Care programming and service change in a psychiatric sector

The effects of service expansion and change (including joint working with social services) following the provision of a community mental health centre and the introduction of care management were examined by auditing service activity. Data were collected on service provision to 20 randomly selected patients who met the local criteria for care management, and also on the general level of service activity as judged by service contacts for all disciplines. Compared to the baseline period, face to face contact with care-managed patients increased six-fold. There were more home contacts, a wider range of professional contacts occurred, and a greater variety of types of treatment provided. A substantial (though not statistically significant) reduction in day hospital attendance was seen over the period studied. The number of service contacts for non-care-managed patients also rose. The introduction of care management was simplified by changes in service organisation. Increased resources were needed to both implement care management and provide an adequate service to the remainder of patients. Both aspects of the service functioned efficiently in parallel.

(a) The opening of a community mental health centre (CMHC). (b) The provision of 'acute' services for selfreferrals and urgent referrals from general practitioners (GPs) in the CMHC.
(c) The commencement of 'care management'. (d) The institution of specialised types of community care (with the emphasis on carers and home-based where possible) for those with long-term mental health problems. (e) The beginning of 'joint service' work involving both health and social services.
The most telling factor in provoking service change was the decision to provide funding for the CMHC, and the staff to work in it. That decision was made when it was seen that the imminent closure of the large district mental hospital, St Augustine's (near Canterbury), could be used to provide capital for services in some of the distant communities (in this case, the Island of Sheppey) which it served.
Although the shape of the service was to a large extent determined purely by the physical reality of the CMHC, the service provided from it was planned with the primary aim of providing better services for those most in need of them.
There were a number of pragmatic consider ations. Although the policies in Caring for People (Department of Health, 1990) were meant to address the problems of providing a service for the more severely ill. In essence, they only described a protocol for more systematic mon itoring of long-term care. However, there seemed to be no reason why such procedures in themselves would increase actual care provision.
Those with severe long-term mental illness, particularly schizophrenia, were known to be both considerably distressed by their ongoing acute symptoms (Melzer et al 1991) and have very inadequate ranges of service provided for them (Salokangos et al 1991). However, models of the type of service to provide for this level of problems among its client group were well described from an empirical standpoint (Isaacs & Bebbington, 1991, Onyett, 1992. both as regards acute interventions and long-term continuing care. It seemed pointless to assess needs en masse when no hope of meeting them was there. For this reason, those involved in care management opted to use it as the basis for providing an Psychiatric Bulletin (1998). 22, 537-542 increased range of services, with an increased level of face to face contact, and with as many contacts as possible involving the family.
Those not acquainted with the issues of continuing care, case management, family coun selling and interventions, home-based treat ments and outreach took it upon themselves to gain the skills necessary.
The question of joint service working was approached from a purely practical standpoint, it was likely to benefit those (and their families) who were at present underserved.
However, the health services had to provide a generally available service for those who were already on case-loads and new contacts. Most of the resources (community mental health nurses (CMHNs), in particular) were at this time being devoted to such a service, the demand being GP led. This demand would undoubtedly continue. The provision of the CMHC might in fact increase this demand purely because of the increased availability and visibility of the service. We were aware that these factors could compromise the care of those with more severe illness (Sayce et al, 1991).
It appeared that the interests of both groups of patients could be best served by differentiating the service into two more specialised separate components. The main thrust of staff deploy ment and activity would be toward the more severely ill. This would centre around those who were to be care managed, but in order to emphasise the active and intervention-oriented aspects, the group involved with this work would be called the 'care management/rehabilitation' team. These staff would work side-by-side with social services.
This side of the team would concentrate on services for long-term and severe mental illness. A named keyworker, or their deputy, would be always available during normal working hours (the CMHC switchboard was manned 09.00-17.00) for patients or relatives, or other profes sionals. When necessary, a 'rapid response' to the home would be made.
A separate team-within-a-team, the 'acute' team, would provide a service to those who did not necessarily require longer-term involve ment, and staff a rota to provide a walk-in, selfreferral service (or at the urgent request of a GP), who could see the patient there and then if this was appropriate, or if the degree of urgency was less, see as a normal appoint ment. This side of the service would also deal with non-urgent, 'routine', referrals. After an initial assessment, appropriate treatments would be offered.
The long-term had input from two CMHNs, though one doubled as coordinator, and both social workers and the community occupational therapist were the other permanent staff. The psychologist worked mainly with the 'acute' team, and this team had one full-time CMHN (who was also an experienced counsellor). The medical staff worked equally with both, as did the clerical and administrative staff. The duty rota was manned by all health service staff.
It would also be the task of the whole team to focus on 'care programming', initially for those being discharged from hospital, and ultimately for the generality of service contacts.
Service changes were not limited to the actual health care workers. At the time that the CMHC was opened, a day centre, providing informal leisure and social activities, moved next door. This had a membership, at this time, of 50, which had increased to 80 by the end of the period of the evaluation.
A fundamental change in social services work ing practices had been caused by the introduc tion of care management.
Concentrating resources on this meant that no work would be undertaken (at least, on a routine basis) with patients who did not meet the criteria for care management implementation.

