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PubMed2005

A study on how mental health practitioners address ethical issues in clinical audit.

Although much debate has taken place within the literature on the differences between research and clinical audit, the ethical dimensions of audit have frequently been neglected. Furthermore, no research has of yet explored what ethical issues auditors consider in relation to their projects or how they manage them in practice. Using data collected from audit documentation, semi-structured interviews and a researcher-administered questionnaire, this study sought to advance this position by exploring how 14 clinicians undertook audits in one mental health Trust addressed the ethical dimensions of their project. Analysis of the data revealed that the Trust had no formal mechanisms for reviewing and monitoring audit projects whilst other informal mechanisms were not utilized by all auditors. A number of projects had contact with both clinicians and service users through interviews, focus groups and questionnaires; however, issues such as informed consent, confidentiality and anonymity were not adequately addressed by auditors. The implications of these findings are discussed and recommendations for practice outlined.

Attitude of Health Personnel↗

PubMed2003

A comparative analysis of disability measures and their relation to home health care use.

This study examines the relationship between various definitions of disability and the use of home health care. Using data from the 1993 Survey of Asset and Health Dynamics among the Oldest Old, four measures of disability are constructed based on the concepts of difficulty and assistance. Logistic regression techniques are used to examine differences across measures in the probability of home health care use for specific subgroups of the older population (e.g., married Black females, unmarried White males). Home health care use was most likely when the presence of both assistance and difficulty were included in the definition of disability. Regardless of the measure used, women, Whites, and unmarried people had higher likelihoods of using home health care than men, Blacks, and married people respectively. If used as a service eligibility criterion, an inclusive measure of disability would result in a large number of potential service users. Efforts to control expenditures through the use of a narrower measure that requires the presence of assistance may disadvantage some subgroups of the older population.

Activities of Daily Living↗

PubMed2002

Can mothers afford maternal health care costs? User costs of maternity services in rural Tanzania.

Following the difficult economic situation various countries introduced health sector reforms, including user charges to finance the system. The assessment of user costs for maternity services in Tanzania was part of a larger study, which covered inputs, outputs and efficiency of services. The study was carried out from October 1997 to January 1998 in Mtwara urban and rural district in South Tanzania. One hundred and seven women attending a quarter of government health facilities were randomly selected and interviewed. Twenty one key informants were also interviewed and service procedures observed. Users of maternity services pay mainly for admission, drugs, other supplies and travel costs. Travel costs represent about half of these financial costs. The average total costs vary between US$11.60 for antenatal consultation and US$135.40 for caesarean section at the hospital. Unofficial payments are not included in the calculation. The amounts vary and payment is irregular. We therefore conclude that time costs are constantly higher than financial costs. High direct payments and the fear of unofficial costs are acute barriers to the use of maternity services. User costs can substantially be reduced by the re-organisation of service delivery especially at antenatal consultation.

Cost-Benefit Analysis↗

PubMed1997

Reclaiming community: an integrative approach to human services.

Taking the community rather than the service system as its starting point, a community-centered approach to service integration seeks to interweave formal and informal systems of care. Working as part of a community--negotiating and building partnerships with families, social networks, and organizations to change problematic patterns and mobilize resources--requires not only collaboration among administrators, but teamwork among front line staff. Team members need to share work, knowledge, and resources, while building collaborative relationships with their counterparts in other organizations, service users, and other residents. Ensuring congruence between new, integrative methods of practice and the way they are introduced and managed may require substantial changes in management behavior. "Resistance" is best understood in this context as feedback to management about its need to change.

Caregivers↗

PubMed2001

Financial Burden and Out-of-Pocket Expenditures for Mental Health Across Different Socioeconomic Groups: Results from HealthCare for Communities.

