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Importance of specialisation in psychiatric services: Commentary on … How did we let it come to this?

  • Helen Killaspy (a1)
Summary

In this issue, Dr Lodge makes a plea for continuity of care in the face of the increased specialisation of mental healthcare over recent years. However, continuity of care is not a straightforward concept and its relationship to clinical outcome is not established. The increased specialisation of mental healthcare reflects an evolving evidence base that has increased our understanding of mental illness and the treatments and delivery systems that are most effective. In other words, specialisation is the sign of a progressive field.

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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
Helen Killaspy (h.killaspy@ucl.ac.uk)
Footnotes
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See editorial, pp. 361–363, this issue.

Declaration of interest

None.

Footnotes
References
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1 Lodge, G. How did we let it come to this? A plea for the principle of continuity of care. Psychiatrist 2012; 36: 361–3.
2 Parker, G, Corden, A, Heaton, J. Synthesis and Conceptual Analysis of the SDO's Programme's Research on Continuity of Care. National Institute for Health Research Evaluations, Trials and Studies Coordinating Centre, 2010.
3 Department of Health. National Service Framework for Mental Health. Department of Health, 1999.
4 Craig, T, Garety, P, Power, P, Rahaman, N, Colbert, S, Fornells-Ambrojo, , et al. The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis. BMJ 2004; 329: 1067–71.
5 Johnson, S, Nolan, F, Pilling, S, Sandor, A, Hoult, J, McKenzie, N, et al. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 599.
6 Killaspy, H, Bebbington, PE, Blizard, R, Johnson, S, Nolan, F, Pilling, S, et al. The REACT study: a randomised evaluation of assertive community treatment in north London. BMJ 2006; 332: 815–20.
7 Glover, G, Arts, G, Balon, KS. Crisis resolution/home treatment teams and psychiatric admission rates in England. Br J Psychiatry 2006; 189: 441–5.
8 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.
9 Killaspy, H. Assertive community treatment in psychiatry. BMJ 2007; 335: 311–2.
10 Drukker, M, Maarschalkerweerd, M, Bak, M, Driessen, G, à Campo, J, de Bie, A, et al. A real-life observational study of the effectiveness of FACT in a Dutch mental health region. BMC Psychiatry 2008; 8: 93.
11 National Institute for Health and Clinical Excellence. Schizophrenia: Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Update). NICE, 2009.
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BJPsych Bulletin
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Importance of specialisation in psychiatric services: Commentary on … How did we let it come to this?

  • Helen Killaspy (a1)
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eLetters

Personal therapeutic relationship does matter

David Dodwell, Consultant in Assertive Outreach
02 November 2012

The commentary by Killaspy (1) rather dismisses literature evidencingthe value of the personal therapeutic relationship. It refers to a single publication which provides a qualitative theoretical classification of continuity issues by synthesising nine studies - most of which have no mental health component. The personal therapeutic relationship is the vehicle for delivering one of the most potent interventions in clinical medicine - the care (or 'placebo') effect (2).

Killaspy's article talks up the scientific basis for new developments, but the nature of randomised controlled trials is that they have significant exclusions which limit generalisability: the difference between efficacy and effectiveness. In particular, multimorbidity is common in the community (3) and greatly diminishes the applicability both of a single trial and of guidelines which synthesise research findings. The commentary (1) appears not to respond to the issue that novel servicesdeveloped by enthusiastic champions tend to lose efficacy when foisted onto reluctant or inexperienced staff by government policy and/or managerial bureaucracy. It makes no reference to the poor implementation of proven research and the fact that government policies are not merely without evidence base but devoid of the mentality of scientific evidence. Scientists should be clear about generalisability, implementation, and other caveats.

Further, the commentary does not answer the point that any change involving reduction in available beds will be associated with reduced bed usage. It claims that tariff-based healthcare will facilitate increased efficiency, whereas there is evidence that marketisation leads to financial inefficiencies and gaming the system, fragmentation of healthcare, and blinkered specialism (4); patients want some continuity and someone to see the 'big picture'. The current multiplicity of teams inevitably increases interface issues which are often highlighted as causing problems in high profile enquiries.It calls into question the claim that "the service-line approach will reduce the need for many patients to move between services".

I endorse the value of a therapeutic relationship with a single practitioner, particularly for long-term conditions (often multimorbid), and which often entails the other benefits noted by the commentary (1) including the efficiencies of personal knowledge standing astride balkanised interfaces. I do not wish to portray therapeutic relationships as a panacea free of side-effects - we know they are not always good and can even be damaging (5) - but it is a recognised starting point with strong positive elements.Of course, there are trade-offs between personal knowledge and other desiderata such as rapid access or specialist skills. We also know that re(dis)organisations have destructive elements and often overestimate the speed and magnitude of their benefits (6).

