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PubMed1997

Epidemiologic assessment of overmet need in mental health care.

The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet "caseness" but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as "treated without CIDI disorder". Their need for care was evaluated by comparing them to "treated depressed" and "healthy" respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as "treated without CIDI disorder" were consistently between those for the other two groups (with the "treated depressed" always showing the highest need) on all indicators as well as on a summary need index. However, their type and intensity of service use appeared to be unrelated to their level of need. Although some of the "treated without CIDI disorder" group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.

Adolescent↗

PubMed2002

Stigma, racism or choice. Why do depressed ethnic elders avoid psychiatrists?

BACKGROUND: Knowledge of mental health service users views is important in service planning, to ensure access for everyone and in particular for those in minority groups. Depression is common in older people and it has been suggested that ethnic elders may be more vulnerable to mental illness. This study therefore explored and compared the views of White British (WB) and Black African-Caribbean (BC) older people on depression as an illness, avenues of help and the place of mental health services. METHODS: A qualitative analysis of semi-structured interviews using vignettes describing an older man with depression and a woman with psychosis. The purposive sample consisted of 40 WB and BC older people half of who had been depressed. RESULTS: 21 WB (10 depressed and 11 not depressed) and 19 BC (10 depressed and 9 not depressed) were interviewed. Most people irrespective of ethnicity or depression recognised that there was something wrong with the man with depression. Most did not consider it an illness. Ethnicity but not depression effected the interpretation of the aetiology of the symptoms. A minority thought that consulting the GP would help but some BC specified that it would be inappropriate. BC who had not been depressed thought that spiritual help was appropriate. Both ethnic groups suggested that mental health services were for care, incarceration or dealing with violence. None of those who had been depressed thought that the mental health services were for dealing with violence. LIMITATIONS: We interviewed established BC immigrants and our results might not apply to new BC immigrants or other immigrant groups. Descriptions within the vignettes of depression and psychosis were defined by us. CONCLUSIONS: Most older people do not view depression as a mental illness. Older people, particularly BC therefore often do not see psychiatric services as appropriate and believe they are primarily for psychosis and violence. These views are amenable to change. Doctors should be explicit that services are for people with depression.

Africa↗

PubMed2003

Developing a social perspective in mental health services in primary care.

The influence of Primary Care Trusts (PCTs) on the reorganisation of UK health and social care provision is already considerable. As well as challenging institutionalised processes of care, PCTs are encouraging innovation. This article reflects on a service pioneered by a small group of mental health social workers, which has been reconfigured within a new PCT, illuminated by examples of direct therapeutic work and service user feedback. In the new service, the practical application of a social perspective in mental health provision is demonstrated by eligibility criteria based on social context as well as psychological adversity. Possible developments arising from the prospective, multidisciplinary team membership and interface with secondary care are anticipated.

Adult↗

PubMed2004

Measuring service quality provision within an eating disorders context.

Traditionally, research concerning quality measurement and improvement has centred on manufacturing and industrial sectors. In the last decade, however, the focus has turned to the measurement of quality in services and more recently to healthcare. In today's progressively competitive health-care environment hospitals increasingly realise the need service quality as a means to improve their competitive position. The aim of this study is to assess the service quality provision of a leading UK-based eating disorder service provider, achieved through the development and application of the SERVQUAL research instrument for measuring service quality. Following thematic analysis of service user feedback, six dimensions of service quality were identified and mapped on to the P-C-P attributes model. The approach adopted for this case study research may usefully inform service assessment programmes for similarly positioned health-care service providers.

Benchmarking↗

PubMed2006

Heavy use of acute in-patient psychiatric services: the challenge to translate a utilization pattern into service provision.

OBJECTIVE: There is an inequality in resource utilization among acute psychiatric in-patients. About 20-30% of them absorb 60-80% of the total resources allocated to this form of treatment. This study intends to summarize findings related to heavy in-patient service use and to illustrate them by means of utilization data for acute psychiatric wards. METHOD: Longitudinal assessment of consecutive acute in-patients hospitalized for the first time. Analysis of individual utilization patterns by using latent class cluster analysis. RESULTS: Four groups with different utilization patterns were found all including heavy service users. In most cases heavy service use was temporary and could only be poorly predicted. CONCLUSION: Specific preventive interventions to contain heavy service use seem to be out of reach for the majority of high utilizing patients. However, services that have proven effective in reducing admissions to in-patient treatment and length of stay may nevertheless help to reduce heavy service use.

Acute Disease↗

PubMed2006

Who listens? The voices of domestic violence survivors in service provision in the United Kingdom.

