The Woodland is full of many different Elves; all with their own identities and needs. We have one thing in common though, we are all part of the National Elf Service and as such we look after all of our needs whether they be overlapping or independent. Can we say the same about our National Health Service?
This blog is about the report recently published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD): Treat as One – Bridging the gap between mental and physical healthcare in general hospitals. The study was proposed by Dr Natasha Robinson, formerly Associate Medical Director and Consultant Anaesthetist at Northampton General Hospital. The full report is 112 pages long, but worth a read for the details.
For those of you who haven’t come across NCEPOD before, their purpose is to assist in maintaining and improving standards of care for adults and children and they do this by very well coordinated national surveys and research. They have completed studies on a wide range of healthcare topics, all of which can be found on their website.
So, Treat as One looks at the fact that high quality mental healthcare offered to patients in general hospitals should be the aim; something I’m sure we would all agree on. The study looked to identify and explore remediable factors in the overall quality of mental health and physical healthcare provided to patients with significant mental health conditions who were admitted to a general hospital.
The study intentionally only looked at patients on an acute inpatient pathway and so mainly looked at the care offered to the patients by the physicians and nursing staff from the general hospital and from staff in the liaison psychiatry service (if present). As people may know, I am a Liaison Psychiatrist and our services (by their very name) expose the gap in the way the services are commissioned and provided, as they describe a service reaching from one place to another. However, we are only part of the solution.
Patients were identified retrospectively from hospital central records relating to admissions to hospital during the study period: 13th October – 13th November 2014. Patients needed to be aged 18 or older who were admitted to a general hospital for a physical health condition, who also had a significant, known mental health condition and/or who were detained under mental health legislation either at the time of admission or during their hospital stay.
Questionnaires were then completed by general hospital clinicians and liaison psychiatry clinicians in relation to the care received on a sample of this identified group. In addition, an organisational questionnaire was sent to the Medical Director of the Trust/Health Board. Finally, a multidisciplinary peer review group reviewed case notes to grade the overall care each patient received.
11,950 patients from 200 hospitals were identified with a selection of 1,064 cases (5 per hospital) for inclusion. 782 (73.5%) general hospital clinician questionnaires were returned, 346 completed liaison psychiatry clinician questionnaires were also returned. 788 (74%) sets of case notes were returned to NCEPOD and case reviewers assessed 552 cases.
- 351/552 (63.6%) were admitted via the Emergency Department (ED)
- 80 (14.5%) were referred by their GP
- 57 (10.3%) were transferred from a mental health or another general hospital
Smoking, alcohol and substance use
- 164/413 (39.7%) were current smokers
- 104/552 (18.8%) had a history of alcohol misuse
- 88/552 (15.9%) had a history of substance misuse
Mental health documentation
- Case reviewers were of the opinion that the ED notes should have but did not mention the mental health condition in 47/96 patients at triage and 24/47 patients at a subsequent senior review
- 101/471 (21.4%) lacked adequate mental health history on admission to hospital ward
- 206/531 (38.9%) had medicines reconciliation at this stage
- 51/279 (18.3%) noted drug interactions
Mental health risk assessments
- 161/476 (33.8%) had a risk assessment documented
- 106/224 (47.3%) adequate risk management plan available to treating team
Assessment and management of mental capacity
- 66/479 (13.8%) noted during initial assessment
Liaison referrals and reviews
- 103/458 (22.5%) patients were referred to the liaison psychiatry team after their initial physical assessment
- Of those not referred, 30/301 (10.0%) should have been at this time and their care was believed to have been impacted as a result.
- 256/552 (46.4%) patients received a liaison psychiatry team review during their hospital stay.
- There was room for improvement in the following aspects:
- mental health risk assessment (22/125; 17.6%),
- mental capacity assessments (11/53; 20.8%),
- prescription of medications (11/48; 22.9%) and
- advice to nursing staff (20/86; 23.3%).
- Liaison psychiatry assessment was substantially delayed in 74/199 (37.2%) patients. This impacted the quality of care in 22/51 patients. The most common reason for the delay in the liaison psychiatry assessment was that “the liaison psychiatry team would not attend until the patient was declared medically fit” (26/74).
Mental health legislation
- 65/541 (12.0%) patients were detained using mental health legislation
- In 15/65 of these patients there were issues in the documentation of the process.
- 23 cases security staff were involved
- Room for improvement in this process in over 1/5 of these
- 13/552 required use of physical restraint.
Multidisciplinary discharge planning
- 209/423 (49.4%) had MDT discharge meetings
- Management plans for the patient changed following MDT meetings in 45/107 patients
- 20/107 (18.7%) liaison psychiatry were involved in the MDT meeting
- 65/443 (14.7%) were delayed discharges
- 95/343 (27.9%) discharge summary lacked the mental health diagnosis
- 90/308 (29.2%) discharge summary lacked the mental health medications
- No discharge summaries were copied to the relevant out of hospital psychiatry consultant
Overall quality of care
- 46.0% (252/548) good
- Examples of good clinical practice were noted for 17.9% (93/521) of patients in this study
- 23.7% (130/548) room for improvement in clinical care
- 16.1% (88/548) room for improvement in the organisation of care
- Room for improvement in both clinical and organisational aspects of care was noted in a further 11.7% (64/548) of the cases reviewed
Good practice in the quality of mental healthcare
- 40.8% (20/49) with no liaison psychiatry team
- 46.2% (97/210) with a Non-PLAN accredited liaison psychiatry
- 59.8% (58/97) with a PLAN accredited liaison psychiatry team
- The effect of having a liaison psychiatry team, especially one which was PLAN accredited was positively associated with better quality of care
The results can make for rather grim reading in some areas, but I don’t think any of them are a particular surprise. I think it is useful to have an honest appraisal of where we are at and what we can do to move things forward.
There were 21 recommendations from the report, however they can be summarised into the following areas:
- Liaison psychiatry services should be fully integrated into general hospitals
- All hospital staff who have interaction with patients, including clinical, clerical and security staff, should receive training in mental health conditions in general hospitals
- Patients who present with known co-existing mental health conditions should have them documented and assessed along with any other clinical conditions that have brought them to hospital
- And when seen by mental health services (liaison psychiatry) the review should provide clear and concise documented plans in the general hospital notes at the time of assessment
- National guidelines should be developed outlining the expectations of general hospital staff in the management of mental health conditions, such as the point at which a referral to liaison psychiatry should be made and what triggers the referral
- Record sharing (paper or electronic) between mental health hospitals and general hospitals needs to be improved.
There is a very useful self-assessment checklist within the documents that you can use to see where you are within your hospital – why not do it today?
You can follow #TreatAsOne on Twitter to read more about the discussion around the launch of this report.
NCEPOD (2017) Treat as One. Bridging the gap between mental and physical healthcare in general hospitals.
National Confidential Enquiry into Patient Outcome and Death, Jan 2017.
By Daniel Sone (photographer) [Public domain], via Wikimedia Commons