Up to 1 in 500 people with severe mental illness are difficult to engage.1 Consequences for patients include social exclusion, offending, homelessness, substance misuse, poor physical health, frequent unplanned psychiatric admission (often compulsory), overdose, risk to other people, poor social function, stigma and isolation. Such patients consume disproportionate National Health Service (NHS) and related resources and overall are treated ineffectively. The 2001 NHS Plan envisaged 220 assertive community treatment services, generally known as assertive outreach treatment (AOT) in the UK, treating 20 000 such patients by 2003; these targets were largely met. Characteristic features of AOT include long-term retention of patients, delivery of services outside standard settings, intensive interventions, inclusion of carers, multidisciplinary and multi-agency staffing, and assistance with non-clinical issues such as housing, employment and finances. There is a particular focus on engagement, team working and extended hours. The aim of AOT is to improve mental health and ameliorate risk to others by increasing the effectiveness of treatment and reducing social exclusion. Several influential studies, however, have cast doubt on the effectiveness of AOT compared with ordinary community mental health treatment. A national observation study attributed reductions in admissions and bed days to the inception of crisis and home treatment teams rather than AOT.2 A systematic review and meta-regression suggested that AOT reduced bed use only when it was high already. Subsequently, a randomised controlled trial of 250 patients over 3 years determined that AOT provided no greater clinical benefit than ordinary community treatment, at the same or greater cost than ordinary treatment. Aims and method To evaluate the suitability of 80 patients referred for assertive outreach treatment (AOT) and their treatment outcomes, by comparing clinical and social data during the treatment period with data before treatment began. To control for service development across the board, patients on ordinary community treatment were identified and matched to patients undergoing AOT for age, gender, clinical diagnosis and duration, and data acquired for the same time period as the patients on AOT. This was a retrospective mirror-image evaluation with contemporaneous controls.Results The patients referred for AOT were more socially disadvantaged and had used more clinical resources than the control patients. Overall, AOT reduced resource uptake markedly following referral, while resource uptake by control patients during the same period remained static or increased; AOT, however, did not lessen most aspects of social disadvantage. Clinical implicationsThe advantages of AOT include much reduced use of services but not the resolving of social exclusion. Some ordinary community provision may fail to afford the quality of AOT and thus suffer by comparison. The demise of AOT may be premature in such services.Declaration of interest None.
Aims and methodNon-medical staff are eligible to assess trainee doctors through mandatory workplace-based assessments (WPBAs). An anonymous questionnaire was given out to non-medical staff working with trainees in community and in-patient settings at Royal Blackburn Hospital. Our aims were to look at their awareness of and familiarity with assessor guidance, trainee competencies, training needs and assessors' views on completing these assessments.ResultsIn total 118 of 150 (79%) individuals returned a questionnaire and 89 WPBAs had been carried out. Most assessors were Band 6 (or equivalent) or below (53%). Most assessors had neither read any assessor guidelines (75%) nor were familiar with the competencies required of a doctor (76%). Although 79% felt that non-medical staff should be assessing trainee doctors, only 44% felt comfortable doing this. None had been trained and 92% felt this would help. Twenty WPBAs (excluding mini-peer assisted tools) were carried out by staff at Band 6 or below.Clinical implicationsNo respondents received guidance or training on being an assessor. This highlights the need for urgent action and delivery of training. This can easily be adapted from training packages developed for medical staff.
Aims and MethodThe aims of the project were to develop a simple, low-cost patient satisfaction questionnaire with face validity and to obtain patient feedback on a range of service areas in a community addiction team. A questionnaire was designed and revised after feedback from multidisciplinary team members and a pilot sample. The questionnaire was distributed until 100 correctly completed forms were received.ResultsThe survey took approximately 30 h of authors' time from commencement to completion and costs were minimal. The majority of the 12 areas evaluated were rated by patients as good or very good. Overall quality of care was rated as good or very good by 88% of participants. There was no enthusiasm in this sample for more active participation in service development.Clinical ImplicationsAll National Health Service staff and services are now enjoined to engage with service users and carers for the purposes of evaluation and development. Simple, affordable methods for obtaining such information about community services can contribute to this process.
Section 5(2) of the Mental Health Act 1983 (MHA) deals with the compulsory detainment of a mentally unwell inpatient in hospital for a period of 72 hours. During this time the Responsible Medical Officer (RMO) must review the patient and either increase the duration of compulsory stay by converting it to a section 2/section 3, or discharge the patient if appropriate or make the patient's stay informal. Section 5(2) can be implemented by either the RMO or his deputy (duty doctor). An audit of the use of section 5(2) MHA within a psychiatric hospital was carried out between October 2000 and September 2001. The medical case notes of those patients identified were used to obtain data on patient demographics, date of implementation of section 5(2), date of reassessment after section 5(2) and outcome of the assessment. We also looked at reasons for the use of section 5(2), and the documentation standards. Section 5(2) was implemented 55 times during this period. Nearly 83% of cases were in the age group 21 to 60 years. Most were implemented out of working hours. Seventy-five per cent of the patients were assessed within the next 48 hours by the RMO. Forty-one per cent of the patients who were placed under 5(2) were re-graded to informal, 32% were put under section 3 of MHA and 27% placed under section 2 of MHA. When compared with similar studies, this study showed a higher conversion rate from section 5(2) to section 2/3 suggesting that section 5(2) may have been used appropriately (Table I). Many current areas of practice do not meet with standards recommended by the Code of Practice as suggested in a cross sectional survey on the use of section 5(2) (Jacob and Freer, 2005). Higher conversion rates of section 5(2) to a further section may indicate appropriate use of Section 5(2), and also increasing psychiatric inpatient morbidity.
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