BACKGROUND: Mental health benefits have traditionally been much less generous than benefits for physical health care, with separate deductibles, higher copayments or coinsurance, and lower limits on covered services, a trend that continues despite a recent wave of 'parity' legislation. In spite of the current policy debates on mental health insurance reforms, little is known about the burden of mental health out-of-pocket expenditures. AIMS OF THE STUDY: This study examines differences in out-of-pocket expenditures and their burden across different populations, stratified by insurance status, age, ethnicity, and socioeconomic groups. METHODS: This study uses the 1998 HealthCare for Communities household survey, the latest national survey data that are currently available, to measure the burden of out-of-pocket mental health expenditures. We use several measures of burden such as total out-of-pocket expenditures, their share of total treatment costs, and their share of family income. To address the methodological issues that arise in the calculation of the relative measures of burden (e.g. outliers, measurement error, systematic underreporting) we consider three different approaches that have been suggested in the literature and discuss their relative advantages given the type of data typically available. RESULTS: Although there is a common perception that out-of-pocket expenditures for mental health services represent a significant burden for service users, the estimates suggest that this is not the case. In fact, across the three measures of out-of-pocket expenditures as a share of income the estimates are under 10 percent for most groups. However, there is some variation in burden across groups with people who are older, uninsured, or minority spending a larger share of their income out-of-pocket. Since many insurance plans have limits on the number of visits covered and on the total amount that the insurer will pay for mental health services, the share of total mental health expenditures that are paid by individuals is another important measure of the burden faced by people with mental health service needs. We estimate that the mean out-of-pocket share of total expenditures for the group as a whole is 25 percent. In addition, we find that the burden varies across groups with older, more educated, or privately insured individuals paying a larger share of expenditures out-of-pocket. DISCUSSION: Although the overall picture regarding the burden of out-of-pocket costs relative to income is encouraging, it is also important to keep in mind that individuals make treatment decisions based on their available income. The fact that the burden of actual out-of-pocket payments is relatively low may also reflect decisions to forego potentially valuable care. Nevertheless, the results for mental health do not suggest that out-of-pocket costs are currently a major burden for most users. This situation may reflect a major change from the past given the recent shifts towards managed care, however there are no comparable data available to test this hypothesis empirically. IMPLICATIONS FOR HEALTH POLICY FORMULATION AND FURTHER RESEARCH: It may be tempting to attribute the low estimates of out-of-pocket expenditures as a share of income in this paper to recent parity legislation. However, recent research shows that parity legislation has not led to significant changes in benefit design. In fact the high ratio of out-of-pocket payments relative to total mental health care expenditures presented in this paper are consistent with a limited role of parity legislation. Another possible explanation for the observed results is the growth of managed care and the shift in treatment style towards greater use of medications, which are comprehensively covered in most private insurance plans, has reduced total treatment costs and consequently the size of out-of-pocket payments.

Journal Article↗

PubMed2002

Investigating the psychosocial impact of anti-HIV combination therapies.

Developments in anti-HIV medication have meant that people with HIV/AIDS are now living longer, with some authors arguing that HIV should now be defined as a manageable rather than terminal illness. However uncertainty about the long-term efficacy of such treatments remains. This research aimed to examine the psychosocial impact of the new treatments and to explore whether, and in what ways, they affect psychological wellbeing. Clients were also asked about their use of services and whether they thought services should be changing in response to new pharmacological treatments. A semi-structured interview schedule was developed to elicit the views of six service users. From multiple readings of the qualitative data generated, prominent themes were identified suggesting that participants had ambivalent feelings about taking antiretroviral combination therapy and that being well with HIV raised a number of difficult issues. Four main themes were revealed: (1) disruptions in daily living: antiretrovirals as intrusions to life, (2) the tablets as a visible marker for HIV infection, (3) tempered optimism and increasing horizons, (4) an uncertain and fragile future: life without benefits and services. The results were discussed in terms of limitations of the current study and suggestions for further research.

Activities of Daily Living↗

PubMed2001

Maintaining contact with people with severe mental illness: 5-year follow-up of assertive outreach.

BACKGROUND: Assertive outreach is a central strand of Government mental health policy in England. Are different long-term models of mental health care which include assertive outreach associated with different service user outcomes and cost? METHOD: We conducted a multi-site 5-year follow-up study of people with severe mental illness. From 0 to 18 months all three sites had Intensive Case Management (ICM) teams practising assertive outreach. From 18 to 60 months one team sustained ICM, one team merged and another was disbanded. All 131 original ICM team clients were the study participants. Outcome was measured in terms of sustained engagement with statutory mental health services, psychiatric symptoms, social functioning, resource use and cost. RESULTS: All 120 live participants were traced. Only four people had no service contact; when contacted by a researcher they appeared to be coping well. No incidents of serious violence were discovered. No differences existed between teams in the mean total symptom or total social functioning change scores at follow-up, after controlling for baseline differences. No differences existed in mean cost between teams during the first 18 months. Mean (standard deviation) annualised costs varied considerably in the 18-60 month period: sustained team Pound Sterling13,734 (10,820); integrated team Pound Sterling11,037 (13,603); disbanded team Pound Sterling5,742 (7,007) (F=4.4, 105 df, p=0.015). CONCLUSION: Continued specialist assertive outreach service models have higher costs than non-specialist services for no apparent benefit. In the long term new assertive outreach services should have procedures in place to transfer people to lower intensity and lower cost care.

Case Management↗

PubMed2006

Financing mental health services in low- and middle-income countries.

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.

Developing Countries↗

PubMed2004

Changing geographic access to and locational efficiency of health services in two Indian districts between 1981 and 1996.

