Audit in practice Audit of a psychiatric liaison service-the value of general practice casenotes

The practice of out-patient psychiatry has undergone a number of significant developments in recent years: the number of patients referred by general prac titioners has steadily increased: a large number of psychiatrists are now seeing patients in the primary care setting and more patients are being seen on one occasion only. Many psychiatrists have adopted a model of work ing that involves greater interaction with the general practitioner (liaison attachment model) (Mitchell, 1983).Attempts to evaluate these changes have been few. We set out to audit the psychiatric work carried out at one health centre. We attempted to evaluate its impact on general practitioner workload and GP management of patients. We also hoped to gain a measure of patient outcome from the use of GP casenotes.

The practice of out-patient psychiatry has undergone a number of significant developments in recent years: the number of patients referred by general prac titioners has steadily increased: a large number of psychiatrists are now seeing patients in the primary care setting and more patients are being seen on one occasion only.
Many psychiatrists have adopted a model of work ing that involves greater interaction with the general practitioner (liaison attachment model) (Mitchell, 1983). Attempts to evaluate these changes have been few. We set out to audit the psychiatric work carried out at one health centre. We attempted to evaluate its impact on general practitioner workload and GP management of patients. We also hoped to gain a measure of patient outcome from the use of GP casenotes.

The study
The study was undertaken at Sighthill Health Centre which is situated in the South-West sector of Edinburgh (Edinburgh adult psychiatric service was sectorised into four catchment areas in 1975,with the South-West sector serving a population of approxi mately 116,000). Resources in the South-West sector include a 23 bedded in-patient unit, a day hospital, and out-patient clinics at the psychiatric hospital (the Royal Edinburgh Hospital on the edge of the sector), at Sighthill Health Centre, and at a group practice in the sector. Psychiatrists work as part of a multidisciplinary team comprising two consultant psy chiatrists, one senior registrar, three senior house officers, 1.5 whole time equivalent social workers, two community psychiatric nurses, an occupational therapist and ward nursing staff.
Sighthill Health Centre, opened in 1953 and the first in Scotland, is situated near the centre of the South-West sector and serves a socially and econ omically deprived area of high density housing schemes. All patients referred by Sighthill Health Centre GPs, and seen at the health centre in the period 1 January 1987 to 30 June 1988, were identi fied. At the time of the study, this was the base for 27 doctors in seven separate group practices (range = two to seven principals per practice), with a total patient list of 31,195. Each week the psychiatric team was present in the health centre for four sessions (consultant: two, senior registrar with community psychiatric nurse: one, and senior house officer: one). General practitioners were encouraged to discuss patients before referral.
In addition to informal meetings, the consultant met two of the practices regularly, while the senior registrar was encouraged to liaise with two of the other larger practices. Despite these opportunities for face-to-face contact, letters remained the formal mode of communication about every patient.
Both psychiatric and general practice casenotes were examined for all referrals. Of 116 patients seen during the study period, access to both psychiatric and general practice casenotes was obtained in 99 (85%) cases (absence of casenotes was due mainly to patients changing GP on leaving the area). The remaining patients were excluded from the study. The study was facilitated by having easy access to well-filed standard A4 casenotes at the health centre.
The following were examined: type of referral; patient outcome at six months post-referral; effect of referral on GP attendance rates; extent to which psychiatrists recommendations were followed by the GP; and factors affecting GPs' compliance with rec ommendations. Results were analysed using the x2 test, where appropriate.

Information from psychiatric case notes
Twenty-six GPs referred the 99 new patients included in the study. The mean age was 35.7 years (range 16 to 73), and 65 patients were female. There were marked differences in referral rates between GPs. Thirteen GPs referred two or fewer patients over the study period, while six referred seven or more. Referral letters were generally brief, and in only 27 cases was a specific question posed. Only four GPs wrote a further letter in the six months after referral. There is no record of the discussions held in informal contacts between GPs and psychiatrists.