One conclusion might be that secondary care workers should abandon any intention to reap the benefits of continuity, and delegate this important role to our primary care colleagues. I personally consider thatprimary care, too, has its interfaces and discontinuities, and that mentalhealth care for long term conditions without long term relationships wouldbe sterile, soulless, and counterproductive.

As the NHS is being cut by 4% annually, the era of separate specialist teams may already be over.

References

1. Killaspy, H. (2012) Importance of specialisation in psychiatric services: Commentary on... How did we let it come to this? The Psychiatrist 36:364-365.

2. Moerman, D.E. (2002) Meaning, Medicine, and the 'placebo effect'.Cambridge: Cambridge University Press.

3. Barnett, K., Mercer, S.W., Norbury, M., Watt, G., Wyke, S., Guthrie, B. (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet, published online DOI:10.1016/S0140-6736(12)60240-2.

4. Woolhandler, S., & Himmelstein, D. U. (2007) Competition in apublicly funded healthcare system. Brit Med J 335: 1126-1129.5. Okiishi, J., Lambert, M.J., Nielsen, S.L., Ogles, B.M. (2003) Waiting for Supershrink: an empirical analysis of therapist effects. Clin Psychol Psychother 10: 361:373.

6. Fulop, N., Protopsaltis, G., Hutchings, A., King, A., Allen, P., Normand, C., Walters, R. (2002) Process and impact of mergers of NHS trusts: multicentre case study and management cost analysis. Brit Med J 325: 246.

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Conflict of interest: None declared

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Re:Missing points - Author's Reply

George Lodge, Formerly consultant in general adult psychiatry
01 November 2012

I agree with Dr MacMillan that unguarded enthusiasm for community services has led us into uncharted waters and that it is important to recognise the value of hospital admission. Every day psychiatric professionals conclude that that admission is necessary for hundreds of patients (1). In my editorial (2), I referred to the draconian reduction in psychiatric beds which has occurred in England over the last decade, a reduction driven, as Dr MacMillan says, by the need to fund the new multifarious community teams. In turn, the current focus on preventing hospital admissions is largely driven by the resulting bed shortages rather than by the needs of patients. These shortages frequently result inthe transient placement of patients far from home, contributing further tothe fragmentation of patients' care pathways, distancing them from family and friends and presenting challenges and delays in liaison. It is ironic that a service model intended to keep patients in their own environment has resulted in many being placed so far from home. A further irony is that it has led to the diversion of huge sums away from the NHS. In 2010/11 out of the GBP925 million spent by Primary Care Trusts in England on secure and psychiatric intensive care unit services, 34 per cent was with non-statutory providers (3).

Hospital admission may be the only practical way of keeping the patient or the community safe or the only environment in which the patientcan be provided with the care they need. It can take the patient out of anadverse environment in which their mental state is deteriorating. However,it is always right to consider whether hospital care is necessary or whether treatment could be safely and effectively provided in the community. Hospital is an alien environment. Many will recognise the wish to be home and that long periods in hospital risk habituation, institutionalisation and disempowerment.

Though accused by Dr Killaspy of nostalgia and looking back through rose tinted spectacles, I can assure her that, having worked in both acuteand rehabilitation psychiatry, I do not need convincing of the benefits ofcommunity treatment and developments in treatment approaches for schizophrenia. However, all doctors should engage in reflective practice, carefully evaluating developments and modifying practice accordingly.

Dr Killaspy quotes the 2009 NICE guideline (4) but she has been selective in her quotations. The guideline also says (p.24): 'Continuity of care from professionals capable of communicating warmth, concern and empathy is important, and frequent changes of key personnel threaten to undermine this process'. On crisis and home treatment teams, it says: 'While such teams can offer a responsive service, they can at times struggle to maintain continuity of care'. Also, 'Other service changes have seen the development in some areas of separate teams for inpatients and community-based individuals. These service changes present further potential seams and discontinuities'. The NHS Institute for Innovation andImprovement observes 'As patients pass through boundaries within and between organisations on their healthcare journey, there is often duplication, inefficiency and waste' (5).

Dr Killaspy also cites Parker et al (6), extraordinarily selectively.The more complete quote is 'For people with severe mental illness, flexibility and longitudinal continuity are the most important aspects'. Flexibility is defined as 'to be flexible and adjust to the needs of the individual over time' and longitudinal flexibility as 'care from as few professionals as possible...', a key element of the continuity which I value. A more careful reading of this 140 page review and re-interpretation of 10 studies, of which only two relate to mental health, reveals more evidence in support of my case. Interestingly, 'the most striking thing to emerge' from questionnaires from professionals was 'the relative lack of enthusiasm for specialist teams such as home treatment (crisis resolution) teams or assertive community treatment (assertive outreach) teams'.

