A systematic approach to practice‐based evidence in a psychological therapies service

This paper describes a systematic approach to generating practice‐based evidence in a United Kingdom adult psychological therapies service. Routine clinical outcomes using standardized measures at referral, assessment, the beginning of therapy, discharge and 6‐month follow‐up are reported. The system is integrated into the clinical service in many ways including contributing to risk assessment and feeding back clinical outcome data to the therapists. A number of issues related to such an approach are discussed in the light of the clinical governance and clinical effectiveness agendas in the UK NHS. These include practical constraints, the costs, getting staff on board, attrition from such services and service user involvement. Such an approach provides a framework for routine, systematic and integrated service evaluation that can be fed back to therapists. It contributes to the evidence for the effectiveness of psychological therapies in routine clinical settings and also provides opportunities to link evidence with practice in more creative ways to enhance therapists' reflection on their practice. Copyright © 2003 John Wiley & Sons, Ltd.     

The impact of NHS based primary care complementary therapy services on health outcomes and NHS costs: a review of service audits and evaluations

Background  

The aim of this study was to review evaluations and audits of primary care complementary therapy services to determine the impact of these services on improving health outcomes and reducing NHS costs. Our intention is to help service users, service providers, clinicians and NHS commissioners make informed decisions about the potential of NHS based complementary therapy services.     

Ethnic differences in mental health services use among the severely mentally ill

Ethnic differences were examined in patterns of service utilization among 4,000 of the most seriously impaired clients in two county mental health services systems having differing histories of specialized minority-oriented programming. Latino and Asian-American clients in one county and, to a lesser extent African-American clients, made more use than Whites of outpatient and supportive/community services. All three minority groups made less use of inpatient care than Whites. The pattern was reversed in a second county. Results point to the need for greater attention to how mental health service systems are organized to meet special sociocultural needs of ethnic minority clients who have severe mental illness. © 1997 John Wiley & Sons, Inc.     

Do adults in contact with Australia's public sector mental health services get better?

This paper describes the outcomes of episodes of care for adults in public sector mental health services across Australia, with a view to informing the debate on service quality. Health of the Nation Outcome Scales (HoNOS) change scores and effect sizes were calculated for 14,659 acute inpatient episodes and 23,692 community episodes. The results showed that people in contact with public sector mental health services generally do get better, although the magnitude of improvement depends on the setting and episode type. This confirmatory finding is particularly positive, given current community concerns about the quality and effectiveness of mental health services.     

The influence of socio‐demographic and illness variables on quality of life in acute psychiatric inpatients

The mental‐health literature highlights the importance of improved quality of life as an explicit goal of the mental‐health service. Recent work indicates that assessment of subjective quality of life can be feasible and meaningful in individuals with psychiatric disorders. Although a number of studies have examined the influence of demographic variables on subjective quality of life in individuals with psychiatric disorders, there remains a paucity of studies that have made comparisons between diagnoses in inpatient populations. We used the WHOQOL‐BREF to examine the influence of different psychiatric diagnoses on quality of life and investigated whether the relationship between demographic variables and quality of life was the same across diagnoses. We found that the relationship between demographic and illness variables was complex, with inconsistent effects across WHOQOL‐BREF domains. Certain domains of the WHOQOL‐BREF were more sensitive to the influence of psychiatric diagnosis than others. Copyright © 2007 John Wiley & Sons, Ltd.     

Mental Health Services Outcome Evaluation

There is an urgent need for pertinent outcome information. Relevance for decision makers must take priority over scientific rigor. However, a review of computer-identified outcome evaluation reports from community service settings, during the past 5 years, suggests that much more has been said than has been done. Although relatively heterogeneous in scope, these studies focused on the effects of community support services for adults with persistent and severe mental illness; traditional outpatient services have been neglected. Studies are characterized by multidimensional, standardized outcome assessment, and nonequivalent comparison group and single cohort designs. Randomized designs, with usual services as the control condition, were feasible in some situations. Inadequate sample size and attrition continue to be method problems.     

Factors explaining the use of psychiatric services by general practices.

BACKGROUND: Referral rates from general practitioners to hospital services vary up to 25-fold, and several studies have sought reasons for this apparent inconsistency in clinical practice. However, few studies have concentrated on, or indeed included, psychiatric patients or psychiatric referral rates. AIM: To determine the effect of population, general practice, and mental health service factors on use of specialist mental health services by general practices. METHOD: Cross-sectional data from computerized records used in managing clinical care on all patients aged 16 to 64 years who had been in contact with any mental health service staff over a two-year period. Twenty-three practices in Huntingdon Health District were studied, with a list population of 87,643 patients aged 16 to 64 years, served by one inpatient ward and three community mental health teams. The main outcome measures were the relation between age-standardized utilization ratio and markers of morbidity, deprivation, community mental health provision, and practice prescribing. RESULTS: Variation between practices in the use of mental health services was relatively limited, especially compared with the use of other secondary medical and surgical services. Three factors together explained 60.8% of the variance in use between practices: a census-based index of long-term limiting illness in females registered with the practice, use of one of the three community mental health teams, and average quarterly defined daily doses of hypnotics prescribed per practice population. Relatively high prescribing of hypnotics was associated with lower service use. CONCLUSION: Population morbidity and factors in the mental health service explain a substantial part of the variation in the use of mental health services between practices. Further work is needed to replicate these findings and explore why team factors and prescribing patterns influence utilization ratios. This study underlines the importance of examining population, practice, and specialist service factors in explaining variation in the use of secondary care by general practices.     