In developing countries, including India, the role of the private sector in the provision of basic healthcare services is gradually expanding, since the public sector provides limited services and covers only limited areas. Using location-allocation models (LAM), this paper (1) examines the changing geographic access to and locational efficiency of basic public healthcare vis-à-vis private healthcare services in two districts located in northwestern part of India, and (2) interrogates the factors that govern their geographic accessibility and locational-efficiency. Although this research confirms regional inequalities in geographic accessibility and locational efficiency of both public and private healthcare services in the selected districts, the locational efficiency of private health services is significantly lower than that of public health services. This paper further demonstrates the use of LAM for new site identification (keeping the existing healthcare sites intact) that will, in the future, improve locational efficiency of these services. This paper not only recommends improved geographic access to both public and private health services and their enhanced complementary role, but also stresses the need to evaluate geographic access from the service-users' perspective and the use of more realistic data on demand and supply in future research. The findings of this paper can be extended to areas with similar geographic settings, and socio-economic and demographic conditions.

Catchment Area, Health↗

PubMed1999

Community care. Home service.

A nurse-led scheme to prevent hospital admissions by providing emergency services in the community for up to 72 hours cared for 155 people in its first six months. The scheme operated well below full capacity partly because of initial opposition from GPs. The mean age of service users was 79 and the main reasons for referral were chest infections, pneumonia and the need for support following an injury. More than three quarters of those cared for were fit to be discharged from the scheme within 72 hours.

Aged↗

PubMedDate not supplied

Treatment and services for drug users in Britain.

The pattern of British drug service provision was transformed during the late 1980s. Policy makers and service providers recognised the need for a more flexible response to changing drug trends and client needs; consequently community-based services proliferated. HIV has had considerable impact on the working approach of many agencies, where harm minimisation is now the immediate goal. This article provides an overview of patterns of drug use and drug service provision in Britain.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Professionalizing action research--a meaningful strategy for modernizing services?

BACKGROUND: This paper outlines how a specific action research approach can be used to secure practice development in services which have found sustained change difficult. For the purpose of this paper discussion focuses upon using professionalizing action research (a form of action research) to secure transformation in acute inpatient mental health services. This speciality has experienced long-term difficultly in meaningful practice change. Not limited to this context parallels can be made with other health and social care services requiring significant modernization. AIM: The aim is to critically discuss the use of professionalizing action research as an approach to sustainable change. DISCUSSION: clarifies whether this method is a suitable vehicle for change, which is ideally suited to services which have a poor record of practice development. METHOD: A review of action research and practice development literature forms the basis of this paper. The literature is sourced through bulletin boards, electronic databases and the British Library Classification Scheme. Keywords searched are action research, team learning, managing change and practice development. Following definition; the components of professionalizing action research are analysed using the themes of educative base, problem focus, improvement and involvement. FINDINGS: The educative base of professionalizing action research is collaborative reflective practice which is used to initiate meaningful change, rooted in everyday practice. The benefit of this is that change actions are based in real-time situations. The problem focus component of professionalizing action research is used to emphasize the views of service users and carers. This is positive in terms of the patient and public involvement agenda although this theme does emphasize limitations of the approach. The final components are involvement and improvement, these are debated as pluralistic notions and the implications of this are acknowledged. CONCLUSION: Reviewing the literature and theoretical application indicates the value of professionalizing action research as a process for modernization. The strength of the approach lies in the opportunity for team learning and change which is grounded in the context of services and pursued through collaboration.

Acute Disease↗

PubMed2002

Identifying 'value' in day care provision for older people.

Day care can play a prominent part in the overall development of high quality health and social care provision for older people. This paper describes an approach to evaluating day care services which brings together costs and service users' views as a means of establishing the overall 'value'. This strategy, it is argued, underlines the purpose of day care itself as a means of promoting the independence and autonomy of older people.

Aged↗

PubMed2006

Evaluating partnerships: a case study of integrated specialist mental health services.

