Skip to main content Accessibility help
×
Home

Splitting in-patient and out-patient responsibility does not improve patient care

  • Tom Burns (a1) and Martin Baggaley (a2)

Summary

Over the past 15 years there has been a move away from consultants having responsibility for the care of patients both in the community and when in hospital towards a functional split in responsibility. In this article Tom Burns and Martin Baggaley debate the merits or otherwise of the split, identifying leadership, expertise and continuity of care as key issues; both recognise that this move is not evidence based.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Splitting in-patient and out-patient responsibility does not improve patient care
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Splitting in-patient and out-patient responsibility does not improve patient care
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Splitting in-patient and out-patient responsibility does not improve patient care
      Available formats
      ×

Copyright

References

Hide All
1 Burns, T. The dog that failed to bark. Psychiatrist 2010; 34: 361–3.
2 Department of Health. The NHS Plan – A Plan for Investment, A Plan for Reform. Department of Health, 2000.
3 Department of Health. National Framework for Mental Health: Modern Standards and Service Models. Department of Health, 1999.
4 Hill, A. The mental health units that shame the NHS. Observer 2008; 29 June.
5 Keown, P, Weich, S, Bhui, KS, Scott, J. Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988–2008: ecological study. BMJ 2011; 343.
6 Goffman, I. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Penguin Books, 1960.
7 Priebe, S, Badesconyi, A, Fioritti, A, Hansson, L, Kilian, R, Torres-Gonzales, F, et al Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ 2005; 330: 123–6.
8 Mackirdy, C. Contrasting ways of delivering adult psychiatric services. Psychiatrist 2006; 30: 283–5.
9 Sennett, R. The Craftsman. Penguin Books, 2008.
10 Puntis, S, Rugkåsa, J, Forrest, A, Mitchell, A, Burns, T. Associations between continuity of care and patient outcomes in mental health care: a systematic review. Psychiatr Serv 2015; 66: 354–63.
11 Priebe, S, Burns, T, Craig, TKJ. The future of academic psychiatry may be social. Br J Psychiatry 2013; 202: 319–20.
12 Appleby, L, Shaw, J, Amos, T, McDonnell, R, Harris, C, McCann, K, et al Suicide within 12 months of contact with mental health services: national clinical survey. BMJ 1999; 318: 1235–9.
13 The Commission on Adult Acute Psychiatric Care. Improving Acute Psychiatric Care for Adults in England. The Commission to Review the Provision of Acute Inpatient Psychiatric Care for Adults. The Commission on Adult Acute Psychiatric Care, 2015.
14 Benchmarking Network. NHS Benchmarking. East London Foundation Trust, 2016 (http://www.nhsbenchmarking.nhs.uk/index.php).
15 Dratcu, L, Grandison, A, Adkin, A. Acute hospital care in inner London: splitting from mental health services in the community. Psychiatr Bull 2003; 27: 83–6.
16 Inglis, G, Baggaley, M. Triage in mental health – a new model for acute in-patient psychiatry. Psychiatrist 2005; 29: 255–8.
17 Coid, J. Failure in community care: psychiatry's dilemma. BMJ 1994; 308: 805–6.
18 Laugharne, R, Pant, M. Sector and functional models of consultant care: in-patient satisfaction with psychiatrists. Psychiatrist 2012; 36: 254–6.
19 Burns, T, Catty, J, Dash, M, Roberts, C, Lockwood, A, Marshall, M. Use of intensive case management to reduce time in hospital in people with severe mental illness: systematic review and meta-regression. BMJ 2007; 335: 336.

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Splitting in-patient and out-patient responsibility does not improve patient care

  • Tom Burns (a1) and Martin Baggaley (a2)
Submit a response

eLetters

Splitting in-patient and out-patient care, and why it has succeded

Luiz Dratcu, Consultant Psychiatrist, South London and Maudsley NHS Foundation Trust
05 January 2017

This debate(1) coincides with the 20th anniversary of John Dickson Ward, which pioneered acute inpatient care as a specialist service separate from community care at Guy’s, and has since moved to the Maudsley(2) .Being reassured to see Baggaley quoting our work, it was natural to write to support his views.

Burns claims that the split is not evidence based, nor could he find any theoretical basis for it. We decided to separate inpatient from community care as a pragmatic and much needed attempt to address the intractable bed crisis and unremitting pressure on services that followed the closure of Victorian asylums and mental institutions. The pre-existing model, where a single consultant provided both inpatient and community care to a designated catchment area, was simply unable to cope with the challenge - and crumbling(3). There was in fact little evidence - or any theoretical basis - to support the intrinsic superiority of the previous model per se, the survival of which owed more to tradition than to any tangible advantage it could offer to our patients. The sad reality was that mental health professionals were difficult to recruit and retain, and retired early as soon as they could. Worse, acute wards were overcrowded and understaffed, chaotic and inefficient, the true Cinderella of the NHS. Talking of ‘continuity of care’ was a platitude when the very provision of any care was in doubt.

Probably the best evidence that the functional split has been successful is that we did resolve the local bed crisis. Our unit managed up to 500 admissions a year(2). We reduced duration of stay by ensuring high standards of care(4). Our model has since been so widely adopted most likely a result of the practical solutions it delivers in everyday practice to both patients and teams. This is because, rather than being an academic or centrally imposed construct, it emerged as a genuine bottom-up response of mental health services to patients’ most pressing needs. Indeed, turning acute care into a specialist service has raised standards of patient care, as exemplified by the implementation of accreditation systems, dedicated multidisciplinary teams and care pathways, which do include effective and well organised ward rounds. Inpatient psychiatry has become an attractive career choice that requires an increasingly specific set of skills(5).

The split has offered local solutions to local problems, an indication that mental health services can be responsive to the community that they cater for and structure themselves accordingly. If rates of bed occupancy are any guide, the need for inpatient care will probably remain unabated, particularly in inner cities. In any branch of medicine, inpatient care is an organised, multidisciplinary and interpersonal service where, to secure consistent care for patients, strategic priority should be given to staff stability and education in order to build teams with collective competence and a shared ethos of responsibility. We have been doing this for the last two decades, and so have many other inpatient teams in my own Trust and across the country. With pleasure.

References

1. Burns T, Baggaley M. Splitting in-patient and out-patient responsibility does not improve patient care. Br J Psychiatry 2017; 210: 6-9.

2. Dratcu L, Grandison A, Adkin A. Acute hospital care in inner London: splitting from mental health services in the community. Psychiatr Bull 2003; 27: 83-6.

3. Marshall M. London’s mental health services in crisis. BMJ 1997; 314: 216.

4. Dratcu L, Walker-Tilley T, Ramanuj P, Lopez-Morinigo J, Huish E. Metropoltitan acute hospital care in psychiatry: measuring outcomes. Eur Psychiatry 2012; 27 (suppl 1): P-1227.

5. Royal College of Psychiatrists. College Centre for Quality Improvement. AIMS Accreditation for Inpatient Mental Health Services (http://www.rcpsych.ac.uk/workinpsychiatry/ccqiprojects/whygetaccredited.aspx#whyfocusonipatientwards).

... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *