'Don't They Call it Seamless Care?': A Study of Acute Psychiatric Discharge

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'DON'T THEY CALL IT SEAMLESS CARE?': A STUDY OF ACUTE PSYCHIATRIC DISCHARGE

CHAPTER FOUR: THE EXPERIENCE OF DISCHARGE

Chapter Three has focused on the specifics of discharge policies and protocols and on how the core elements addressed by these procedures were experienced by the users in this study. The discharge experience, however, embraces a broader context which will be addressed in the current chapter. In particular the need to relate discharge to the earlier stage of admission and the role of assessment and diagnosis will be examined.

ADMISSION PROCESS

The study aimed, in Phase 1, to assess the extent to which admission policies had been developed and were in use both at Trust and ward level. Taraborrelli et al. (1998) have argued that for older people admission policies are important for discharge because if good quality assessment is carried out on admission this can promote more effective transfer back into the community. This argument could equally be applied to discharges from acute psychiatric settings. The importance of admission policies and protocols with regard to discharge is to allow the early identification of any social, economic, family or housing problems which could make discharge more difficult. The Hospital Discharge Workbook (DoH, 1994) stresses that the interaction of health and social needs of the patient will have an impact on the length of stay in hospital. For this reason early identification of social needs is vital to assess continuing care requirements. Durgahee (1996) found that psychiatric patients were being discharged without adequate assessment of their health or social needs and consequently lacked co-ordinated services to support them after discharge. The Sainsbury Centre report on acute psychiatric in-patient care (1998) suggests that, because of the high number of readmissions to acute wards within a year,

"it is likely that many of the problems apart from symptoms that may have contributed to breakdowns in the first place - such as housing, finance, social relations, daily occupation or stigma - are not being tackled satisfactorily." (Sainsbury Centre, 1998:20)

They drew this conclusion because the data from CAN assessments completed with both patients and staff showed that staff rating of patients' social needs on admission was lower than patients' ratings of such needs, and by the end of the in-patient episode staff felt that patients' social needs had not been addressed.

Fifteen trusts at the mapping stage reported that they worked to a specific admission policy for acute psychiatry. The two policies actually forwarded both provided comprehensive policies which covered emergency and planned admissions:

  • preadmission information for planned admissions

  • allocation of a named nurse

  • initial risk assessment within 15 minutes of arrival

  • orientation to ward within 2 hours of arrival

  • co-ordination of medical and nursing staff to avoid duplication of information requests to patients and carers and completed within three hours of admission

  • record of referral to other services within 24 hours of referral

  • patients under section must be given information and explanation about their rights.

Twenty-six of the ward informants indicated an admission protocol was in place on their ward. While not all wards and Trusts operated an admission policy or protocol, the key informants reported that screening for problems other than health was carried out with all patients. The individual responsible for this was the named nurse who would usually be appointed to the patient within 24 hours of admission. Two wards indicated that named nurses were allocated to patients according to the patient's problem and the nurse's specific skills or training. In these wards, for example, there were several nurses who had undertaken courses on eating disorders and patients were therefore allocated accordingly. All informants also stated that if the named nurse was not on duty then the associate nurse within the nursing team would carry out the initial screening process. Although all informants stated that this was policy, one ward informant underlined the discretionary element that may intervene:

"there is one [admission protocol] - it is not often used because of the pressure of work and the way people are admitted".

It can be argued that ward staff should not be concerned with addressing the social needs of the patient. Their focus should remain with the user's health needs. Almost all of the key informants on the wards suggested that if social difficulties such as housing and finance were identified then another agency would be contacted. Overwhelmingly this would be a social work department, either within the hospital or the locality. Other agencies that featured in these areas were welfare rights, often with a welfare rights officer dedicated to the ward, and housing departments. One Trust informant described how the housing department, if invited, would come to ward meetings and they had joint action group meetings each month to make sure all agencies were in touch with each other.

Another function of the screening process is that ward staff are made aware of any other community service that the user is in contact with in order to inform them of the admission. This may not be necessary in many cases as the CPN or member of the CMHT may have been involved in the admission process, indeed may have triggered the admission to hospital. Community support staff, however, as detailed in their interviews, are not always informed of admission. It is difficult to assess the impact of poor communication at this level on the user: no users in the sample spoke about a lack of communication between the agencies. The extent to which problems are identified and addressed during the admission process will be explored further in relation to accommodation and finance.

