Therapeutic community provision at regional and district levels

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Therapeutic community provision at regional and district levels

Steffan Dovies, Penelope Campling and Kerry Ryan
Aims and method The aim of the study was to investigate changes in service utilisation following therapeutic community treatment for patients with severe personality disorder.The study examined service usage, in the form of acute psychiatric admissions,of a seriesof 52 admissionsto a residential therapeutic community in the three years before and year after admission.Results Therewas a reductioninthe mean durationof acute psychiatric admissions after treatment, this was greater for extra-contractual referral patients than local district patients.Clinical implications Thisstudy replicates resultsfrom previous studies.It also suggests that more accessible local services may be able to intervene earlier in patients' psychiatric careers preventing heavy use of acute services.We argue for greater provision of therapeutic community treatment for severe personality disorder.
There has been much interest in recent years in the treatment of personality disorder in therapeu tic communities.Recent research gives some support for the efficacy (Dolan & Coid, 1993) and cost-effectiveness (Chiesa et al. 1996, Dolan et al 1996) of this form of treatment, although no controlled trials exist for practical, ethical and financial reasons (for a fuller discussion see Lees, 1999).Much of the published research has come from the Henderson and the Cassel Hospitals which offer supra-regional services and are largely funded by extra-contractual referrals (ECRs) (Dolan & Norton. 1992).The patients referred to these units are highly selected and often have a long wait for funding to be agreed, if any is forthcoming.The recent joint Department of Health/Home Office Review of Services for Mentally Disordered Offenders Sub-Committee on Psychopathic Disorder recommended the provision of more therapeutic communities (De partment of Health & Home Office, 1994).Effective treatment of patients with severe per sonality disorder (SPD) may also contribute to the attainment of the 'Health of the Nation' targets, particularly on suicide (Norton, 1992).There are a number of other National Health Service (NHS) units operating as therapeutic communities, either as in-patient services like our own (Francis Dixon Lodge) or as day services, such as Winterbourne in Berkshire (Knowles, 1997).While there is good evidence that the supraregional services are clinically-and cost-effective, the optimum level of therapeutic community provision across the country is not known.
There has been a recent debate in the British Journal of Psychiatry over the optimum style of service.Units operating as day services are limited in the area they can serve by daily travelling times and may have problems contain ing some of the more disturbed patients treated by in-patient units (Campling & Davies, 1997).They are, however, much cheaper to run as they do not require 24-hour cover, have reduced hotel costs (Haigh & Stengen, 1996) and can be more easily integrated with other services (Knowles, 1997).In-patient units can provide services to a much greater geographical area and can contain higher levels of disturbance but are inevitably more costly.The follow-up of patients on discharge (Norton & Hinshelwood, 1996) is also more difficult.
The cost-offsets of therapeutic community treatments are predominantly through reduced psychiatric admissions and periods of imprison ment but also in the consumption of general medical, accident and emergency, general practi tioner (GP), probation and social services.Costoffset is in addition to the 'health gain' in clinical, psychological and social terms.Those referred for ECR-funded treatment are likely to be high consumers of psychiatric or criminal justice services and skew the cost analysis in favour of supra-regional services.Services provided at a more local level are likely to get fewer high service users and it is therefore more difficult to demonstrate cost-offsets.Local and more acces sible services, which avoid the long delays of obtaining ECR funding, may.however, be able to intervene earlier and create additional gains.This may prevent costly acute in-patient stays aimed at reducing risk, which generally appear to be of little therapeutic benefit to this group, and are sometimes detrimental (Norton & Hinshelwood, 1996).
Our 16-bed service is funded by the district health authority but takes around 20% of its referrals as ECRs, mainly from the Trent Region but from as far away as South Wales.This allows comparison of the psychiatric service use of a district and ECR group which may throw some light on the ideal levels of service for a given population.Leicestershire, as the largest health authority in the country (population 930 000), is in a better position than most to support a district in-patient psychotherapy unit.The potentially difficult transition at discharge is reduced by a group (Next Step) beginning six weeks before discharge and continuing for six months.Francis Dixon Lodge also offers on-going follow-up in the form of an ex-resident drop-in group which meets weekly for those in crisis.In therapeutic terms the treatment at Francis Dixon Lodge is similar to the Henderson Hospital in that therapy takes place exclusively in group settings in contrast to the individual therapy provided at the Cassel.The previous service usage is also more like the Henderson Hospital with many patients being heavy users of general psychiatry in-patient services in contrast to the greater usage of out-patient psychotherapy for Cassel patients (Chiesa et al, 1996).The diag nostic status of the patients and their severity of personality disorder remains open to debate.Using DSM-III-R criteria (American Psychiatric Association, 1987) and a self-report question naire, patients at the Henderson received a mean of 6.04 personality disorder diagnoses.ICD-10 (World Health Organization.1992) uses the most clinically significant personality disorder diag nosis, and does not normally permit multiple diagnoses.Standardised measures of severity, particularly for people with severe personality disorder do not exist, although work in this area is underway (e.g.Tyrer & Johnson, 1996).