It is a truism that specialists tend to do what they do better than generalists. However, against this should be balanced the impact of the short duration of contact these specialists will have with a patient, something unlikely to foster the good relationships the Parker study says patients (p.43) and carers (p.58) value. Patients' 'experience was often that repeated staff changes led to feelings of helplessness and isolation.Having continually to retell their story to new staff was experienced as devaluing the story'(p.43). The result can be that the story is never fully told or recorded, thus reducing the chances of an effective patient-centred care package.

Dr Killaspy expresses the concern that 'it is unrealistic for every psychiatrist to remain fully informed and competent to treat all mental health conditions in accordance with the best available evidence'. However, in my experience, teamwork can provide specialists from within the team or specialists can be called in from outside, when needed, without having to change the whole team.

I have made it clear that I support the principles of helping patients to remain at home, of psychoeducation and family interventions. What I object to is the disjointed way in which services are typically provided today, which, in my experience, is inefficient and often ineffective.

References

1.HES online, Hospital episode statistics. Primary diagnosis summary:2010-2011. NHS Information Centre for health and social care, 2011/11. (http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=202)

2.Lodge G. How did we let it come to this? A plea for the principle of continuity of care. Psychiatrist 2012; 36: 361-3.

3.Mental Health Network. Mental health and the market - briefing. NHSConfederation, October 2012

4.National Institute for Health and Clinical Excellence. The NICE guideline on core interventions in the treatment and management of schizophrenia in adults in primary and secondary care - updated edition. NICE, 2009.(http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf)

5.NHS Institute for Innovation and Improvement. Joined-up care, delivering seamless care. NHSIII. (http://www.institute.nhs.uk/qipp/joined_up_care/joined_up_care_homepage.html)

6.Parker, G. Corden, A. Heaton, J. Synthesis and Conceptual Analysis of the SDO's Programme's Research on Continuity of Care, National Institute for Health Research Evaluations, Trials and Studies CoordinatingCentre, Southampton, 2010.

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Conflict of interest: None declared

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Missing points

J Fiona Macmillan, consultant psychiatrist
15 October 2012

In response to the two articles by Lodge and Killaspy (1) I feel, with respect, that the authors have missed two terribly important points. Firstly that our enthusiasm for community services overcame us and secondly that we forgot admission to hospital can be a very powerful intervention.

The 11th report of the now deceased Mental Health Commission wrote cogently in 2003/5(2):- />
"The systemic relation between hospital and community elements of mental health care make it difficult to determine whether inpatient overcrowding should be addressed by increasing bed numbers or further concentration on community support."

The report also gave information about inpatient care:-

".. the number of psychiatric beds has reduced dramatically from a highpoint in the early 1950s... The number of NHS mental illness beds available to services in England in the last twenty five years(up to 2002)...shows a 40% reduction since the 1983 act..however, as these figures do not include beds in the independentsector...the available but incomplete data on NHS and independent bed provision ..appears to show that, while the numbers of available beds in NHS facilities fell by around 20% between 1994 and 2001, the overall decrease in bed availability during that period was approximately 5% ,oncethe growth in the independent sector is taken into account,

..In our view it is appropriate to note that independent sector services, whether profit-based or not, will rise and fall according to thedictates of the market.Given our estimate...that the actual reduction in beds was 5% up to 2000/1... it could be that we have already attained the minimum number of psychiatric beds for a viable service."

It seems that the road taken was to invest in community services over the following decade - quite commonly at the expense of inpatient care. Now some services are reducing the number of functional teams. Few seem to be re-investing in acute inpatient care.

I remain to be convinced that developing community services across multiple functions (or specialisms, if you prefer) or putting these resources in catchment based teams would solve the issue that most of us (clinicians and patients) have faced sometime painfully recently.. where and when might we get a bed?

Dont get me wrong ,my threshold was high enough,but sometimes admission is the kindest thing. (1) How did we let it come to this? A plea for the principle of continuity of care, George Lodge, and Importance of specialisation in psychiatric services: Commentary on... How did we let it come to this? Helen Killaspy, The Psychiatrist Online October 2012 36:364-365; doi:10.1192/pb.bp.112.039537 (2) Mental Health Act Commission 11th Biennial Report, 2003/5, In Place of Fear.praesed from chapter 2 , The Context of CareISBN 0 11 322717 5

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Conflict of interest: None declared

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