The screening process not only drew attention to longer term problems but also highlighted more immediate problems such as worries about caring for pets while in hospital or the security of property. Once a problem was identified, interviewees proffered several ways in which they were dealt within their ward or Trust. Firstly, it was seen as the named nurse's responsibility to address the problem. Thirty-eight out of the 45 key informants said they would refer the problem to the social worker, either the patient's own or the social worker attached to the ward. However 16 of these would only refer to the social worker if there were no family or friends who could look after the patient's affairs. The remaining seven said they would refer the problem to the CPN or the police.

The named nurse was also seen as responsible for developing a care plan which in all but three wards was started on admission. Two wards used emergency care plans for patients who were too ill to provide formal information or undergo any type of initial assessment or interview. The use of emergency care plans was seen as a positive aspect of care by those who used them as it made the admission process less stressful for the patient.

Diagnosis

A study carried out in Grampian indicated that diagnosis was the most important item for GPs on a discharge summary following a psychiatric admission (Walker and Eagles, 1994). The issue of diagnostic labels being given by professionals to mental health service users has created much debate. This study explored with key informants when a diagnosis was made during an admission and if this was passed on to the user. The data suggest that diagnosis was not seen as a priority by those questioned. It was felt that a diagnosis could be difficult to make, especially on the first admission. Some informants also thought that consultant psychiatrists were disinclined to label users according to a specific illness but preferred to treat them symptomatically.

"I generally deal with patients symptomatically rather than label. The consultant will give a diagnosis if requested by the family. It can help."

Once a pattern had been established or the illness was clear cut, a diagnosis could be made if necessary. There were no Trust policies on diagnosis, so practice was at the discretion of the individual psychiatrist.

These accounts from respondents have to be treated with some caution, however, not least because of the requirement to provide a diagnosis for the SMR4 returns for ISD. The data collected from these returns for the study sample indicated that a diagnosis had been entered for all users. However, only 75% of the sample reported knowing this diagnosis. There was no difference in being given a diagnosis according to gender, age or diagnostic group (psychotic or non-psychotic). Slightly higher numbers of users were given diagnoses in Borders, Highland, Forth Valley and Western Isles. There was a strong relationship between being given a diagnosis and number of admissions, indicating that those users with longer contact with services were more likely to be given a diagnosis 10.

There was a difference in user and professional understanding of the diagnosis. Table 4.1 details the diagnosis recorded in medical records and the diagnosis offered to the study by the users. In only 77 of the 173 cases (45%) do the official and user-given diagnoses agree. This has implications for patient access to information and to medical records.

Table 4.1 User and professional diagnoses

User given diagnosis

SMR4 diagnosis

S

SA

B

D

P

PT

A

AJ

BD

E

PD

SM

SY

DK

N

total

S

14

1

2

2

1

3

1

9

33

SA

2

2

1

5

B

15

3

2

2

22

D

1

5

38

1

1

2

1

6

3

4

14

76

P

1

1

PT

1

1

2

A

1

1

1

3

AJ

1

1

1

3

BD

1

1

E

1

1

PD

2

7

1

4

1

1

3

19

SM

1

1

1

3

U

1

3

4

total

20

4

23

53

2

3

2

3

0

1

5

8

7

8

34

173


S

schizophrenia

PT

post traumatic stress disorder

PD

personality disorder

SA

schizoaffective disorder

A

anxiety disorder

SM

substance misuse

B

bi-polar disorder

AJ

adjustment disorder

U

unspecified disorder

D

depressive disorder

BD

behaviour disorder

P

puerperal psychosis

E

eating disorder

SY

symptoms only

DK

don't know

N

none given

Two main themes emerged from the comments made by users about diagnosis: the importance or not of having a diagnosis, and the understanding of the diagnosis. A large majority of users (over 70 per cent of those offering comments) felt that having a diagnosis was important. Some thought that having a name for their condition would help them in some way. For instance one man said

"if you don't know what is wrong you're not able to fight it" (103).

Another woman said that it removed any blame from herself for how she was.