The study
A series of consecutive admissions (n=52) between 1 January 1993 and 31 December 1995 was identified from admission records at Francis Dixon Lodge.(One patient who had a very brief admission of two days from outside the region and for whom information was incomplete was excluded.)The psychiatric admissions of these patients were traced for three years before admission and after discharge from Francis Dixon Lodge until 30 June 1997 (further followup is planned).For Leicestershire patients this was done through the Patient Administration System (PAS) and for ECR patients by contacting their referring consultants and the psychiatric units in the area to which they were discharged.This was cross-checked with their GPs when necessary.By the 30 June 1997, 47 of the 52 patients had been discharged for at least one year.Data analysis used SPSS 7.5.

Findings
The mean age of patients was 27.3 years (range 19-44).Thirty patients were women and 22 men.Forty patients were from Leicestershire and the remaining 12 ECR.Diagnoses ICD-10 diagnoses were made by the clinical team, usually at each patient's three-week review (one patient had a very brief admission and insufficient information was available to make a diagnosis).The predominant ICD-10 personality disorder diagnosis was F60.3 (emotionally unstable, 86.5%) (74% of Henderson patients were diagnosed as suffering DSM-II1-R border line personality disorder).Other personality disorder diagnoses were: paranoid, 3.8%: depen dent, 3.8%; schizoid.1.9%; and anakastic, 1.9%.Secondary ICD-10 diagnoses were diagnosed for 61.5 and 17.3% tertiary.Forty per cent met criteria for harmful use or dependence on alcohol and/or drugs, 25% for eating disorders and 13% recurrent depression or dysthymia.There were no significant differences between ECR and district groups in terms of diagnosis, gender or historical factors on y2testing.The ECR patients had a mean age of 24.5 (s.d.=3.9) which was significantly different from the Leicestershire mean of 28.1 (s.d.=6.8), (-test for equality of means, unequal, P=0.026.

Service usage
By 30 June 1996, 47 first admissions to Francis Dixon Lodge had been completed.The mean length of stay for the 12 ECRs was 265 days (total 3178 days, cost Â£418924) and for the 35 Leicestershire district patients 180 days (total 6310 days, cost Â£831924).By 30 June 1997 two of the ECR patients had been readmitted to Francis Dixon Lodge for a total of 42 days, four of the Leicestershire patients had been readmitted for a total of 545 days.

Cost-offset
For ECR patients the average cost of acute admissions in the year before treatment at Francis Dixon Lodgewas Â£9499.The average cost of Francis Dixon Lodgeadmission was 265 days at Â£131.82a day=Â£34 932.The average cost in the first year after admission of 7.2 days at Â£128.94a day=Â£928.Consequently, the cost-offset in first year was Â£9499-Â£928=Â£8571.The time to fund treatment was (Â£34 932/Â£8571)four years.

