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The dog that failed to bark

  • Tom Burns (a1)
Summary

UK mental healh services have been distinguished by their continuity of care but recently there has been a move to separating consultant responsibility for in-patient and out-patient care. Local examples of the success of this approach have been published but there has been remarkably little careful thought about its longer-term impacts. International comparisons would suggest that there are significant potential disadvantages, including increased bed pressures. Some disadvantages, such as the poor fit with the Mental Health Act and patient dissatisfaction with structural discontinuity are already obvious. A more considered debate is called for.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Tom Burns (tom.burns@psych.ox.ac.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Department of Health. National Service Framework for Mental Health: Modern Standards and Service Models. Department of Health, 1999.
2 Department of Health. The NHS Plan: A Plan for Investment, a Plan for Reform. Department of Health, 2000.
3 Burns, T, Dawson, J. Community treatment orders: how ethical without experimental evidence? Psychol Med 2009; 39: 1583–6.
4 Hill, A. The mental health units that shame the NHS. Observer 2008; 29 June.
5 Katsakou, C, Priebe, S. Outcomes of involuntary hospital admission – a review. Acta Psychiatr Scand 2006; 114: 232–41.
6 Khandaker, G, Cherukuru, S, Dibben, C, Ray, MK. From a sector-based service model to a functional one: qualitative study of staff perceptions. Psychiatrist 2009; 33: 329–32.
7 Coid, J. Failure in community care: psychiatry's dilemma. BMJ 1994; 308: 805–6.
8 Burns, T. Models of community treatments in schizophrenia: do they travel? Acta Psychiatr Scand 2000; 102: 11–4.
9 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.
10 Shaw, J, Appleby, L, Amos, T, McDonnell, R, Harris, C, McCann, K, et al. Mental health disorder and clinical care in people convicted of homicide: a national survey. BMJ 1999; 318: 1240–4.
11 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.
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The dog that failed to bark

  • Tom Burns (a1)
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eLetters

Toward integrated care in continental Europe

Wulf R�ssler, Professor of Clinical and Social Psychiatry
02 October 2010

The split responsibility for inpatient and outpatient care is one of the most serious problems facing mental health care in continental Europe. The strict separation of the inpatient and outpatient sector is a major obstacle in the continuity of care, particularly with severely mentally ill patients.

I have been involved in mental health services research for 30 years. During that time I have observed increasing efforts to overcome this split responsibility. There are several ongoing evaluations of “integrated care” all overcontinental Europe which have been developed to overcome this divide. Britain has always set a good example in integrated care, and it would be a great pity if the NHS were to abandon this well-accredited approach. ... More

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Two heads are better than one

phil steadman, cons psychiatrist
02 October 2010

An article starting with a quote from Sherlock Holmes always grabs my attention and Burns' article is no exception(1)

We made the inpatient-outpatient split in Greenwich in 2006 which resultedin my relinquishing my inpatient work.Initially I was not at all keen on the idea for the very reasons laid out by Professor Burns. As time has gone on however,I have completely changed my mind.

The main positive feature for meis that one has the benefit of a very experienced consultant colleague reviewing the case including the diagnosis and the management plan. When there is agreement,I feel reassured and move on with improved confidence. When there is a difference of views, I have the opportunity to examine what is being said and to learn from it.

I thought many patients would hate it but in the 4 years that have elapsed since the change, only one or two patients have complained to me about it. It has been a helpful change.

(1)Tom Burns. "The dog that failed to bark" pp361-363 The Psychiatrist Sept 2010
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The "Wrexham hybrid model" for acute care - achieving change and continuity of care

Peter Lepping, Consultant Psychiatrist, Visiting Professor, Associate Medical Director
02 October 2010