This article discusses, in the context of the United Kingdom, service user participation in domestic violence services and how much the voices of domestic violence survivors are heard in policy and service development. If services addressing domestic violence are to continue to develop and to effectively meet abused women's needs, then the views of those using them need to be heeded and acted on. In the UK, these views have been mainly overlooked in the past. Now, however, as in some other countries, domestic violence survivor participation has been addressed to a small extent. This article discusses some of the pioneering techniques being tried out and the sensitivity and difficulties involved, within a context of an understanding of empowerment and the activist movement against gender violence. The article considers the participation of UK women experiencing violence in both shelter and advocacy services, in wider interagency forums and in policy development.

Battered Women↗

PubMed2001

Benchmarking can facilitate the sharing of information on outcomes of care.

Recent restructuring in the national health service (NHS) aimed to effect cultural and organisation changes that would ensure fair and equal access for service users to effective and efficient services. Clinical governance has been introduced as a means of delivering quality improvement. One element of this is the use of benchmarking to assess current process and outcome and to use comparative information to inform about current and best practice. The use of the Therapy Outcome Measure (TOM) (Enderby and John 1997) was investigated as an indicator to benchmark the outcomes of treatment for different client-groups and compare patterns of outcomes from different speech and language therapy (SLT) services. The study recruited eight SLT trust sites and ran for eighteen months. The TOM data was analysed to note similarities and differences in cases entering treatment, in the direction of change resulting from treatment, and on completing treatment. Variation was found on these points between cases with different disorders and across the trusts. TOM data could be used to provide a benchmark for a disorder against which services could make comparisons. However, for benchmarking to succeed there is a need for support and commitment from every level of an organisation.

Benchmarking↗

PubMedDate not supplied

The needs of recently diagnosed cancer patients.

The early diagnosis programme at Rossendale Hospice is a specially designed service to cater for the needs of patients with a recent diagnosis of cancer. This article discusses the development of a service model based on the needs of the service users. This nurse-led service provides informal nurse counselling, practical advice, complementary therapies and peer support.

Adaptation, Psychological↗

PubMedDate not supplied

Patient feedback on liaison mental health care in A&E.

Standard 4 of the National Service Framework for Mental Health states that all mental health service users should have access to services at all times. Liaison mental health services in A&E departments across the country are central to the realization of this objective. This article reports on a study carried out in an East London A & E departments to evaluate the effectiveness of liaison mental health nursing. Quantitative data was collected on referrals made to the service and qualitative data was collected through interviews with clients and a postal questionnaire to determine client satisfaction.

Emergency Medical Services↗

PubMed2001

Carers and community mental health services.

BACKGROUND: There is a growing appreciation of the role and needs of carers for people with mental health problems. Carers are a diverse group, including partners, relatives and friends who are seen as such by service users. METHODS: Sixty-four carers of people with severe mental health problems served by four different mental health care providers were interviewed using the Experiences of Care-giving Inventory. The districts were selected to differentiate services that are targeted at more severely impaired users from those that include a wider spectrum, and to contrast services that have greater integration between health and social care providers with those whose health and social care agencies operate relatively discretely. RESULTS: In the two districts where service users had more severe mental health problems, carers worried more about negative symptoms and thought less about good aspects of the caring relationship. In the two districts where health and social services worked more closely together, carers worried significantly less about the need to back up services. CONCLUSIONS: These findings suggest that service organisation can affect carers, in particular that integration between health and social care for people with mental health problems may benefit carers in ways that were hitherto unproven. They highlight the needs of carers for younger people. They show that the ECI is a useful instrument in measuring the impact of caring for people with severe mental health problems.

Adult↗

PubMed2005

The English smoking treatment services: one-year outcomes.