Therapists' Experience of Working with Interpreters in NHS settings: Drawing Upon a Psychoanalytic Theoretical Framework to Contextualize the Findings of an IPA Study

NHS therapists are required to work with interpreters. Therapy with an interpreter may take longer and aspects of the work may be challenging. Surveys of NHS mental health staff, particularly those working in Improving Access to Psychological Therapies (IAPT) services, indicate that they are experiencing burn-out, low morale, and increasing stress and depression as a result of ever-increasing targets and workload demands. This study aimed to gain an understanding of the impact of the context of therapy on the experiences of therapists in the NHS of working with interpreters. Semi-structured interviews were conducted with 10 qualified therapists working within an IAPT or secondary care psychology service from one NHS Trust. The verbal data were analysed using interpretative phenomenological analysis (IPA) methodology. The key finding of the study was that participants’ experience of their organizational context (whether supportive or pressured and demanding) appeared to drive how they related to the interpreter. Previous literature has applied a psychoanalytic framework to understanding organizational, group and individual responses to stress in healthcare settings, including IAPT. Following the initial analysis, aspects of psychoanalytic theory were used to contextualize the findings. Epistemological and ethical tensions in making links to theoretical frameworks within an IPA study are acknowledged and discussed.     

Psychological Consultation in a Children's Hospital: An Evaluation of Services

The pediatric psychologist's role in children's inpatient medicalhospitals has rapidly expanded. Few studies have examined thetypes of referrals for psychological consultation or programevaluation of these services. This paper describes an archivalevaluation of the types of referrals received by a pediatricpsychology inpatient service over a period of 4 1/2 years andan evaluation of these services by physicians, nurses, and socialworkers. The survey of services indicated that the most frequentreferrals were for depression/suicide attempt, poor adjustmentto a chronic illness, and behavior problems. Medically relatedproblems accounted for 42% of all of the consults. Approximatelytwo-thirds of the children were referred for outpatient psychologicalservices. The pediatric psychology service was more likely tofollow, on an outpatient basis, children with medically relatedproblems. A 26-item questionnaire obtained an overall responserate of 48% and response rate of 84 and 60% for faculty andresident physicians having contact with the pediatric psychologyconsult service. The evaluation of the pediatric psychologyservice by physicians, nurses, and social workers indicatedoverall satisfaction with the services they received. The levelof satisfaction was strongly related to the level of diagnosticagreement between the physicians/nurses and psychologist. Thelowest level of satisfaction was on verbal and written feedback.Suggestion for further research was offered.     

A psychological re-analysis of the scientist–practitioner model

For decades, NHS clinical psychologists have struggled to implement the scientist–practitioner model of professional practice. The pressure for effectiveness and efficiency in health services internationally, and the advent of the NHS research and development (R & D) strategy in the UK make this a suitable moment to reframe this model, in favour of the more attainable, complementary and timely approaches of ‘empirical clinician’, ‘evaluative clinical scientist’ and ‘clinical scientist’. As well as being harmonious with the R & D programme, these more discrete models of professional practice can facilitate arrangements for basic training and continuing professional development. In this review paper, the R & D strategy is analysed from the standpoint of a ‘self-regulation’ model, as applied to clinical psychology. This psychologically reflexive approach focuses attention on the need for professions to observe their own research behaviour, to set appropriate improvement goals for themselves, and to alter their behaviour if they are to adapt successfully to the changed NHS. The literature concerned with modifying the behaviour of a range of professionals is used to highlight promising ways to self-manage effectively in the future. Copyright © 1998 John Wiley & Sons, Ltd.     

The impact of NHS Direct on the demand for out-of-hours primary and emergency care.

In order to assess the impact of NHS Direct on out-of-hours primary and emergency care, we sought data on service demand from all GP cooperatives, ambulance services and emergency departments in England, Wales and Scotland. We analysed the impact of NHS Direct on demand, taking advantage of the fact that the service was introduced in waves over a period of 2 years. The results showed that the introduction of NHS Direct was associated with a reduction in calls to GP cooperatives, but with no evident effect on emergency services.     