"I felt better when I was given a name and was relieved that it wasn't my fault, that it was an illness." (276)

A number of users felt they had had to ask for a diagnosis, that one was not being offered and they had to "press" or "pester" the clinicians for an answer (303, 313). Two users related how they first found out about their diagnosis when they saw it on benefit forms the clinicians had filled in for them. One man described how it was a "shock" for him to see the diagnosis of schizophrenia on the benefit form and he was "taken aback" by it (325).

A number of users expressed their agreement with the diagnosis given by clinicians. Some others, however, did not understand their diagnosis. One woman, for example, said that her diagnosis was bi-polar disorder but that she was "not sure what this means" (163). A small number of users also felt that they did not agree with the diagnosis they had been given.

Only 9 users suggested that having a diagnosis was not important to them and would not help in any particular way - "just a label" (260); "it does not alter my life and it does not help to have a name for the condition" (99).

A small number of users made comments about labelling, an issue that has attracted a lot of attention from the mental health user movement. One young man told how the psychiatrist had informed him that he was unwilling to give a diagnosis as he thought labels were detrimental, a stance with which he was in agreement. Although he knew he had been suffering from something, he felt he was now "normal" (168).

Accommodation

Accommodation is one of the main social factors other than ill health contributing to admissions to acute settings. Accommodation issues are considered sufficiently important to be one of the 12 dimensions of the Health of the Nation Outcome Scale (HoNOS) (Wing et al., 1998; Orrell et al., 1999) and were highlighted in the user consultation carried out by the Clinical Resource Audit Group for the report on outcomes in acute psychiatry (CRAG, 1996).

Just over a quarter of the user sample had been unhappy with their accommodation prior to admission (n=45, 27%). A higher (although not statistically significant) proportion of users with a psychotic diagnosis (31%, n=18) identified accommodation problems that they felt had contributed to their ill health than those with a non-psychotic diagnosis (24%, n=27). The main problems for both groups included overcrowding, problems with the local area, relationship difficulties either present or previous, or not managing to look after the house. The other problems identified concerned substandard housing, safety and neighbours, with 6 users being roofless or living in homeless accommodation. A further 10 users identified accommodation as a problem on the CAN, but felt that it had not contributed to their ill health and reason for admission. Fifteen users had moved house by the follow-up stage. The follow-up sample included 33 who had identified accommodation problems at Time 1, 12 with a psychotic diagnosis and 21 with a non-psychotic diagnosis. There was no difference between Health Board area and incidence of accommodation problems, save that no problems were identified in the Western Isles.

A larger proportion of users with psychotic diagnosis reported that their accommodation problems had been resolved by the time of the first interview (7 pg: 2 npg 11). By the follow-up interview a further 6 users (non-psychotic group) felt their accommodation problems had been addressed. Thus, less than half of the users who identified accommodation problems had found some resolution by the 6 month stage. There was a sense amongst health and social care professionals that little could be done about accommodation problems as resolution rested with the housing departments who were felt to be slow to act.

The agency most often reported by users as helping with accommodation issues was social work. This is supported by the data on the role of social workers as perceived by the users (see below). No users reported receiving direct help from the ward staff, reflecting the argument that ward staff are not best placed to deal with such problems. Others reported as helping were psychiatrist, community psychiatric nurse, occupational therapist, housing department, psychologist and in one case, the local MP.

A small group of users reported that they would have liked help with their accommodation but had not received it. This was either because they had not asked the ward staff, had not known whom to ask, or did not know help would be available. Although screening is said to take place and the wards report making appropriate referrals, little had been resolved in respect of the accommodation problems in the sample.

Individual finances

The financial situation of individuals is another issue that could be expected to feature during the admission screening process. Users in the CRAG consultation identified that mental ill health has an impact on financial security both in the short and long term (CRAG, 1996). A National Schizophrenia Fellowship (Scotland) survey of user and carer experience of hospital discharge (1998) highlighted the lack of attention given to service users' welfare rights. This research explored whether mental health professionals address these concerns to any extent and whether this is borne out by the experience of the users in the sample.

Only 44 users remembered being asked about finances by the ward staff. Fourteen (23%) of the users in the psychotic group and 33 users (28%) in the non-psychotic group identified finance as a problem on the CAN assessment. There was no correlation between those being asked about finances and those reporting it as a problem: only 6 people who reported finance as an issue were asked about it on the ward. By the follow-up stage, similar proportions in each group reported finance as a problem on the CAN (pg 24%, npg 26%). Further exploration of the data shows that some users had resolved their financial difficulties over the study period whilst others had developed new ones. In total for both diagnostic groups about 40% of users reported some experience of financial difficulties.

