Functional model: Mind the Gap

Dr Ankush Singhal MBBS, MD (AIIMS), MRCPsych

ST6 (General adult psychiatry)

BIPA Annual Conference 2010

My ContributionConceived the idea and led the study.Literature review, the protocol and ethics

approval. Collected the data. Co-ordinated.Merged the data & analysed it.Prepared the manuscript and sent for publication. Revisions as first & corresponding author.Presented in RCPsych AGM, Liverpool and in my

Trust.

BackgroundNWW: enabling consultant psychiatrists,

among others, to deliver effective and person-centred care.

Acute care pathway – CRHT + In-patient.Functional model.Acute in-patient psychiatry – a subspecialty?

Community consultant

In-patient consultant

Service user

Mind the gap

AimTo investigate

health professionals’, service users’ and carers’

opinions about the provision of separate consultants

for in-patient settings and the community

DesignMulticentre study : North Hertfordshire; the

south lakes region of Cumbria; and Winchester.

Tool semi-structured semi-qualitative questionnaire (paper and online version)

An information leaflet (without introducing any bias).

Data CollectionPersonally, by post and online.

Through CMHTs, out-patient clinics, mental health wards and other places (e.g. the local centre of MIND).

Admitted patients were not invited.

Reminder - after a month.

AnalysisQuantitative data – descriptive statistics.

Qualitative data – framework analysis.

Carers: too few to be included in the analysis.

Results

Quantitative: Service providers170/330 responded - response rate about

50%.

56 participants left after introductory questions.

72% participants having > 6 years experience in mental health.

GPs

CPNs

Psych

iatr

ists SW

staff

nur

ses

Suppo

rt w

orke

rs

Man

ager

sOT

Psych

olog

ists

Oth

ers

3734

30

23

12

7 73 2

15

Distribution of respondents

Distribution of Respondents

CMHT; 63

Primary care; 37

In-patient; 35

CRHT; 19

AOT; 10 Liaison; 2 Addiction; 2 Others; 2

Results: contd...

Yes; 134

No; 36

Awareness

Yes; 47

No; 49

Need

No; 30

Yes; 66

Would it stay?

No; 88

Yes; 8

Subspecialty?

Satisfaction of service providers

Quantitative: Service users

20/43 respondents had a history of admission.

Duration of contact with mental health: 2-10 years.

Awareness: 16/43 (36%) aware

Satisfaction of service users

Qualitative resultsNeed of functional model:

Unaware; divided opinions.to save money and/or time to reduce workload on consultantsto improve patient care.Service need, no clinical need.

Long-term future:driven by financial issues, so will stay (2/3)would be reversed (1/3)

Qualitative resultsAdvantages

1/3 : no advantages of this changeDisadvantagesIn-patient psychiatry – NOT a separate sub-

specialty.Skills Training

Qualitative data

CONTINUITY/COMMUNICATION•Both consultants attend CPA•Care-coordinators•Shared electronic records

Functional Model:

Mind the Gap

DYNAMICS•Disagreements•ResponsibilitySuggestions:•Communication•Shared decisions PATIENT CARE

•Easily available consultant.•Time/cost efficient.•↓ trust.•Problems with discharge.Suggestion: Communication

SU’s SATISFACTION•Poor engagement•Repetition•2nd opinionSuggestion: Involve SU & C in service designing.

STRESS, SKILLS & TRAINING

•Less stress, more time.•De-skilling Vs specialisation,•Poor training.Suggestion: Rotation

In their own words...Assessment tools & referral notes - not a

substitute for first hand knowledge of a patient and their circumstances.

......... a GP.

Smooth running of wards.Likely to improve in-patient and community care

individually but discontinuity will offset advantage.

.......... Mental health professionals.

The old system was on paper and we were seeing a different consultant every 3 months anyway.

.......... A service user

DiscussionAwareness.Driving force for NWW.It would continue despite a high level of

dissatisfaction.The most consistent view - continuity of care,

the therapeutic alliance, the doctor-patient relationship and trust

Ensuring continuity of care was already a challenge

Evidence basePioneering work at Guy’s hospital.East Suffolk (pilot in 2005).

A survey of psychiatrists (Dale & Milner, 2009) : Generally negative attitudes, particularly effect on patient care, the erosion of the professional role of the consultant and quality of work life.

Malik et al (2008) : the implications on training.

StrengthsExplorative studyMulticentre Both service providers (primary and

secondary care, medical and non-medical) as well as service users included

Highly relevant and Topical.Solution focussed.

LimitationsSample size and response rate.

Response bias.

Many participants did not experience this model.

Admitted service users were not included.

Future directionsTo study that ‘actual’ long term impact of

functional model on these issues.

Thanks