51) and GAF functioning (difference 4.15, 95% CI 1.08-7.22) but not GAF symptoms. Admissions to alternatives were 20.6 days shorter, and hence cheaper (UK pound3832 v. pound9850). Standard services cost an additional pound2939 per unit HoNOS improvement. CONCLUSIONS The absence of clear-cut advantage for either type of service highlights the importance of the subjective experience and longer-term costs.

Alternatives to standard acute in-patient care in England: differences in content of care and staff–patient contact

BACKGROUND Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched. AIMS To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction. METHOD Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews. Quantitative investigation of the care provided at four alternative and four standard services was undertaken using three instruments developed for this study. The relationship of care received to patient satisfaction was explored. RESULTS No significant difference was found in intensity of staff-patient contact between alternative and standard services. Alternative services provided more psychological and less physical and pharmacological care than standard wards. Care provision may be more collaborative and informal in alternative services. All measured types of care were positively associated with patient satisfaction. Measured differences in the care provided did not explain the greater acceptability of community alternatives. CONCLUSIONS Similarities in care may be more marked than differences at alternative and standard services. Staff-patient contact is an important determinant of patient satisfaction, so increasing it should be a priority for all acute in-patient services.

Alternatives to standard acute in-patient care in England: roles and populations served

BACKGROUND Key questions regarding residential alternatives to standard acute psychiatric care, such as crisis houses and short-stay in-patient units, concern the role that they fulfil within local acute care systems, and whether they manage people with needs and illnesses of comparable severity to those admitted to standard acute wards. AIMS To study the extent to which people admitted to residential alternatives and to standard acute services are similar, and the role within local acute care systems of admission to an alternative service. METHOD Our approach combined quantitative and qualitative methods. Consecutive cohorts of patients in six residential alternatives across England and six standard acute wards in the same areas were identified, and clinical and demographic characteristics, severity of symptoms, impairments and risks compared. Semi-structured interviews with key stakeholders in each local service system were used to explore the role and functioning of each alternative. RESULTS Being already known to services (OR = 2.6, 95% CI 1.3-5.2), posing a lower risk to others (OR = 0.49, 95% CI 0.31-0.78) and having initiated help-seeking in the current crisis (OR = 2.2, 95% CI 1.2-4.3) were associated with being admitted to an alternative rather than a standard service. Stakeholder interviews suggested that alternatives have a role that is similar but not identical to standard hospital services. They can divert some, but not all, patients from acute admission. CONCLUSIONS Residential alternatives are integrated into catchment area mental health systems. They serve similar, but not identical, clinical populations to standard acute wards and provide some, but not all, of the functions of these wards.

Alternatives to standard acute in-patient care in England: readmissions, service use and cost after discharge

BACKGROUND Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions. AIMS To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services. METHOD Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission. RESULTS After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services. CONCLUSIONS Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

The Relationship between Therapeutic Alliance and Service User Satisfaction in Mental Health Inpatient Wards and Crisis House Alternatives: A Cross-Sectional Study

Background Poor service user experiences are often reported on mental health inpatient wards. Crisis houses are an alternative, but evidence is limited. This paper investigates therapeutic alliances in acute wards and crisis houses, exploring how far stronger therapeutic alliance may underlie greater client satisfaction in crisis houses. Methods and Findings Mixed methods were used. In the quantitative component, 108 crisis house and 247 acute ward service users responded to measures of satisfaction, therapeutic relationships, informal peer support, recovery and negative events experienced during the admission. Linear regressions were conducted to estimate the association between service setting and measures, and to model the factors associated with satisfaction. Qualitative interviews exploring therapeutic alliances were conducted with service users and staff in each setting and analysed thematically. Results We found that therapeutic alliances, service user satisfaction and informal peer support were greater in crisis houses than on acute wards, whilst self-rated recovery and numbers of negative events were lower. Adjusted multivariable analyses suggest that therapeutic relationships, informal peer support and negative experiences related to staff may be important factors in accounting for greater satisfaction in crisis houses. Qualitative results suggest factors that influence therapeutic alliances include service user perceptions of basic human qualities such as kindness and empathy in staff and, at service level, the extent of loss of liberty and autonomy. Conclusions and Implications We found that service users experience better therapeutic relationships and higher satisfaction in crisis houses compared to acute wards, although we cannot exclude the possibility that differences in service user characteristics contribute to this. This finding provides some support for the expansion of crisis house provision. Further research is needed to investigate why acute ward service users experience a lack of compassion and humanity from ward staff and how this could be changed.

Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial

BackgroundAlcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this.Methods/DesignIn this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participants home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare.DiscussionResults of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial.Trial registration numberISRCTN: ISRCTN22775534

Implementing successful residential alternatives to acute in-patient psychiatric services: lessons from a multi-centre study of alternatives in England

BACKGROUND Standard acute psychiatric care in the UK is costly but problematic. Alternatives to standard in-patient wards exist, but little is known about their effectiveness, implementation and sustainability. This paper explores successful features and limitations of five residential alternative services in England and factors that facilitate or impede their initial and sustained implementation and success. METHODS Semi-structured interviews about the functioning of six alternative services were conducted with 36 mental health professionals with good working knowledge of, and various connections with these services. A group interview with study researchers was also conducted. Data were analysed using thematic analysis. RESULTS One service did not show evidence of operating as an alternative and was excluded from further analysis. The remaining five alternatives are valued for providing a more holistic style of care than standard services that confers many perceived benefits. However, they are seen as less appropriate for compulsorily detained or highly disturbed patients, and as providing less comprehensive treatment packages than hospital settings. Factors identified as important to successful implementation and sustainability are: responding to known shortcomings in local acute care systems; balancing role clarity and adaptability; integration with other services; and awareness of the alternative among relevant local health-care providers. CONCLUSIONS Residential alternatives can play an important role in managing mental health crises. Their successful implementation and endurance depend on establishing and maintaining a valued position within local service systems. Findings contribute to bridging the gap between research evidence on the problems of standard acute care and delivering improved crisis management services.

The spectral efficiency of the eye of Ephestia cautella (Walker) (Lepidoptera: Pyralidae)

Abstract The spectral efficiency of the dark-adapted eye of Ephestia cautella has been measured using the electroretinogram technique (ERG). Two regions of high efficiency were found, one in the yellow-green, around 546 nm, and one in the ultraviolet (UV), around 350 nm. A regional specialisation of the eye was revealed, the spectral efficiency in the ultraviolet region being greater in the dorsal and ventral regions of the eye than that in the equatorial region. It is suggested that the high dorsal UV efficiency may be of importance in the navigation of E. cautella , while the high ventral UV efficiency may act in the orientation to nectar sources by the use of nectar guides.