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Keywords:

  • benchmarking;
  • clinical audit;
  • early intervention in psychosis;
  • evidence-based practice;
  • quality

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References

Aim

As early intervention in psychosis (EI) continues to develop, clinical governance maintains an important role in the ‘real world’ analysis of services. This paper details an audit of all discharges from a regional early intervention service in the United Kingdom, providing benchmarking information on service structure, interventions and outcomes. The background places the service in the context of national and international guidelines.

Methods

All discharges between service inception in 2004 and February 2011 were retrospectively examined and audited according to identified standards, based upon international and national guidelines. A total of 110 patients were discharged from the EI service after a period of involvement of at least 6 months.

Results

A high proportion of service users (55%) had their care transferred back to primary care after discharge. Physical health and social needs were well addressed, and almost half of individuals were in education, training or employment upon discharge. Most service users (69%) did not require inpatient admission during their involvement with the service. Although the majority had psychological, pharmacological and physical health needs addressed, there remained room for improvement when measured against identified standards.

Conclusions

This paper details outcomes of every patient seen by an EI service since inception, providing valuable benchmarking information for those involved in management of similar services, service redevelopment, commissioning, and implementation of evidence-based practice. The proportion of service users in education, training or employment after discharge exceeded expectations considerably.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References

Early intervention in the United Kingdom

The drive to establish early intervention in psychosis (EI) services in the United Kingdom gained momentum following the publication of the National Service Framework for Mental Health in 1999[1] and the National Health Service (NHS) Plan in 2000.[2] The target was the establishment of 50 EI services by 2004. The NHS Plan further emphasized a commitment at policy level by stating ‘All young people who experience a first episode psychosis should receive early and intensive support’.

In 2004, the Early Psychosis Declaration jointly published by NIMH in England, the World Health Organisation and Rethink,[3] set out key aims for EI services, including: reducing the duration of untreated psychosis; the provision of pharmacological and psychological interventions; improving access, engagement and treatment; raising community awareness; promoting recovery and ordinary lives; family engagement in support; and promoting recovery, including employment and education. The 2004 National EI Programme in the United Kingdom[4] set certain agreed indicators of adherence to national targets.[5] These included: a stand-alone service model, dedicated consultant psychiatrist input, access to the team for the age range 14–35, care provided for up to 3 years, assertive community outreach work, extended opening hours, caseloads of 10–15 patients, provision for adolescents, primary care referral and designated access to acute beds. By 2005, 63 EI in psychosis teams were operational in the United Kingdom.[5]

The United Kingdom Department of Health policy document, New Horizons (2009),[6] stated that EI services should continue to ‘develop and extend’, and the 2009 updated United Kingdom National Institute for Health and Clinical Excellence (NICE) guideline for schizophrenia[7] stated that ‘Early intervention services should aim to provide a full range of relevant pharmacological, psychological, social, occupational and educational interventions for people with psychosis’, as well as ‘physical healthcare interventions’. The guideline provided national directives for health-care staff and services managing service users with psychosis at all stages of illness.

The climate today is one of financial austerity. Health services are being asked to do more with less, and EI is no exception. A 2007 report by the Sainsbury Centre for Mental Health[8] found that the United Kingdom required an additional 18 000 community mental health staff in order to deliver agreed national standards of care. They noted that shortfall between provision and expectation was felt particularly acutely in EI, where they estimated that staffing was at ‘only about a fifth of the required level’.[8] There is growing evidence base for the long-term cost-effectiveness of the EI model,[9] suggesting that specialized services are able to provide higher rates of recovery than generic community mental health teams, for a considerably lower cost.

