Tony Ryan

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.

Exploring the risk management strategies of mental health service users

This article describes an exploratory study of risk management strategies employed by users of mental health services. A wide range of risks was examined in 22 semi-structured interviews with users, designed to explore their risk management experiences from the onset of their illness to the time of interview. The grounded theory approach, first developed by Glaser and Strauss (1968), was used to collect and analyse the data and test the three theoretical models of risk management developed from the interviews. A description is provided of the three models of service user strategies; proactive risk management, passive risk management and no risk management. Each model is summarised through highlighting key characteristics relating to users and their behaviours, risk situations and risk decision-making.

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.

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.

A collaborative approach to meeting the needs of adolescent offenders with complex needs in custodial settings: An 18-month cohort study

Recent studies and policy documents have recognised the need for support for adolescent offenders under the age of 18 who experience both mental health and behavioural difficulties. Although mental health services are provided within all Young Offender Institution (YOIs), the level of provision is highly variable. Further, these services can find it difficult to meet the needs of young offenders whose mental health needs are compounded and inextricably linked with their behaviours. A specialist facility was established within an adolescent prison in North-West England to meet the needs of this population. The unit used a multi-agency approach in which prison officers worked in collaboration with mental health staff. This article describes the aims of the unit and reports on the first cohort of young people admitted; there were significant improvements in behavioural and social functioning across all three main outcome measures. Implications for future policy, service development and research are discussed.

Care pathways to in‐patient alcohol detoxification and their effects on predictors of treatment completion

Aims: This study aimed to (i) test the hypothesis that stable housing, older age, gate‐kept admission route and female gender are predictive of completion of in‐patient detoxification treatment, and (ii) compare two care pathways into treatment. Methods: Multiple logistic regression of 6,745 cases of admission to an independent sector in‐patient detoxification service between January 1995 and March 2003. Findings: Factors predictive of treatment completion were found to be older age, female gender, employment and undergoing a process of gate‐keeping for admission. A comparison of treatment completers between gate‐kept and non‐gate‐kept admissions indicated that while gate‐keeping is sensitive to potential completers by favouring people with stable housing it may also be excluding a proportion of clients among younger males with unstable housing who would otherwise benefit from admission. Conclusions: In developing care pathways that ensure effective and appropriate use of services careful consideration must be given to the impacts upon some client groups who may be disadvantaged by the process.

Risk management and system failure analysis in mental health investigations

This editorial explores the way in which mental health investigations are developing in England and in particular those involving a homicide. A move away from traditional panel inquiries and towards investigations using root cause analysis (RCA) is aimed at shifting the focus from individual blame to identifying system failure. Thus it is envisaged by policy makers that the RCA approach will offer greater learning opportunities for mental health services. The key difficulties associated with panel inquiries are highlighted before describing the intended benefits of the RCA approach. Finally, five key areas where systematic research can support the development of this approach are suggested.

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.

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.