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Fifty-one patients were assessed by the consultant, 27 by the senior registrars and 20 by the senior house officers. As a measure of quality, the psychiatrists' initial assessment letters were scored for key information (Pullen & Yellowlees, 1985).
Psychiatric contact was generally brief; 60 patients were seen once only, and contact was maintained for more than six months in six cases. Diagnoses, reported at the time of initial assessment, are shown in Table I.
Three patients were referred to the day hospital following psychiatric assessment, and one of these was admitted to the in-patient unit soon afterwards. One patient was referred to an out-patient behavioural/cognitive therapy unit.

Information from GP casenotes
Information, giving an indication of patient outcome at six months post-referral, was available in 59 cases. There was an improvement in clinical state in 31 cases, a deterioration in 10, and no change in the remaining 18.
Patient attendances at the GP surgery in the six months before and after referral were compared. The mean number of visits for the six months before referral was 7.0, and after referral 6.3. Twenty-four previously high attenders (those attending more than 10 times in the six months prior to referral), were identified. Referral of these patients was generally followed by a decrease in the frequency of attendance (see Table II). This drop in attendance rates was sig nificantly lower than in the group as a whole (P = 0.02, x2 test). This difference remained significant when sessions with the psychiatrist were combined with GP attendances in the six month period post- Eighty-four separate recommendations were made to the GPs concerning 64 patients following initial psychiatric assessment. Sixty-seven of these concerned the prescription of medication: advice to avoid specific drugs (18); the prescription of new medication ( 18);change in dosage or discontinuation of prescribed medication (31). Seventeen recommen dations concerned other management, such as advice on GP support (7), and referral to other agencies (5).
For 77 recommendations, information was avail able on GP implementation. Of these, 75% were implemented fully (89% where the recommendation was to avoid specific drugs; 76% for the prescription of new medication; 67% where a change in dosage or discontinuation of medication was advised; and 75% for other management).
The degree to which recommendations were fol lowed by the GP varied somewhat with the patient's diagnosis: they were followed completely when the diagnosis was that of functional psychosis and in only one out of five cases when the diagnosis was personality disorder. As numbers were small, these differences could not be tested for significance. No significant relationship was found between the following factors and the degree to which recommen dations were followed: referring rate of the GP; whether or not a specific question was posed by the GP; grade of psychiatrist, and quality of psy chiatrists' assessment letter as estimated by the number of key items scored.

Comment
Psychiatric practice at Sighthill Health Centre fits the liaison-attachment model, as described by Creed & Marks (1989). A majority of patients are seen once only for consultation. Few patients are admitted to the in-patient unit although more are referred to the day hospital. There is a preponderance of minor psy chiatric disorder. Patients are often discussed with the GP without formal referral.
Audit has recently been defined as "the systematic critical analysis of quality", the three compon ents of 'quality' being effectiveness, efficiency and acceptability (Metcalfe, 1989).
To assess the effectiveness of this service at Sighthill Health Centre, impact has been examined in terms of patient outcome and the effect on GP work load. General practice casenotes proved an unsatis factory means of assessing patient outcome as frequently this information was not recorded. Williams & Balestrieri ( 1989)reported that the devel opment of general practice-based psychiatric clinics in England and Wales was related to a decrease in psychiatric hospital admissions, due primarily to an effect on the admission of non-psychotic patients. The fact that only one patient in our study required hospital admission in the six months after referral cannot in itself be taken as a measure of good outcome.
Psychiatric referral was followed by a decrease in GP surgery attendances, most marked in those who were high attenders prior to referral. Psychiatric appointments did not merely replace GP appoint ments, but served to decrease significantly the burden placed by high attenders on the GP. The psychiatrist did not. therefore, duplicate the work of the GP, and efficient use was made of medical time.
In assessing the acceptability of the service to GPs, we found that 75% of recommendations were followed fully. Few studies have examined this out come measure. However, in Cask's study of 30 new out-patients seen once only in a hospital out-patient clinic, recommendations made to the GP on 19 729 patients were carried out fully for only four (Gask,