AIMS: To assess the impact of English treatment services on CO-validated quit rates at 52-week follow-up, to explore the relationship between service-related characteristics and socio-demographic and behavioural factors with cessation outcomes, and to compare the characteristics of service users lost to follow-up with CO-validated quitters. DESIGN: Observational study of administrative information linked with survey data for 2069 recipients of smoking treatment services who set a quit date between May and November 2002. SETTING: Two contrasting areas of England, Nottingham and North Cumbria, consisting of nine primary care trust (PCT) localities. MEASUREMENTS: Routine monitoring data specified by the Department of Health included information about basic demographic characteristics, postcode of residence from which a deprivation category was identified, nature of intervention, and smoking status at 4-week follow-up. These data were supplemented with information about smoking status at 52 weeks, referral pathways, relapse experiences, number of follow-up contact attempts, socio-economic status and smoking-related behaviours obtained from consenting service recipients by treatment advisers. FINDINGS: One user in seven (14.6%) reported prolonged abstinence and was CO-validated as a successful quitter at 52 weeks. This rose to 17.7% when self-report cases were included. Relapse rates between 4 and 52 weeks were almost identical between the two study areas--75%. Relapse was most likely to occur in the first 6 months following treatment. Users who self-reported quitting at 4 weeks were less likely (13.7%) than those with biochemical verification of smoking status at 4 weeks (25.2%) to be CO-validated quitters at 52 weeks (P = 0.004). Older users (OR 1.023; CI 1.014-1.032), people who smoke mainly for pleasure rather than to cope (OR 1.38; CI 1.02-1.87), and those who were extremely determined (OR 1.58; CI 1.21-2.05) were more likely to be quitters at 52-week follow-up, whereas those with lower socio-economic status (OR 0.86; CI 0.78-0.96), who smoked their first cigarette of the day within 5 minutes of waking (OR 0.73; CI 0.55-0.96) or had another smoker in their household (OR 0.65; CI 0.49-0.86) were less likely. In contrast, users lost to follow-up tended to be younger and experienced different referral pathways than CO-validated quitters. Gender was not statistically significantly associated with cessation at 52 weeks and nor were any of the key characteristics of intervention, such as group or one-to-one counselling. CONCLUSIONS: These results obtained from routine services are consistent with those obtained from clinical trials in relation to abstinence at one year. Given that a high proportion of smokers relapsed between 4 weeks and 1 year it is important that future assessments of longer-term outcomes are conducted. However, following-up service users many months after an intervention is expensive, and reasonable estimates of quit rates can be estimated from short-term outcomes, provided that they have been CO-validated. Future studies should monitor outcomes from a selection of services treating different groups of smokers, particularly if more is to be learned about the role of smoking treatment services in reducing inequalities in health.

Adolescent↗

PubMed1997

State variations in Medicare expenditures.

OBJECTIVES: This study examined variations in Medicare expenditures across states. METHODS: 1992 data on average Medicare expenditures per enrollee, users of services per 1000 enrollees, service use per user, and payment per unit of service were compared across states for various services. Weighted least squares regression analysis was employed to examine total Medicare expenditures per enrollee by state. RESULTS: Variation in Medicare expenditures across states is driven more by average number of service users per 1000 enrollees and average service units per user than by average payment per service unit. Medicare expenditures per enrollee by state are primarily a function of Medicare HMO penetration rate (P = .000), urban area (P = .001), hospital bed supply (P = .005), elderly mortality rate (P = .012), Medicare physician assignment rate (P = .026), percentage of primary care practitioners (P = .042), and interactions between urban elderly and percentage of primary care physicians (P = .005) and Black elderly and nursing home bed supply (P = .012). CONCLUSIONS: Before sweeping Medicare cuts are undertaken or excessive reliance on managed care occurs, attention should be focused on the current disproportionate distribution of expenditures across states.

Aged↗

PubMed1996

An interview based approach to seeking user views in genitourinary medicine.

OBJECTIVES: To assess user and potential user views on the appropriateness, nature and quality of genitourinary medicine (GUM) provision in Bristol, UK and to develop a model for ongoing user consultation by GUM providers and purchasers. DESIGN: This qualitative study was based on semi-structured interviews with service users, potential users, community informants and NHS professionals. PARTICIPANTS: 76 current, past or potential users, 10 community informants and 11 NHS professionals were interviewed. African-Caribbean women and men, homeless men and women, lesbians and gay men, men and women living with HIV and women working in the sex industry were recruited to maximise the diversity of the sample. RESULTS: The interviews demonstrated that participants commented positively on many aspects of the service available. The research also identified a number of areas where the service could be improved. Many users emphasised their initial difficulty in finding out about the department and the need for greater publicity and outreach. Users reported coming to the clinic with high levels of anxiety and negative preconceptions about the GUM service. Specific issues were identified for different groups of users. There was a strongly expressed need from a number of women and African-Caribbean men for completely single sex clinics. CONCLUSIONS: The research identified a number of issues of importance to service users that had not been identified in the department's own questionnaire surveys. The results support the premise that qualitative interviews can be successfully employed to access a diverse sample of users, and can offer insights significantly beyond those available from structured patient questionnaires.

Appointments and Schedules↗

PubMed2002

Good practice towards homeless drug users: research evidence from Scotland.