Dear editor,

Professor Burns eloquently defends the need for continuity of care (1). This is very close to our own thoughts and has indeed been neglected as an important point of discussion. We write as two consultantswho are relatively young (appointed in the last 7 years), British trained but with experience in other European countries. In the UK, the changes tothe inpatient service were phased in gradually and, similar to the new changes the government proposes to the health service were completely untested and no evidence for the benefit was provided. They were hailed asa new English innovation when in fact they were merely a copy of what manyother European countries do and by-and-large are trying to move away from - for many good reasons. We have some understanding of the psychiatric services in Germany and Italy, which, as Professor Burns rightly pointed out, almost represent a dichotomous position in care provision: the German model with its traditional split between inpatient and community care and the Italianmodel with its focus on continuity of care. We would like to examine the consequences of these models for us in Britain. We accept that our positions are supported largely by anecdotal evidence, but this is precisely our point: there is little evidence to suggest that the changes we allowed to happen have any beneficial effect, never mind long and medium term unintended negative consequences:- 1. the patient: since the introduction of inpatient services, patients particularly deplore discontinuity of care. In Germany, this is even more poignant. Patients are kept on inpatient wards longer than necessary because they often have inadequate regional community provision, or because they will only see a community consultant if they choose to do so.They will often then get their medication changes because communication between the inpatient and community services are poor, because clinicians disagree or because of cost pressures on community budgets, leading to more disruption. This should be a stark warning to us of the dangers that disruption causes, as if our own enquiries have not shown this already, time and time again. As Professor Burns points out, patients appreciate continuity of care, especially when they are very ill. The patient should not have to pay with a disruption of that continuity because we struggle to improve inpatient services in the light of more admissions of disruptive patients. 2. the clinician: Professor Burns rightly mentions the differences in status and its consequences for research when inpatient clinicians are kept in higher esteem than community consultants. The danger is, however, not justlimited to this. Where we have inpatient consultants burnout is high and many places have to change consultants after only a few years. Moreover, community consultants get disenchanted with not being able to look after their patients when they are acutely ill, as many did not choose to be pure rehabilitation specialists. Losing the knowledge of the acute phase of the patients’ illness may have serious consequences for long term treatment plans. On the other side, seeing a patient only in the acute phase may lead to misguided case formulations. The current changes ergo endanger the satisfaction of both inpatient and community consultants, andthe same can be seen in Germany. 3. the CRHT: Many CRHTs get dissatisfied with having to take emergency GP referrals because by and large the patients they see do not have severe mental illnesses. In fact at a recent CRHT conference in London many teamsreported that up to 50% of their referrals are patients with alcohol dependency in temporary crisis. The benefit to that patient group from intense CRHT input is very limited and disillusions teams. However, many teams seemed compelled to take any referral in order to fulfil their throughput targets. 4. the system: How did we get to a position that the acutely ill patient sees four different consultants and teams within the first three years of his or her illness (Inpatient, CRHT, First Episode Psychosis Team, CMHT, possiblysecond inpatient consultant, as the first one will have left the job by then)? How did we ever think this would be good for patients, only becausewe were unable to improve inpatient care in a different way? In Wrexham we have developed a different model, which tries to utilise thenew teams whilst keeping continuity of care. CRHTs are integrated into acute care teams that include in-patients services and are lead by a consultant. Referrals are open to CMHTs and Liaison Services only, thus making sure the service targets those with SMI or other significant psychiatric problems, such as patients with personality disorder. The acute care consultant chairs daily MDTs on the ward to insure that treatment plans are being followed through, that therapeutic interventionsare not delayed unnecessarily and that patients ready to be home treated are identified rapidly. Moreover, the consultant leads CRHTs clinical review meetings and attends CMHTs meetings, to insure effective communication. Community consultants still maintain direct input into their patients whilst they are on the ward including RC responsibility (except for PICU patients). This collaborative or “hybrid” model provides additional support in times of acute episodes and second opinions but doesnot disrupt continuity of care. We think it is possible to combine specialist services with CMHTs in a waythat ensures that continuity of care is not disrupted, that improves services without throwing the baby out with the bathwater. There is still time to bark.

Peter Lepping (CMHT Consultant Psychiatrist, Associate Medical Director, Visiting Professor) and Alberto Salmoiraghi (Head of Acute Care Programme Services, CRHT and CMHT Consultant Psychiatrist), Betsi Cadwaladr University Health Board and Glyndŵr University, Wrexham

References

1.Tom Burns. The dog that failed to bark. The Psychiatrist 2010; 34:361-363
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The dog didn't bark because it was usefully occupied

Andrew Blewett, Consultant Psychiatrist
19 September 2010

An instinctive medical conservatism compromising the ability of psychiatry to adapt for the future has perhaps been inadvertently exposed in Professor Burns's editorial (1). Very little of his editorial paper really stands up. The focus is on the in-patient community “split”. He assumes that the split has to or is likely to remain at the ward door. Dysfunctional relations between egocentric psychiatrists reminiscent of the most troubled splitting and projection associated with “psychopathology” sound like a “mess” and would be if they were to become established or even desired practice. No doubt there are some examples of fractured systems like this. He may know of hard-bitten consultant psychiatrists favouring community treatment orders (CTOs) without proper clinical consensus between colleagues; but it is not logical to condemn a movement, a “silent revolution” or otherwise by reference to its worst exemplars. His reasoning is reminiscent of the Dangerous Dogs Act.

Why is the role of the inpatient consultant “obvious nonsense”? It isno such thing. The task of the inpatient consultant is to think clearly about the best interests of the patient in context: doctors shouldn’t be inpatient consultant psychiatrists unless they possess the skills to communicate with their community colleagues and hold their confidence. Burns is pessimistic about human nature and consultants in particular. He fears that they won’t work well together, and culturally never have. Consider surgeons and anaesthetists. I can recall some examples of pretty odd behaviour; but out of necessity either would accept or cope with the consequences of decisions taken by the other. Burns’ attachment to sustaining individual medical autonomy across the whole process of patientcare is just not helpful or necessary. He refers to the Oxford Community Treatment order Evaluation Trial (OCTET) study highlighting the need for psychiatrists to demonstrate tolerance and collaboration as if this were an unreasonable suggestion. These are characteristics that should be developed in all doctors, but especially psychiatrists. Is that a problem?