The study
The present study aims to describe and evaluate the most important aspects of the functioning of a service manipulated to facilitate better working practices with the long-term mentally ill while maintaining a general 'acute' service. The out come measures were chosen as being those best quantifiable from available data.
The report is based on service details obtained from the case notes and computer records of a random sample of 20 patients at present being care managed, and comparing these on three, six-month periods: June-December 1992 (base line), 1993 (intermediate, when the CMHC was operating, and staff relocated there), and 1994, when the CMHC, and care management, were fully operative.
The impact of the service changes, based on the number of patient contacts, on the level of activity of the 'acute' services is discussed. The details of patient contacts with health services at the CMHC are entered and held on a compu terised mental health information system, 'Men tal Health Connection IF.
As this system was not used by social services during the period of the evaluation, details of their activities (though substantial) cannot be provided. No figures for voluntary services activities are available.

Findings
The demographics and diagnostics details of the cohort are shown in Table 1, and the relevant team structure changes are shown in Table 2. review. Within service documented communi cation has increased five-fold.
Urgent, emergency and hospital care (Table 4) Urgent calls and urgent out-patient department appointments have declined. Urgent out-patient department appointments fell from nine and 10 in Period 1 and 2, respectively, to zero in Period 3. Emergency domiciliary visits, overdoses and casualty assessments have not changed, though the numbers are small. There has been a reduction in the numbers of admissions to the day hospital. Mean weeks of day hospital attendance (with 95% confidence intervals) for the three periods were: Period 1, 6.9 (3.1-10.7): Period 2, 2.2 (-1.4 to 5.8), Period 3, 3.1 (0.1-6.1). In-patient weeks dropped by about 25%.
Routine care (Table 3) Average routine psychiatric out-patient contact levels have not changed, but the number of those seeing someone other than just the doctor alone (in this example CMHN)has risen to 17/20 from 10/20. The other three patients were care managed by other disciplines. All patients had at least two points of contact with the service.
The number of patients on medication has gone up, possibly due to increased awareness of symptoms or increased compliance. The level of communication with GPs has doubled (without counting invitations to reviews, individual ser vice plans, or correspondence from social ser vices). However, no GP actually attended a Care management-related contacts and activity (Tables 5 & 6) These tables show the ranges of treatments, services and activities being provided in the final period. These are specific treatments (behaviour al, psychotherapeutic and family counselling), as well as non-specific (supportive counselling).
The average number of health service staff contacts (this includes all disciplines) has in creased from a baseline figure of 11.5 per patient (though only half saw anyone other than the doctor) to 29, over the relevant periods. One patient only did not have a review, or an ISP update, in the six months studied. However, this person had the highest overall time in contact  anxiety management), often jointly, and also family work (education, counselling and therapy).
with the service. This makes review relevant. statistic itself clearly Community occupational therapist CMHN activity in the team The tables of care management generated con tacts and activities relate mainly to the com munity occupational therapist and CMHN (they also include psychology contacts). Both occupa tional therapist and CMHN functioned as care managers (three patients by community occupa tional therapist, eight by CMHN). otherwise occupational therapist involvement was decided by the necessity of specific occupational thera pist skills (assessment, activities, occupation, etc). These two staff undertook group activities Social services activities There were many similarities between the activ ities of care managers from both services, in the areas of assessing general needs, discussing benefits, proving support, discuss housing issues and encouraging socialisation. However, the policy was to allocate a care manager to patients with specific therapeutic needs who had some relevant clinical skills, for instance, In family therapy. Although social workers might participate in running various groups, the primary responsibility for example the hobbies group was with the occupational therapist. Social workers did engage in counselling regard ing the impact of symptoms on patients' lives but the team clinical psychologist and the continuing  (Table 7) There was a gradual rise in overall community team activity from the opening of the CMHC in May 1993, and the total number of team consultations (see Table 7) roughly doubled in this period. The total number of consultations by the CMHNs doubled also, though these figures include care management-related activities.
In the year prior to the opening of the CMHC. about seven new patients a month were seen in the out-patient department by the psychiatrists. Immediately following the opening of the CMHC (second half of 1993) the numbers of new patients seen rose to 20 per month, though they then fell.
However, compared to the first six months of 1992 (4.5 new patients per month seen) the overall activity by the psychiatric services in 1994 had doubled, seeing an average of 10 new consultations a month throughout 1994. The comparable figures for out-patient follow-up consultations was 54 per month (first six months of 1992) and 100 per month (all 1994).
The CMHNs had been able to make an increase in the number of new assessments undertaken from 14 per month in the second half of 1993 (prior to their team restructuring, and an in crease of staff from 2 to 2.5 whole time equivalents) to 24 per month in the second half of 1994.
The service output has increased by > 100% for all activities (all CMHN contacts) and > 50% as regards acute assessments.
Face to face contact with the service During the baseline period, any patient was seen (on average) six times by the psychiatrist and, if they were seen by the CMHN, an additional 12 times. This would have been roughly 15 minutes for each contact, that is, an average of 4.5 hours for those seen by the doctor alone, in face to face contact. The average time in contact with the services has increased to 24.5 hours each. A large proportion of this activity is home based and/or family oriented.