The North Derbyshire EI Service

The North Derbyshire EI Service was established in March 2004 (the ‘Service’). The Service covers a total population of 450 000 people, and includes both urban and rural areas.[10] The average socioeconomic status is similar to that of the United Kingdom as a whole, with 3.2% unemployment in North East Derbyshire (NE Derbyshire) compared with 3.3% in the United Kingdom, although there is a marked divide in income between the richer rural areas, such as the High Peak, and poorer urban areas.[10] The area displays a lower ethnic minority percentage than the UK average (1.5% NE Derbyshire, 9% United Kingdom).[10] The Service accepts individuals with potential prodromal symptoms of psychosis, psychotic symptoms or affective-psychotic symptoms, and service users undergo an assessment period of up to 6 months. If the service user fulfils the criteria for EI after this time, they are taken on to the caseload for an extended health-care spell of up to 3 years. Patient episodes are completed when an individual shows a sustained cessation of psychotic symptoms, or the individual reaches the end of the 3-year period when a decision is made in relation to ongoing care.

In terms of adherence to the 2004 National EI Programme indicators[5] during the duration of the discharge audit, the Service remained stand-alone and retained a dedicated consultant, as well as a senior psychiatry trainee, junior psychiatry trainee, clinical psychologist, occupational therapist, eight psychiatric nurses (including one dual diagnosis worker), a support worker, youth worker and one non-clinical team leader. The Service provided access for the age range 14–35, in conjunction with child mental health services where appropriate, attempted to engage assertively with clients, accepted referrals directly from general practitioners, and service users had access to designated acute beds. The total caseload at the end of the audit period was 151, with an average caseload per community worker of 15 service users.

This is an audit of all individuals discharged from the Service from March 2004 to February 2011. It is the first local comparable discharge audit and has been arranged as part of the ongoing clinical governance of the Service to assess performance against national targets for interventions received during the health-care spell and outcomes on discharge. The audit aimed to follow guidance as set out by the National Institute of Health and Clinical Excellence in terms of best practice in clinical audit.[11]

Methodology

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References

The admission and discharge records of all service users under the North Derbyshire EI Service were accessed through the trust-wide electronic database. Electronic data were cross-referenced with paper records held by individual care plan coordinators and a paper centrally-held discharge file. The audit adhered to Trust data protection policy. This generated a list of all service users discharged from the Service between March 2004 and February 2011. At the outset, it was decided that only those who met the criteria for EI after the 6-month assessment period would be included in the auditable cohort. Individuals who were discharged within 6 months of commencing involvement were excluded as it was considered that these service users were likely to fall into two main categories: those seen but not felt to be appropriate for the EI approach, and those who left the catchment area before a period of regular involvement could be established. The absence of complete electronic and paper records was also agreed as an exclusion criterion for the audit, although information was available on destination on discharge for all service users, and as such has been included.

All data were collected on 5 April 2011 by four members of the project team. Prior to data collection, the researchers undertook a training session with a cohort of 10 sets of electronic and paper records to ensure consistency in data collection. Paper case notes and electronic care records were then examined by the project team in order to assess whether each individual adhered to the standards set for the audit. Data were collected using a bespoke tool designed by the project team for the audit process. Whereas one aim of this was to provide ease of data collection in the short term, there was a longer term goal of incorporating the tool into all sets of paper case notes in the future. This would ensure that future data could be collected both contemporaneously, and at the point of discharge by any multidisciplinary team member, rather than retrospectively.

During the audit process, best practice dictates the setting of benchmark figures for performance against certain standards.[11] Standards for this audit were developed prior to data collection from international and national guidelines, and are displayed in Figure 1. Standards 1–10 concern potential interventions during a health-care spell under the Service, Standards 11 and 12 concern outcomes on discharge.

figure

Figure 1. Duration of Early Intervention involvement (days). †Indicates mean length of involvement: 820 days. ‡Indicates 3 years of involvement.

