Use of specialist services for obsessive-compulsive and body dysmorphic disorders across England

Aims and method In April 2007, the National Specialist Commissioning Team of the Department of Health commissioned a group of services to provide treatment to patients with the most severe and profound obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). We decided to examine the usage of these services across England 4-5 years after the start of the new funding arrangements. This survey used data about patients treated in the financial year 2011-2012. Results Despite the services offering intensive home-based as well as residential and in-patient services, there was a greater proportion of referrals from London, the South East of England and counties closer to London. Clinical implications It is important that all patients, regardless of where they live, have access to highly specialist services for OCD and BDD. We discuss potential ways of improving this access but we hope this paper will act as a discussion forum whereby we can receive feedback from others.

psychiatrists in England and to all the commissioners. We therefore decided to audit the referrals from different geographical regions in England and to compare the rate of referral and uptake of different treatments for these patients, to determine whether and how usage of the NSCT OCD service varies according to place of residence.

Method
All referrals made to the nationally commissioned services for England were recorded during the financial year of 1 April 2011 to 31 March 2012. Records were kept of the demographic data including age, gender and diagnosis as well as the geographical origin of the referral. In addition, the severity of the OCD or BDD symptoms were assessed using the Yale-Brown Obsessive Compulsive Scale (YBOCS) for patients with OCD 3 and the Yale-Brown Obsessive Compulsive Scale modified for BDD (YBOCS-BDD) for those with BDD. 4 Because the YBOCS is scored out of a maximum of 40 and the YBOCS-BDD out of a maximum of 48, patients with BDD had the YBOCS-BDD score divided by 12 and multiplied by 10 to ensure all scores of severity were equivalent. For all patients treated as out-patients or with home-based therapy, the number of hours of treatment was recorded.
All data were analysed using Statistical Package for the Social Sciences version 14 for Windows.  Table 2.

Referrals from different regions
Dividing the referrals into the ten health authorities in England the overall number of referrals from each region is shown in Fig. 1. The greatest number of patients referred derive from London and the South East quadrant of the country. Patients from outside London and south-eastern regions would be expected to be less likely to attend for out-patient treatment but the rate of home-based therapy, residential treatment and in-patient treatment may be expected to be more evenly spread. The data were therefore reanalysed excluding out-patients (Fig. 2). This still shows a preponderance of patients from London and the south east of England but with a slightly greater spread of geographical referrals.
As there is a slight variation in the population in each of the ten regions, a more accurate picture was obtained by dividing the number of referrals from each region by the total population in the area to produce the referral rate. This was multiplied by 10 6 (Fig. 3).
It can be seen that London and the South East still refer more patients than other areas, with the North West, North East and Yorkshire/Humber having the lowest rate of referrals per head of population. The ten referring authorities were divided into four zones depending on the distance from London (Appendix 2). The number of patients as a percentage of referrals from that zone treated in each way is shown in Fig. 4. Owing to the smaller number of patients treated from Zones 3 and 4 this is shown as a percentage of total referrals. Figure 4 shows that patients from London and the South East are more likely to be offered out-patient treatment; home-based treatment was most likely to be offered to patients living in Zone 3 (150-250 miles away; South West, West Midlands and East Midlands). In-patient treatment remained fairly constant across all areas (presumably due to the severity of the condition requiring 24 h care). Residential treatment (without 24 h nursing cover) was less likely to be offered to patients from London and the South East.

Types of treatment offered to patients from different regions
Analysis comparing patients treated with out-patient compared with in-patient treatment demonstrated that those with a higher YBOCS score were more likely to be offered more intensive treatments. 3). The difference in severity between those treated as out-patients and in-patients was found to be significant (t-test, P50.009).
Examining those treated with out-patient or homebased therapy, it was found that out-patient treatment was more likely to be offered to patients nearer to London (chi-squared test, P50.0009). Home-based therapy is not related to distance from London (chi-squared test, P = 0.3220), although there remains an overall lack of referrals from the North of England. For all patients treated by the service as out-patients or by home-based treatment, the average number of hours (excluding assessment) is 17.7 h per patient (range 1-55, s.d. = 11). When number of out-patient and home-based treatment hours was compared for geographical distance from   London, it was found that patients further from London were likely to receive as many hours of treatment as patients from nearer to London (chi-squared test, not significant).

Discussion
Overall we demonstrated that there was a significant geographical variation in patients referred to a specialised OCD/BDD service for those individuals with severe, treatment-refractory OCD and BDD. This could either be because of there being fewer patients requiring this level of intervention outside the South East of England or due to lack of knowledge of the services or an unwillingness to refer patients far from home. It would seem unlikely that there are fewer patients outside the South East of England requiring such specialised intervention. It is also notable that some areas seem to send more referrals than others. This variation in referral rates may reflect variation in the distribution of interested clinicians and/or low referral rates could represent the availability of high-quality local services that compete with NSCT referral. Alternatively, low referral rates may represent failure to recognise and refer patients with severe OCD to appropriate resources. Our data did not allow us to analyse this at the current time. It is, however, likely that there are a large number of people with the most profoundly disabling OCD and BDD who are not receiving treatment. Most surveys of specialised services for OCD and BDD seem to suggest that most patients wait almost 20 years from first diagnosis to receiving highly specialised treatment. [5][6][7][8] Treatment, even with this most difficult and treatmentrefractory group of patients, is however remarkably successful, demonstrating average improvements in YBOCS and other measures of OCD symptomatology of approximately a third [5][6][7][8] and with these changes remaining after treatment termination. 5 It thus seems unlikely that referrers are unwilling to refer elsewhere and seems more likely that the problem lies with their knowledge of the availability of the service. It would seem logical that this is due to the specialist clinics all being in the South East of England.
The low rate of referral from outside London and the South East could be tackled in the following ways.   with a recent television programme featuring one of the services resulting in a spate of enquiries from healthcare professionals the next day. The effect of these events tend, however, to be short-lived, with enquiries reducing over a few days. . Involvement in patient groups. All of the clinical directors of the services have been involved in meetings for the three main patient groups: Triumph over Phobia, UK (TOP UK), OCD Action and OCD-UK. Many patients and relatives find out information about services in this way and subsequently urge their mental health teams to refer them to a specialist service. . Papers describing the availability of the service in publications read by potential referrers. Several papers about the service have appeared in academic, peerreviewed publications, including The Psychiatrist, and more generally read publications. . Setting up satellite clinics for patients in various parts of the UK. Although therapists have travelled throughout the UK in order to work with local community mental health teams and in-patient units for joint working with individual patients, there have not been any satellite clinics operating to date. This would seem to be the next logical step and would have the advantage that local clinicians may become interested in the work while involved in such a venture, which could ensure a wider geographical spread of expertise in the future. Indeed, other nationally commissioned services such as treatment for Ehlers-Danlos syndrome operate in this way, with clinics in both North West London and Manchester.
There is little or no systematic research on how to improve referrals to specialist mental health services. The general concepts that have been deployed in other areas of medicine are largely educational, for example working with general practitioners and other referrers, and providing information via service-user/voluntary sector groups. The national specialist OCD services collaborate closely with the national OCD charities mentioned earlier, OCD Action (www.ocdaction.org.uk), OCD-UK (www.ocduk.org) and TOP UK (www.topuk.org), all of whom have several projects aimed at informing health professionals and providing advocacy for patients.