Take outpatient clinics out of the system

People waiting to be seen in outpatient clinics are usually looking forward to specialist insight into their problem as they pursue the road to recovery. However, mental health outpatient clinics are an outdated model of care delivery, existing in a twilight zone between inpatient admission and community based models of care.

To understand this, it is worth knowing a little bit about the origin of the current model of mental health care. When the asylums were being closed in the 1980s, mental health services were relocated to district general hospitals. As a result, these services initially adopted a model more similar to other hospital disciplines − inpatient wards and outpatient clinics.

More recently, outpatient services have been somewhat “usurped”, owing to plethora of community based mental health services. These range from the formation of community mental health teams to other models of community based mental health care, including primary care liaison and the Care Programme Approach.

‘Mental health services are currently commissioned in a way that does not require detailed data on outpatient clinic activity’

Professor Helen Killaspy suggests, pointing to research on reasons for outpatient appointments as well as reasons for non-attendance, that mental health outpatient services are no longer required at all. 

Currently, mental health services are commissioned in a way that does not require detailed data on outpatient clinic activity. Unlike the payment by results system in the acute sector, NHS commissioners contract mental health trusts through a block contract; this takes no account of the number or length of inpatient admissions, nor the frequency at which patients are seen. This is also true of the diagnoses and interventions given. As a result, there is little robust activity data within mental health, since there has never been a need to collect it.

Beacon UK recently studied an English mental health trust that had asked for help in understanding what was happening in its outpatient clinics. These were being operated at more 70 sites, with little insight into which patients were being seen and why. The trust was also concerned about its “did not attend” rate (more than 30 per cent, though this is not uncommon for psychiatric outpatient clinics).

Patient survey

Between December 2009 and December 2012, we worked with trainee psychiatrists to review the notes of 400 adults whoattended outpatient clinics with mental health problems. Using a custom built online survey tool, we captured data on patient demographics, diagnosis, appointment purpose, mental state risk assessment, employment status, rate of non-attendance, inpatient admissions, Mental Health Act assessments and more.

Analysis of 1,302 separate appointments over the three years surveyed showed:

• Routine follow-up appointments accounted for nearly nine out of every 10 outpatient appointments, with a seven-fold difference between lowest and highest new-to-follow-up ratios when analysing by individual consultant, and a sixteen-fold difference in the overall number of appointments seen.
• People with mood disorders had the highest rate of outpatient appointments per person (6.4 over three years).
• The patient was seen by a consultant psychiatrist in 62 per cent of appointments.
• In the opinion of the reviewing doctors, only half of all appointments were conducted by the most appropriate healthcare professional.
• Half of all surveyed outpatient attendees had at least one chronic physical health problem. This is likely to be an underestimate as our review was based only on what was documented in the patient notes.

Next steps

As a result of the survey, here are a number of recommendations, several of which are relevant to other mental health trusts:

• Invite the clinical body to innovate new practices for following up on patients with mood disorders and neurotic, stress related and somatoform disorders to potentially reduce the outpatient use rate for these specific diagnostic groups. Through segmenting the diverse range of mental health conditions seen in outpatients’ clinics, this enables clinical expertise to be developed to improve overall outcomes and drive value.
• Introduce “single point of access” triage, using protocols developed by clinicians, to ensure that consultant psychiatrists only see patients when their input is medically indicated. Input from the most senior clinicians should be reserved for the most complex cases, rather than for routine follow-up appointments.
• Investigate whether alternative care pathways exist for patients who are both being seen frequently in outpatient settings and still being admitted. Ensuring this small group of “high users” of inpatient services are engaged with community care coordination is critical.
• Consider developing new care pathways for people with both physical and mental health problems to improve outcomes across both domains. Examples of such models are starting to emerge, including widespread adoption of the rapid assessment interface and discharge (RAID) model. Such innovations linking physical and mental health care are not mainstream and have not yet infiltrated into community models of care delivery.

The first three recommendations above involve engagement with and innovation by the clinical body at the trust. These should be well received in light of the problems with the outpatient model highlighted by the New Roles for Psychiatrists report:

“There was almost universal dissatisfaction with outpatient clinics. The doctor is isolated from the team and patients frequently do not attend. Patients may present very differently in the artificial environment leading to differences with staff who see the patient at home. Patients are brought back routinely so as not to lose touch with them rather than out of necessity.”

The fourth recommendation is supported by efforts around the country to develop new contracting and care delivery models, based on outcomes, which aim to improve care for people with long term physical and mental health comorbidities. Such individuals have worse outcomes and cost the system more than twice as much as those with long term physical conditions alone.

By continuing to work with the mental health trust to implement the full set of recommendations and by aiming to deliver improved outcomes for the trust’s patients by looking at new models of care delivery, we hope to dramatically reduce the need for outpatient clinics.

Laura Dunkley is analyst, David Cox is head of strategy and Emma Stanton is CEO at Beacon UK