Partnerships are designed to facilitate the negotiation and delivery of public programmes cutting across the boundaries of a fragmented organisational landscape. This paper makes an empirical contribution to the study of the outcomes of partnership working, reporting results from a detailed United Kingdom case study of mental health services integration. It considers the county-wide establishment of a range of partnerships between a county council and multiple National Health Service organisations under Section 31 of the Health Act (1999), relating to mental health, learning disability, drug and alcohol, and child and adolescent mental health services. Arrangements included: integrated county-wide provision via a partnership trust; pooled commissioning and provision budgets; and joint commissioning arrangements between eight primary care trusts and the county council at a joint commissioning partnership board, supported by a joint commissioning team of officers. The evaluation explores the impact of integrated provision on service users, carers and team staff between 2002 and 2004. A multimethod approach incorporating qualitative and quantitative data was used: individual semistructured interviews and focus groups with staff, users and carers (2004); and questionnaires to team staff to explore role clarity and job satisfaction (2002 and 2004). While users and carers were largely positive towards the new provision, a range of alternative frames of reference towards inpatient episodes were identified, including notions of sanctuary and asylum, as well as lack of privacy and fears over safety. Similarly, there was some ambivalence over the dual focus of the teams on both users and carers. Small improvements overall in team staff scores for role clarity and job satisfaction masked variations between localities; such differences seem less to do with prior experience of partnership working than with recruitment difficulties. Additionally, the study raises methodological issues of relevance to the evaluation of complex social interventions. While partnership forms are themselves relatively easy to define, the attribution of improved outcomes to such arrangements is less straightforward - they are complex social interventions requiring enactment by individuals within specific contexts, typically involving many service changes against a turbulent policy background. Some implications for partnership evaluations are considered.

Humans↗

PubMedDate not supplied

The views of children and their families on being in hospital.

This study aimed to elicit the separate views of children, young people and carers after a period in hospital as an inpatient. Questionnaires were administered to 130 children and their families discharged after a period as hospital inpatients in January 2003. Anonymized data were returned from 50 families. Data analysis indicated that there were differences in the way that the three groups perceived the period of admission. Although parental sleeping and other social arrangements were subject to some critical review, the nursing care experienced by families was highly rated. Although arrangements for discharge were deemed satisfactory, 38% of carers had to wait for medicines to arrive on the ward before they could go home. Only six of the young people felt there ward catered for their age group and five indicated poor levels of privacy. None of the young people indicated that they had used the equipped teenagers' room. Attempts to include the voice of the younger child in this study proved unsatisfactory as parents elected to act as proxies in completing the child-specific questionnaires. Child healthcare professionals attempting to involve all service users in determining optimum levels of care need to consider fully the methods of data collection and their applicability for differing age groups of children. Dependence on adult carers to reflect accurately the voice of the child is not fully satisfactory.

Adolescent↗

PubMedDate not supplied

Role of graduate mental health workers within primary care.

The concept of primary healthcare graduate mental health workers came into being following the implementation of The NHS Plan (Department of Health, 2000) and the National Service Framework for Mental Health (DH, 1999). It is now generally agreed that service users must be consulted in order to fully understand and judge the effectiveness of this new role. It is this knowledge that can then position precisely where this new role will fit within the NHS's mental health organisational structure.

Certification↗

PubMed2006

Living arrangements of individuals with schizophrenia in Japan: impact of community-based mental health services.

AIMS: In Japan psychiatric hospitals and family play the predominant roles in caring for people with serious mental illness. This study explored how the introduction of community-based care has changed this situation by examining living arrangements of individuals with schizophrenia who were treated in one of the most progressive systems in Japan (Kawasaki) compared with national norms. METHODS: The proportion of clients with schizophrenia in the community versus hospital and living arrangements for those in the community were compared between the Kawasaki and national treated population, using data from the Kawasaki psychiatric service users survey in 1993 and two national surveys in 1993 and 1983. The variation in living arrangements was examined across five different age cohorts. RESULTS: The estimated national population was 36.7, which was similar to 32.7 clients per 10,000 population in Kawasaki. Some 71% of the Kawasaki clients were treated in the community compared with 55% nationally. The difference between the Kawasaki and national populations was the largest among clients aged 40 to 59. The Kawasaki community clients had a higher proportion of clients living alone. CONCLUSIONS: The community mental health services available in Kawasaki appeared to reduce hospitalisation and help clients to live alone in the community.

Adult↗

PubMed1997

Personality disorders in people with learning disabilities: a community survey.

The prevalence of personality disorders has been determined by studies of both the general population and mental handicap hospitals. The present study attempts to determine the prevalence of personality disorders in a community sample and to check the implications for treatment. A community sample of learning disability service users was surveyed by obtaining a rating from a good informant to establish demographic data, level of functioning and the nature of personality disorders, if any, using the ICD-10 version of the Standardized Assessment of Personality (SAP). Fifty per cent of the sample had personality abnormalities, and 31% had sufficient impairment of the social and occupational domains and personal distress to warrant a diagnosis of personality disorder. These findings are compared with previous studies. Paranoid, schizoid, impulsive and dissocial personality abnormalities were seen to be associated with a high referral rate to psychiatric services and needed considerable therapeutic input. The prevalence of personality abnormalities in community populations with a learning disability is high. The SAP is a useful instrument for screening. This subpopulation makes significant demands on community psychiatric services.

Adult↗