Evidence of large numbers of people who are both homeless and drug dependent, the complexity of their needs, and the many difficulties which they can encounter when trying to access assistance highlight the importance of basic standards of good practice in working with homeless drug users. This is particularly relevant given the growth of new managerialism and the expansion of social care markets occurring within the UK public sector since the 1980s. Within this context, the aim of the present paper is to further understanding of how best to provide support to homeless drug users by examining good practice from the perspectives of both service providers and service users. Data were collected from 48 semi-structured interviews (12 with staff and 36 with clients) conducted in six case study agencies (three homelessness agencies and three drug agencies). Interviews were audio-recorded and the data were analysed using Framework. Findings from the study revealed that good practice related to five broad areas. These were: (1) staffing; (2) agency environment; (3) support provided; (4) service delivery; and (5) agency aims and objectives. Similarities between the views of service providers and users were evident. However, differences of opinion suggested that the best definitions of good practice are achieved by consultation with a range of stakeholders (including staff and clients). Data also showed that good practice is fundamentally related to the qualitative and intangible aspects of service provision, and not just to more easily quantifiable inputs, processes, outputs and outcomes. The paper concludes by arguing that the challenge for new managerialism is to build evaluation frameworks which can accommodate this complexity, and thus, begin to portray good practice in a more accurate and meaningful light.

Adult↗

PubMed2006

[User involvement in mental health services research].

BACKGROUND: User involvement in mental health services research is discussed in Great Britain, and a number of user-led research initiatives can be found. In Germany, less attention is paid to the concept while virtually no initiatives can be found. METHOD: The concept of user involvement is introduced by reviewing the relevant literature. After discussion of theoretical and methodological implications, practicability of the concept for mental health services research is illustrated by some examples from Great Britain. RESULTS/DISCUSSION: User involvement in mental health services may promote the provision of user focused services. User involvement aims at the empowerment of mental health service users and can also improve the quality of mental health services research. Frequently, user-led/collaborative studies are focused on mental health service assessment. Some problematic aspects (e. g. representativeness, knowledge/skills of users) are discussed. Although more research is needed to document the additional benefit of user involvement in mental health services research it is conceivable that the concept will gain in importance.

Cross-Cultural Comparison↗

PubMed2001

Evaluation of community mental health services: comparison of a primary care mental health team and an extended day hospital service.

Alongside mental health policies emphasising the need to focus on people experiencing serious, long-term problems, recent general healthcare policy is leading to the development in the UK of a primary care-led National Health Service. While most primary care-led mental health initiatives have focused on supporting general practitioners (GPs) in managing milder depression and anxiety, this article describes an evaluation comparing primary care-based and secondary care-based services for people with serious long-term problems. A survey of service users was carried out at three points in time using three measures: the Camberwell Assessment of Need, the Verona Satisfaction with Services Scales and the Lancashire Quality of Life Profile. Staff views were sought at two time intervals and carers' views were obtained towards the end of the 2-year study period. The results indicate that both services reduced overall needs and the users' need for information. The primary care service also reduced the need for help with psychotic symptoms whereas the secondary care service reduced users' need for help with benefits and occupation. There were no major differences in terms of satisfaction or quality of life. Primary care-based services therefore appear to have the potential to be as effective as more traditional secondary care services. However, a more comprehensive range of services is required to address the whole spectrum of needs, a conclusion supported by the views of staff and carers.

Adolescent↗

PubMed2003

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.

Community Health Centers↗

PubMed2004

Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy.

UNLABELLED: In efforts to decrease emergency department (ED) crowding and health care costs, frequent users of ED services have been targeted for interventions to decrease their utilization. Previous studies have had different definitions for "frequent users" and have considered all frequent users as a homogeneous group. To the authors' knowledge, no study has examined visit characteristics and resource utilization of different levels of frequent use. OBJECTIVES: 1) to determine the rates of ED utilization by five user groups defined by number of annual visits, 2) to examine variations in visit characteristics by frequency of ED use, and 3) to compare levels of resource utilization among frequent user groups. METHODS: This was a retrospective, cross-sectional study of clinical and financial records for all ED visits to an urban, academic hospital in 2001. Multinomial logistic and linear regression models were used for analyses. Estimates were corrected for multiple comparisons (with Bonferroni corrections), where applicable, and adjusted for clustering within individuals (with Huber-White estimators). Outcome measures were triage acuity, diagnosis-related group (DRG) severity, disposition status, primary complaint, medical diagnosis, hospital inpatient length of stay, payment method, costs, and demographics. RESULTS: Patients with three to 20 visits were more likely to be admitted to the hospital than patients visiting once or twice. Patients visiting more than 20 times were less likely to require hospital admission and more likely to present with "nonurgent" conditions, have lower severity scores, and elope or leave the ED without medical attention than patients visiting the ED once. The group had fewer inpatient days and lower average costs than patients visiting once. Patients with six to 20 visits had traditional Medicaid coverage more often than those with one or two visits. Virtually no patients visiting more than 20 times had Medicare or Medicaid managed care, a health maintenance organization, or a preferred provider organization. CONCLUSIONS: Frequent ED users are a heterogeneous group. Many patients previously thought to overutilize the ED for socioeconomic or insignificant medical problems are as sick as less-frequent ED users. There is a small subgroup with more than 20 visits who are less ill or injured but also incurred lower-than-average costs per visit.

Adult↗