Comment
The results show important differences between local (Leicestershire) and ECR patients (see Tables 2 and 3).The ECR patients had spent longer periods on general psychiatry wards in the three years preceding admission to Francis Dixon Lodge than Leicestershire patients.Our findings were similar to those of the Henderson Hospital (Dolan et al, 1996), who found a mean bed occupancy of 71 days in the year before referral, whereas our ECR group occupied an average of 74 days.In the year of follow-up after admission to the Henderson there was a mean bed occupancy of 7.5 which is almost identical to the 7.2 for our ECR sample.The less striking changes for Leicestershire district patients suggests that there is a gradation of severity, in terms of in-patient usage, from regional/supraregional more selected ECR patients to district referrals.For ECR patients the cost-offset calcu lated for the year before and after treatment would lead to treatment funding itself in about four years.For the ECR group, 43% of the total acute occupancy over the preceding three years occurred in the year before admission.This would argue against a ceiling-floor effect where patients are referred at their worst and improve ment which may have occurred naturally is ascribed to treatment.Although using more bed days in the year before admission substantial usage had also occurred in the second and third years before admission.
The difference between the ECR and district group is of interest.In the three-year period before admission they occupied an average of 168 and 57 occupied bed days respectively.The year before admission this accounted for 43% of the three year total for the ECR group but 63% for the district group.Referral to a district service, which is more familiar to referrers and does not involve obtaining ECR funding, may promote earlier treatment and prolonged general admissions may be avoided.The easy availability of alternative treatment facilities may also  influence management by general psychiatrists.The availability of a local alternative to prolonged acute admission gives more treatment options and better opportunities to manage severely personality disordered patients constructively.One possibly negative result is that as there is less invested in the referral by referrer and patient (as there are less obstacles and easier exits) district patients are less likely to complete their treatment suggested by reduced average stay (180:265).The average stay of the four district patients who were re-admitted was 132 days, suggesting that some may have completed treatment after an abortive first admission.

Therapeutic community provisions
This evidence has a number of implications for the provision of in-patient psychotherapy for patients with severe personality disorder.Region al/supra-regional services, with more selected patients and greater barriers to referral, have demonstrated cost-offsets implying treatment is self-funding in the medium-term.
The ECR patients in our sample also demonstrate a costoffset, although the costs on which these assump tions are based are different.(For further discus sion of economic evaluations of therapeutic communities see Davies (1999).)It is likely there fore that there are sufficient patients for every region to justify an in-patient unit for SPD patients as rates of SPD are likely to be similar throughout the UK.This is only likely to be feasible with a degree of central planning and an alternative funding mechanism to the current ECR system.The much higher proportion of inpatient usage in the year before admission in the patients from district rather than regional origin suggests a preventative effect for in-patient therapeutic community treatment earlier in pa tients' psychiatric career.The easy availability of a district service is also likely to lead to less disturbed patients being referred, possibly indi cated by the greater mean age of the district sample.It is possible that some of these could be effectively managed in local day services (Vaglum et al 1990;Haigh & Stengen. 1996).We are currently experimenting with the use of day attendance towards the end of patients' treatment at Francis Dixon Lodge.
The reduction in usage of psychiatric in-patient beds following treatment of severe personality disorder in a therapeutic community adds to the growing body of evidence for the efficacy of therapeutic community treatment for this group of patients.The demonstration that a service can be effective on a regional level suggests that there should be provision of an in-patient unit for SPD patients in every region.The differences between ECR and district referrals suggest that locallybased, easily-accessible therapeutic community facilities may reduce, or prevent, usage of general psychiatry beds by this patient group relieving pressure on these overburdened services.

Table 2 ,
General psychiatry admissions three and one year before admission to Francis Dixon Lodge test showed a significant difference (0.009) between the mean length of previous admissions for ECR and district patients after data reduction by standardised z scores.2. Paired sample f-tests showed no significant differences between the mean admissions one year pre-and postadmission to Francis Dixon Lodge for the total sample, district and ECR groups after data reduction (z scores).3. The costs are 1996-97 contract costs for Leicestershire Mental Health Services NHS Trust/Leicestershire Health and average costs for Trent Region for ECRs (Francis Dixon Lodge=Â£131.82,Leicestershire acute=Â£l 10.14, Trent acute=Â£l 28.94) further details available from the author upon request.

Table 3 .
General psychiatry admissions in the year after admission to Francis Dixon Lodge Paired sample Mests showed no significant differences between the mean admissions one year pre-and postadmission to Francis Dixon Lodge for the total sample, district and ECR groups after data reduction (z scores).2. The costs are 1996-97 contract costs for Leicestershire Mental Health Services NHS Trust/Leicestershire Health and average costs for Trent Region for ECRs (Francis Dixon Lodge=Â£131.82,Leicestershire acute=Â£110.14,Trent acute=Â£l 28.94) further details available from the author upon request.