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Standards 1–5, pharmacological intervention, psychological intervention, social intervention, physical health-care intervention and carer involvement, were derived from the NICE guidance for schizophrenia,[7] and a target of 100% achievement for all service users was set. Each Standard was considered as being achieved if there was evidence that the patient had received the intervention during their period under the Service, or the intervention had been considered and a documented reason given as to why it was not initiated. The minimum intervention to achieve the standard for psychological therapies was assessment for formal Cognitive Behavioural Therapy, family therapy or other psychological input. For physical health-care intervention, the minimum standard was a full physical health screen by a doctor on the team, or referral to a specialist health-care physician. In addition to the NICE guidance, Standards 1–5 are all supported by a developed evidence base. The use of pharmacological interventions to reduce the duration of untreated psychosis is well documented,[12] as is the provision of psychological therapies.[13] The need to improve existing social support networks alongside more specific social interventions is well supported,[14] and it has been found that service users with psychosis suffer from more physical illness than the general population.[15]

Standard 6 relates to the Staying Well Plan, a document produced by the care coordinator in conjunction with the service user. It contains information on service user-specific symptoms, including relapse signatures, as well as practical guidance on how to stay well and access help if needed. The importance of providing good quality and accessible information to all service users is well supported,[7] and as such, the standard target was set at 100%.

Standard 7 relates to admission to hospital, and Standard 8 to involuntary admission. Research data on figures for admissions during the first episode of psychosis vary between 50% and 95% in different studies,[16, 17] and previous studies have demonstrated a figure of around three quarters of admissions happening involuntarily.[18, 19] This audit sets a benchmark standard at 50% of service users necessitating admission during the health-care spell, and 50% of these (i.e. 25% overall) necessitating involuntary admission. This is in line with the EI Joint Declaration[3] that sets a figure of a maximum of 25% of all service users necessitating involuntary admission.

Service users with first-episode psychosis can be difficult to engage.[20] Engagement is fundamental to achieving the aims of service delivery to reduce the impact on the individual and their families, and to facilitate recovery,[21] as reflected in Standard 9. For the purposes of the audit, it was decided that difficult engagement would be judged as three or more missed outpatient or care coordinator appointments during the health-care spell.

Standards 10 and 11 relate to employment or education. The audit has set a target of 100% for needs addressed during the health-care spell, with a target of 50% of service users in employment or full-time education on discharge. Previous studies[22] have demonstrated an increase in employment among those receiving EI input rather than stand-alone treatment.

The Early Psychosis Declaration[3] promotes ‘Recovery and People leading a Normal life’. More recent research[23] has demonstrated that in between 37% and 59% of those experiencing a first-psychotic episode there is symptomatic remission at follow-up. A target of 50% has therefore been set for discharge back to general practitioner in relation to Standard 12.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References

A total of 180 people were discharged from the North Derbyshire EI Service between March 2004 and February 2011. Of these, 70 were under the Service for less than 6 months, and as such were excluded from the sample. Paper case notes were unavailable for 13 of the remaining 110. Electronic records for these 13 individuals were available on discharge destination and have therefore been included in Standard 12, destination on discharge. They have been excluded from the other Standards. Of the audit sample of 97 remaining, duration of involvement with the EI service ranged from 190 to 1911 days, with a mean duration of 820 days (SD = 436 days) as demonstrated in Figure 1.

The results of the audit are displayed in Table 1. 93 (96%), 68 (70%) and 81 (84%) of individuals received pharmacological, psychological and social interventions, respectively, during their health-care spell (Fig. 2); 81 (84%) service users received a physical health-care intervention; and 78 (80%) had carer involvement. 74 (76%) individuals had a Staying Well Plan available in their case notes. These percentages compare to a figure of 100% set by the audit.

figure

Figure 2. Evidence of pharmacological, psychological and social intervention.

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Table 1. Summary of audit results. n = 97 unless stated otherwise
StandardBrief descriptionTarget percentageYes (%)No (%)
  1. CMHT, community mental health team; EI, early intervention in psychosis; GP, general practitioner.