Most of the sample (82%) were not in employment, with many reliant on benefits for their income. Comments about benefits were a common feature in the responses made by users. A small group of users mentioned the social work department in connection with financial problems and some mentioned specific agencies such as the Citizens Advice Bureau (CAB) or advocacy. Some people who had previously been in hospital were familiar with the Department of Social Security (DSS) rule that a patient who is in hospital for 6 weeks has his or her benefits reduced.

"I was not in long enough for my benefits to be stopped so no financial worries." (15)

"No-one asked about finances but they probably thought I was OK because I was only in for 3 weeks." (94)

In one case it appears the decision to discharge was based on this rather than the state of the person's health.

"I asked if I could be discharged because of the 6 week problem with benefits. The psychiatrist agreed to this." (152)

One of the key informants from a ward indicated that patients may want to be discharged to preserve benefits. They stated that if users discharged themselves for this reason then some follow-up arrangements were made, but if the user was detainable then compulsory measures under the Mental Health (Scotland) Act 1984 would be used to prevent early discharge for financial reasons.

Other individuals felt that the staff on the ward were aware of their circumstances and did not need to ask if they had any financial concerns. However, others reported financial problems that were not dealt with by nursing staff and the respondents were not aware of where to get help. Some reported having to go to the DSS on the day of discharge to try to get some money as they had no other access to cash. One user asked why social workers do not tell anyone what benefits are available. Another said that she did not know her benefits would be cut and that "luckily I had a bit saved so I could use that" (108). Another explained that they only found out about the social work office in the hospital because another patient informed them.

One woman reported that she had to deal with her financial problems herself when she was an in-patient and she found this difficult when she was ill. She said that the DSS staff were rude in their replies to her queries; she had complained about the service and received an apology and assurance that training would be given to help DSS staff deal with patients.

The CAN assessment covers problems with receiving appropriate benefits. After discharge, 40 users (23%) reported that they did not think they were receiving all the benefits to which they were entitled. Of those who identified this as an unmet need (33), only 11 felt they were getting the right input to start to address this need. The remaining 22 thought that they required a higher level of support from services. At follow-up a similar picture can be seen, with 23% identifying benefits as a need. Twenty-one users reported an unmet need for benefits and 16 thought they were not getting the sufficient level of support to address these problems. As with other financial problems, however, the picture is complicated in that a number of those who identified benefits as a problem at Time 1 reported no difficulties at Time 2, whilst other users had developed problems over the period. It is not possible to determine whether these financial problems resulted from their mental health problems, but it is apparent that financial and benefits issues are subject to change over a short period of time.

CONSULTANT PERSPECTIVE ON COMMUNITY SERVICES

Consultants have a pivotal role in the discharge process. It is most unusual for an in-patient to be discharged without the consultant's direct involvement. Consultants rely upon an infrastructure of acute admission wards and community resources which vary considerably from area to area. The majority of consultants in adult general psychiatry operate within a sectorised or catchment area system. Individuals living, or registered with general practitioners, in a certain area automatically become the responsibility of one or possibly two consultant psychiatrists. There are still some areas which operate an open referral system, but the vast majority work within a sectorised service. The intention is that this should allow consultants to develop local awareness and close working relationships with general practitioners, social workers, community psychiatric nurses and local voluntary organisations. They should therefore be aware of local resources, statutory and voluntary, which can be accessed at the point of discharge from hospital.

In the postal survey of consultants, respondents were asked whether they had any problems involving social workers, CPNs, voluntary agencies and advocacy workers in the discharge of acute patients. Eighty-six per cent of respondents commented on this question. Fifty-three percent of those responding described problems with the social work department, predominantly noting that their slow response-time precluded their involvement at the time of discharge. Comments included:

"Involving social services is a nightmare!"

"Social work involvement - promises are made re input, but often not followed through."

"Impossible to obtain social work input - no staff available in our area team to pick up cases unless on CPA or children at risk (even then you'll be lucky!)."

Twenty-five per cent of respondents described problems accessing community psychiatric nursing services. The difficulties centred around lack of availability, waiting lists and shortage of staff.