A further misunderstanding concerns bed numbers and pressure. I wouldcontend that acute bed numbers have reduced for a number of reasons in recent years, one being that the appearance of crisis teams has reduced the admission rate by managing the route into acute beds and offering a preferred alternative to admission for many, thereby of necessity setting a different threshold. The inpatient mix has consequently changed. Is thisan argument for re-expanding inpatient care? Surely not, the idea that we take people into hospital to dilute the experience of others is absurd. There has been pressure on beds for as long as I can recall it first hand,since 1986, long before the changes he contests. Burns rightly dislikes confusing multiple ward rounds. It is hard to fathom why this is his experience in contemporary systems, other than through eccentric implementation of change. Is something strange happening in Oxford? If there is one inpatient consultant, there will be one ward meeting, or at least if there are more, they will feature the same consultant. This contrasts with old-style sector ward rounds, several per week, each to do with a small number of patients managed in contrasting ways quite arbitrarily by disconnected consultants interacting at times only to argueabout what sector someone lives in. I recollect strong views being expressed about a patient moving over the road. That particular problem should be consigned to history.

Burns alludes to a continental professional and service model. The reason for the arguable historical success of the British approach, in so far as it has been a success, is not in the location or otherwise of splits in the system. It is in the existence of a social health care system in the NHS and a now strained sense of collectivism. It is in AngloSaxon empiricism, sceptical of medical obscurantist-elitism feared by Burns, and an excellent and ever-necessary defence against pomposity and hierarchy building.

Finally, it is invidious to infer increased suicide rates from studies of discharge from examples of private sector units with no interest in supported discharge, or indeed follow up. Considering NHS inpatient services, what is the evidence that suicides have become more prevalent, let alone that there is a causal link?

Burns may over-estimate the importance that individual psychiatrists should attach to their role. The flip side of “continuity” is the patient who is shackled to an unliked consultant for years without fresh thinking and no automatic second opinion. Burns concedes potential advantages rather gamely. He acknowledges that we may all need a rest from each other, doctors and patients included. In past years this happened unofficially – let us recall without nostalgia the patients who revolved from one trainee to another for years on end without a shred of consultantcontinuity. They taught me a lot, but such practice is now hopefully extinct. The Care Programme Approach (CPA) involving continuity with nurses or social workers as an alternative strand to the discussion bears mentioning. Indeed CPA is probably the key to consultants having a consultant role rather than acting as a kind of parallel ghetto-ised general practitioner for people with enduring psychosis.

People do of course need stability in their key relationships. I am not at all sure that psychiatrists should appropriate a role, which properly lies “out there”; our difficult job is to try and help make that a reality and then quietly withdraw. Good psychiatrists are quite capable of sharing thoughts and plans, don’t unilaterally and thoughtlessly imposedirectives on their colleagues, are considerate of their own limitations and ultimately the very conditional nature of the impact that we personally should aim to have on peoples’ lives. When the water closes over us as if we were never there, we succeed. We have to see ourselves asless linear and more systemic, less unique and more integrated, and act humanely mindful of all, which may involve a healthy modesty and ability to share and even to let go.

1. Burns T. The dog that failed to bark. Psychiatrist 2010; 34, 361- 363.
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Conflict of interest: None Declared

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Continuity of care and consultant responsibilities

Max Lanzaro, Consultant Psychiatrist
17 September 2010

The disadvantages of the so called "split models", such as the poor fit with the Mental Health Act and patient dissatisfaction with structural discontinuity are, in my experience, increasingly reported by service users, as Tom Burns points out. One of the keys to the functionality of the new approaches is perhaps that mental health teams should work having ‘semipermeable membranes’, rather than being watertight compartments (as unfortunately they often are). I had the opportunity to work as IP/CRS Consultant withina model where the in-patient team and crisis resolution team were seen as being separated by a membrane in a two-way process that allowed gatekeeping and promoting early discharge. Within this model, the Consultant would provide supervision, leadership and medical input when needed to both the Crisis Resolution Service and the in-patient teams. One of the Consultant responsibilities was therefore to "facilitate the osmosis" whilst having abirds eye view of continuity during the acute phase of illness and the initial recovery. The bed occupancy rate dropped by 25% over 12 months, a decreased number of involuntary hospital admissions and a lower prevalence

of antipsychotic polypharmacy when compared with previous approaches was registered. Indeed we need further systematic evaluation of the new models

and their various developments in the UK.

References

Burns, T. The Psychiatrist (2101) 34 371-363

Department of Health (2005) New Ways of Working for Psychiatrists: Enhancing Effective, Person-Centred Services through New Ways of Working in Multidisciplinary and Multi-Agency Contexts. Final Report ’But Not the Endof the Story’. Department of Health.
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