Mental retardation in Nance-Horan syndrome: Clinical and neuropsychological assessment in four families

Nance-Horan syndrome (NHS) is a rare X-linked condition comprising congenital cataract with microcornea, distinctive dental, and evocative facial anomalies. Intellectual handicap was mentioned in seven published NHS patients. We performed a clinical study focused on psychomotor development, intellectual abilities, and behavior in 13 affected males in four NHS families, and present the results of a neuropsychological evaluation in 7 of them. Our study confirms that mental retardation (MR) can be a major component of the NHS. Combining our data with those from the literature leads to a frequency of MR in NHS of around 30%. In most cases, MR is mild or moderate (80%) and not associated with motor delay. Conversely, a profound mental handicap associated with autistic traits may be observed. MR has intra- and inter-familial variability but does not appear to be expressed in carriers. Awareness of MR in NHS may be of importance in the management of the patients, especially in terms of education. Cloning and characterization of the gene and analysis of mutations will be an important step towards understanding the molecular basis of mental deficiency in NHS, and in delineation from the other XLMR conditions at Xp22. Am. J. Med. Genet. 71:305–314, 1997. © 1997 Wiley-Liss, Inc.     

Examining the effects of ethnic‐specific services: An analysis of cost‐utilization and treatment outcome for Asian American clients

Ethnic‐specific mental health services have developed to meet the unique cultural and linguistic needs of the ethnic client. It has been assumed that this type of service configuration provides more accessible, culturally‐responsive mental health care, which in turn, encourages utilization and enhances outcomes. Previous studies have found that ethnic‐specific services (ESS) increase utilization of mental health services, but there has only been inconsistent evidence that ESS results in better outcomes. This study compared patterns of the cost‐utilization and outcomes of Asian American outpatients using ESS to those Asians using mainstream services. Consistent with earlier studies, cost‐utilization for ESS Asian clients was higher than that for mainstream Asian clients. Better treatment outcome was found for ESS clients compared to their mainstream counterparts, even after controlling for certain demographics, pretreatment severity, diagnosis, and type of reimbursement. Moreover, there was a significant relationship between cost‐utilization and outcome for ESS clients, whereas for mainstream clients, this relationship was not significant. The findings strongly suggest that mental health services with an ethnic‐specific focus provide more effective and efficient care for at least one ethnic minority group. Implications for the delivery of culturally‐competent mental health services are discussed. © 2000 John Wiley & Sons, Inc.     

The patterns and costs of services use among homeless families

This study examines families' use of behavioral health hospitalization and foster care placement before, during, and after shelter use, comparing families based on shelter pattern and type of housing exit. Results show that inpatient and foster care services use drops in the homelessness period, but rebounds after exit, regardless of pattern of shelter use and type of housing exit. Results suggest that shelters supplant use of services, but not on a sustained basis. Despite declines in concurrent services use, the homelessness period is overall more costly for episodically and long‐term shelter users, primarily owing to the high costs of shelter. High rates of inpatient and foster care services use after the homeless spell suggest that providers of homeless assistance should systematically screen and refer homeless families to ongoing community‐based service supports. Service use patterns indicate that homeless spells may disrupt continuity of care with community‐based health and social services. © 2011 Wiley Periodicals, Inc.     

Urban and rural perspectives towards traditional and community-oriented mental health services in the schools: An initial investigation

Urban and rural school mental health personnel's attitudes towards potential community mental health services were assessed by a 20-item questionnaire tapping both traditional clinical and community-oriented activities. Both groups rated traditional services more highly than community ones, but urban respondents were more receptive than rural ones to the community approach. Implications for community psychology and service delivery in the schools are noted.     

Acute knee clinics are effective in reducing delay to diagnosis following anterior cruciate ligament injury

BackgroundDelays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway.MethodsAn uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust.Results81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury.ConclusionsIntroducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.     

Considering a multisite study? How to take the leap and have a soft landing

Although most policymakers agree that a fundamental goal of the mental health system is to provide integrated community‐based services, there is little empirical evidence with which to plan such a system. Studies in the community mental health literature have not used a standard set of evaluation methods. One way of addressing this gap is through a multisite program evaluation in which multiple sites and programs evaluate the same outcomes using the same instruments and time frame. The proposition of introducing the same study design in different settings and programs is deceptively straightforward. The difficulty is not in the conceptualization but in the implementation. This article examines the factors that act as implementation barriers, how are they magnified in a multisite study design, and how they can be successfully addressed. In discussing the issue of study design, this article considers processes used to address six major types of barriers to conducting collaborative studies identified by Lancaster or Lancaster's six Cs—contribution, communication, compatibility, consensus, credit, and commitment. A case study approach is used to examine implementation of a multisite community mental health evaluation of services and supports (case management, self‐help initiatives, crisis interventions) represented by six independent evaluations of 15 community health programs. A principal finding was that one of the main vehicles to a successful multisite project is participation. It is only through participation that Lancaster's six Cs can be addressed. Key factors in large, geographically dispersed, and diverse groups include the use of advisory committees, explicit criteria and opportunities for participation, reliance on all modes of communication, and valuing informal interactions. The article concludes that whereas modern technology has assisted in making complicated research designs feasible, the operationalization of timeless virtues such as mutual respect and trust, flexibility, and commitment make them successful. © 2002 John Wiley & Sons, Inc.