Comment
In the old style service, whether a patient with severe long-term illness saw anyone other than the doctor was determined by whether they were receiving medication by long-acting injection or not. This meant that virtually no patient with a diagnosis other than schizophrenia ever saw any other health service professional than the doctor, except in a crisis situation.
Contact with patients' families was by and large restricted to that possible during consulta tions, and counselling of patients and their families was likewise limited. This can be contrasted with the range of treatments, services and activities now provided for this group of patients across all diagnostic categories (half the patients described have diagnoses other than schizophrenia). This is still not a vast level of input (clearly much less than would be provided by a day hospital), but it is a four-fold increase on the part of the health services.
How well services are matched to needs, and what level of overprovision or wastage is occur ring, is of course relevant. On the other hand, there are still many service gaps, and we are still not able to state categorically that quality of life has improved.
The service changes have been quite complex. There is no doubt that no major changes in team structure are necessary solely in order to implement care management (Kingdon, 1994). However, the question remains as to whether the assessment and review processes of care man agement can ensure more effective care delivery, if they cannot provide any worthwhile change in the amount or quality of care provided.
The type of service attempted by us is not as intensive as "assertive community treatmentan interdisciplinary team-oriented approach (which) provides field-based, individualized, di rect treatment and rehabilitation services to a limited set of patients" (Santos et al 1995), nor was it an attempt to provide a substitute for hospital care such as the Daily Living Programme (Muijen et al 1992). The value of these kind of 'assertive outreach' programmes for the highly vulnerable is clear, but the effects, or effectiveness, of community care in other guises, or current policies to implement it, are not so clear (Marshall, 1996).
Although there may be some debate as to whether a service such as ours, with less restrictive criteria for response, may be wasteful of the skills of those trained in mental health care (Gournay & Brooking, 1994) in practice, the psychiatric service must be able to serve the needs of those across the spectrum of mental illness. We would argue that the balance has at least been shifted in the right direction.
On the other hand, the introduction of care management has led to a contraction of social services' role in mental health care, in that they can no longer cater for patients with less severe illness. Many of these patients would benefit from 'traditional' social work input and contact. Some of these cases are probably being dealt with, by default, by services such as our 'acute' service.

Phil Thomas
Recent changes in the law and mental health policy have forced psychiatrists and other mental health professionals to review the traditional cloak of secrecy that surrounds record keeping and letter writing. This paper establisheswhat proportion of patients attending a psychiatric out-patient clinic are interested in receiving letters from their psychiatrist. Those who are interested tend to be better educated, whereas those who are not interested are much more likely to have an ICO-10 diagnosis of schizophrenia. Overall, there appear to be high levels of satisfaction with the nature of the letters received. Thesignificance of these findings is discussed in relation to the difficulty of engaging people with the most severe and enduring forms of mental health problems as active participants in the process of care.
A recent Government paper (Department of Health. 1996) emphasises the importance of patient involvement in decision-making pro cesses about treatment. Everyone agrees that psychiatric patients should be given the infor mation necessary to understand and participate in their treatment, but there is no consensus as to the best way of achieving this. A Court of Appeal ruling in 1994 made it clear that while patients have a prima facie right of access to their clinical notes under the 1991 Access to Health Records Act. this may be denied under certain circumstances (Brahams, 1994). The 1991 Act triggered a flurry of papers examining the ethics of patient access (McLaren, 1991;Weil, 1993) or its practicalities (Parrott et al, 1988;Asch et al 1991;Bernadt et al, 1991). This signifies a move away from the tradition of medical paternalism to a more person-centred approach to health care. However, the discussion about access to medical records, and the related issue of patient involve ment in decision-making processes about treat ment, is dominated by an important assumption: