The Joint Homelessness Team (JHT) is a specialist mental health service for rough sleepers in Westminster. Patients have many years of declining mental health, leading to a downward social decline, resulting in homelessness.There is a concern that mental health patients are discharged prematurely due to bed pressures. This means treatment may not be optimised, with social issues and risks remaining. Serious mental illness (SMI) is associated with reduced life expectancy and high morbidity. Thus, homelessness and SMI are a double-hit of risks for people. For JHT patients, there are many barriers to admission, including coordinating complex street or S135(1) assessments and police availability; some cases have taken months or years to plan. If patients remain sub-optimally treated at discharge, there's a high risk they abandon accommodation and return to rough-sleeping; leading to further lost years of illness and homelessness.

This was a retrospective analysis. Via SystmOne, we identified all JHT admissions in 2021 and their LOS. Data were collected, including demographics, mode of admission, discharge destination and whereabouts at three months (as a secondary endpoint). LOS figures were gathered for other Westminster patients from general adult wards for 2021.

There were 57 JHT admissions in 2021. 1 patient was excluded as still admitted. 22 patients were already care-coordinated by JHT and admitted for relapses; for the remainder it was a first admission.

For Westminster patients, there was a low variation throughout the year in number of monthly admissions and LOS; monthly average LOS range was 30-38 days. For JHT, there was higher variability for number of admissions and LOS with no seasonal pattern; monthly average LOS ranged from 4-95 days.

At three months, 22 (39%) patients were not housed in the community. Of these: 3 were discharged to the streets; 9 became street homeless; 3 were discharged to ‘Stepdown’ and went AWOL soon after; 5 patients were readmitted; 2 patients their location was unknown. 28 (50%) were housed in homeless hostels.

The data were presented at a borough-wide academic meeting.

While the dataset is small, the LOS for JHT was inconsistent, reflecting the variability of the cohort. This may need further exploration.

With 39% of admissions having unsatisfactory endpoints, this suggests that many patients were not well enough to work collaboratively out in the community. There was a consistent pattern of shorter admissions leading to poorer endpoints at three months.

Alcohol misuse is estimated to cost the NHS £3.5 billion/year. Only 6% of people suffering from alcohol dependence in England, receive treatment per year, highlighting that alcohol misuse is under-identified. During the COVID-19 pandemic, people have significantly changed their drinking habits, evidenced by government tax receipt data, suggesting alcohol sales increased by 3% to 5% in the UK compared to 2019. Problems associated with harmful alcohol consumption were intensified by the crisis, even though the long-term impacts of COVID-19 on alcohol consumption are uncertain. There was a notable increase of patients with dual diagnosis of mental illness and alcohol misuse on our ward, which is a general adult inpatient psychiatric ward. As such, the aim was to assess and improve alcohol screening on admission to an acute mental health ward.

Through a System One review, we assessed whether alcohol consumption is documented on admission (within 72 hours) in units, and a validated screening tool is used (AUDIT-C), which was expected in all patients. Their notes were initially retrospectively analysed and subsequently reviewed approximately six weeks following the implementation of interventions.

Interventions included presenting the findings of the primary survey to our colleagues during a multidisciplinary team meeting on the ward and a trust-wide audit meeting attended by both junior and senior doctors. Additional interventions included posters outlining the importance of alcohol screening in the interview rooms of the acute wards (including a QR code link to our presentation and findings).

Out of the 17 patients on the ward, 47% (8/17) were not appropriately screened for alcohol misuse during their first 72 hours of admission. 47% (8/17) had no documented alcohol history on admission clerking. Only 12% (2/17) had partially quantifiable alcohol intake, both drinking above the recommended weekly amount. None of the ‘Current Drinker’ patients had AUDIT-C screening. Improvement was noted following the interventions during the secondary survey.

Although alcohol screening in acute psychiatric admissions is often vague or incomplete, simple reminders and education can improve screening. If the alcohol history cannot be obtained from the patient on admission, which is often the case, the clinician should clearly document review of notes for historical alcohol use, to avoid potential complications, such as alcohol withdrawal, delirium tremens or seizures.

This project raises further questions on how effective brief interventions for excessive alcohol consumption in acutely unwell/psychotic patients are, encouraging a further area of research.