"Insufficient CPN staff to provide rapid response at discharge."

"In the area where I work there is a shortage of all community staff - it is concerning."

"CPN allocation meetings only on Tuesdays. Discharges must be geared around this date unless there is existing involvement. Also the CMHT decides who sees which patient."

"Shortage of CPNs limits discharge options."

Fourteen per cent of the respondents described having problems accessing both social workers and CPNs while only 25% of the respondents felt that they had no problems with either. Consultants occasionally involved voluntary organisations when discharging acute in-patients, but advocacy workers were almost never involved.

Table 4.2 suggests that, according to consultants, CPNs are involved in a significant percentage of discharges, social workers in relatively few and voluntary agencies in very few. Advocacy workers are almost never involved.

Table 4.2 Consultant involvement with other professionals

Percentage of discharges involving:

Social workers

CPNs

Advocacy workers

Voluntary organisations

<25%
~50%
>75%

55
29
17

24
34
43

98
1
1

86
14
0

The overall picture from the survey, therefore, is of consultants, predominantly isolated from community teams and social workers, balancing the need to prevent blocking of their beds with providing what they consider to be a reasonable period of notice before discharge. There was a strong impression of professionals working within different time frames, with consultants requiring decisions within days and CPNs and social workers responding within weeks.

THE CARE PROGRAMME APPROACH

The Care Programme Approach was first mooted in the 1989 White Paper, Caring for People (Department of Health, 1989b). Initial guidance was issued in Scotland in 1992 (Scottish Office, 1992); revised guidance in 1996 (Scottish Office, 1996). The CPA seeks to ensure that individuals with enduring mental health problems benefit from co-ordinated and targeted support in the form of a sustainable package of care designed to address their individual needs. Particular attention is given to sustained collaboration between different professionals involved with the individual, with a named individual, the keyworker, playing a pivotal role in co-ordination across different professionals and different agencies.

The model of implementation for the CPA in Scotland has been one of selective targeting, focusing on those with the highest levels of need. This differs from England where health authorities have been required to implement CPA, albeit distinguished into three levels, for all patients in contact with specialist psychiatric services. The discharge event would of course be a critical event for the intervention and activity of the CPA keyworker. In the event, as highlighted in Chapter Two, only a very few users within the initial sample (5) were on CPA.

Consultants were asked in the postal survey whether they believed that their patients, in general, benefited from the Care Programme Approach. Overall 54% of consultants felt the CPA benefited their patients. Those that considered the CPA did benefit their patients highlighted improved co-ordination and multi-disciplinary working with prioritised access to social work and housing. A number noted, in particular, the benefit of involving carers. Others were not so sure of the value of the CPA.

"Does not get us any more social work input or GP contact and meet the same staff you've had coffee with upstairs five minutes before the meeting. A complete waste of my time".

"We use CPA sparingly as it seldom adds benefit to the co-ordinated team approach we already have".

The number of patients reported by consultants as being on the Care Programme Approach is shown in Table 4.3. It should be noted that the majority of such patients will have long standing severe mental illness and do not necessarily fall within the category of acute discharge. Fifty per cent of consultants had only 3 or fewer patients on CPA.

Table 4.3 Consultant involvement with CPA

Number of current patients on CPA

% of consultants

0
1 - 3
4 - 6
7 - 10
11 - 15
16 - 20
21 - 30
31 - 47

21
29
18
10
8
8
4
2

Whilst the CPA may be of value in preparing for the discharge of individuals with long-term mental illness, this snapshot suggests that consultants perceive its usefulness in the discharge of acute short-term admissions as limited.

SUMMARY

  • Key informants reported that individuals should be screened on admission by the named nurse to identify issues requiring the involvement of other agencies. Determination of a specific diagnosis was not necessarily regarded as a priority at this stage.

  • Almost a third of users reported accommodation problems that they wished to have addressed; less than half of these had been resolved by the six-month follow-up. A range of unresolved difficulties relating to finances and welfare benefits were also cited.

  • Consultant psychiatrists perceived major difficulties in involving community services in discharge. Over half described problems with social work, primarily the speed of response. A quarter reported problems accessing CPN services.

  • Few service users in the study were on CPA; only just over half of the consultants responding to a general survey considered that CPA benefited their patients.