 1Pharmacological intervention10093 (96)4 (4)
 2Psychological intervention10068 (70)29 (30)
 3Social intervention10081 (84)16 (16)
 4Physical health-care intervention10081 (84)16 (16)
 5Carer involvement10078 (80)19 (20)
 6Staying well plan10074 (76)23 (24)
 7Inpatient admission5030 (31)67 (69)
 8Involuntary admission (n = 30)5020 (67)10 (33)
 9Engagement issues5049 (51)48 (49)
10Education/training needs addressed10080 (82)17 (18)
11In employment or full-time education on discharge5045 (46)52 (54)
12Destination upon discharge (n = l 10)50 to GPGP61 (55)
CMHT35 (32)
Substance misuse2 (2)
Assertive outreach2 (2)
Other EI team5 (5)
Prison2 (2)
Rehabilitation2 (2)
Deceased1 (1)

Thirty individuals (31%) required at least one admission during their health-care spell. Of these, 20 (67%) individuals required involuntary admission on one or more occasions, that is, 20 out of the total caseload of 97 (21%) required involuntary admission. Forty-nine individuals displayed difficult engagement (51%). During the health-care spell under EI, 80 service users (82%) had evidence of education or employment needs being addressed. Forty-five service users (46%) were in active employment or education on discharge (Fig. 3).

figure

Figure 3. In employment or full-time education upon discharge.

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Sixty-one out of 110 service users (55%) were discharged back to their general practitioners, 35 (32%) were transferred to community mental health services for ongoing secondary health care, with two individuals (2%) being transferred to higher input assertive outreach services and two individuals (2%) to longer term rehabilitation. Five service users (5%) moved area at the end of their health-care spell and were transferred to other EI services, and two (2%) were discharged to substance misuse services. One individual died during their health-care spell under the early service, with cause of death unknown (Fig. 4).

figure

Figure 4. Destination upon discharge (n = 110). †General practitioner. ‡Community mental health team. §Substance misuse. ¶Assertive outreach.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References

The concept of EI in psychosis is still relatively young, and services continue to evolve as they adapt to successive international and national guidelines and research. It is essential that individual services take part in an ongoing programme of clinical governance to ensure maintenance in standards relating to service structure, interventions and outcomes. This audit provides important service information regarding the North Derbyshire EI Service.

In terms of structure, all of the criteria as set out by the Mental Health Policy Implementation Guide[5] were met, which allows for benchmarking against other similar services. In terms of interventions received during the health-care spell, although not hitting the NICE target[7] of 100%, the Service performed well on pharmacological, social and physical health interventions, with over 80% of service users receiving each of the interventions. The figure of 70% for psychological interventions is lower than the pre-defined standard set, however, and addressing this was one of the main recommendations that was produced. A fault of the initial audit design is that specific forms of psychological interventions received were not identified, and future cycles would need to differentiate to allow comparison with other services. Furthermore, the audit does not provide an indication of the frequency of specific interventions received. Readjustment of the data collection tool would allow for this improvement, which would provide further quantitative data.

The proportion of service users admitted to hospital during the health-care spell under the North Derbyshire EI Service (31%) was lower than expected and compares well to similar services.[22] The figure of one in five of all service users requiring involuntary admission during their health-care spell is in line with the Joint Declaration in EI target.[3]

In terms of the audit standards relating to outcomes, the figure of 46% of service users in education or employment on discharge, while falling short of our standard, exceeded expectations considerably and compares well to the joint statement on EI target figure.[3] The audit finding of 55% of individuals being discharged out of mental health services back to primary care is also a positive outcome and supports data from similar services,[24] adding weight to the role of EI in the recovery model following a first psychotic episode. Although not within the original audit design, the finding of no confirmed suicides with one death during the audit period supports previous findings,[25] which have demonstrated reduction in suicidal ideation after initiating EI.

Overall, this real-life insight into an EI service in the United Kingdom provides valuable benchmarking information for those involved in management of similar services, service redevelopment, commissioning and implementation of evidence-based practice. It adds weight to the argument that a structured EI service that provides evidence-based interventions can improve real-life outcomes for service users.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methodology
  5. Results
  6. Discussion
  7. References