Cervical screening in assertive outreach team patients

AimsTo assess the uptake of cervical screening in patients under Birmingham and Solihull Assertive Outreach Teams; this included a re-audit of patients under the Central Birmingham Assertive Outreach Team.BackgroundPatients with severe and enduring mental illness are known to have poorer physical health outcomes. In Birmingham and Solihull there are 6 Assertive Outreach Teams. These teams manage patients with a diagnosis of psychosis who have complex needs requiring intensive multidisciplinary input and often struggle to engage with health services. The national cervical screening programme aims to prevent cervical cancer by detecting and treating cervical abnormalities. Acceptable coverage is defined as screening at least 80% of people aged 25–49 years within the last 3.5 years and 80% of people aged 50–64 years within the last 5.5 years. In 2018 71.4% of women in England and 70.9% in the West Midlands were screened adequately. An audit of 15 patients under the Central Birmingham Assertive Outreach Team in 2014 showed 46.2% had taken up screening, measured in the last 5 years for those aged 50–64 years and the last 3 years for those aged 25–49 years.MethodA list was obtained of all female patients under the Assertive Outreach Teams with patients excluded if they were under 25 years or over 64 years or if they were known to have undergone a total hysterectomy. All GP practices with eligible patients registered to them were written to requesting the date of the patient's most recent smear test. Cervical screening was classed as in date if carried out in the last 3.5 years for patients aged 25–49 years or 5.5 years for patients aged 50–64 years.ResultOut of 127 eligible patients, 110 had correct GP details on their record. Responses were received regarding 101 patients, 48 of whom had in date cervical screening (47.5%). Of 58 patients aged 25–49 years, 26 had in date cervical screening (44.8%). Of 43 patients aged 50–64 years, 22 had in date cervical screening (51.2%).Conclusion13.4% patients did not have a known GP practice, increasing the risk of multiple poor physical health outcomes. The rates of cervical screening among Assertive Outreach Team patients are similar to the original audit in 2014 and fall significantly below the national standards and averages. These findings, along with the importance of working together to address the need for physical health monitoring in this population, will be communicated with the local Assertive Outreach Teams and GP practices.

Impact of community treatment orders on inpatient bed usage in assertive outreach team

AimsTo examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team.BackgroundCurrently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact.MethodOur primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO(“mirror-image”). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage.ResultAll the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53–1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21–215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was £250, and there were 8145 bed days saved in total, making a potential saving of just over £2million, during the study period.ConclusionThis study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.

Community-Based Mental Health Care in Britain

Community mental health care in the UK was established by two influential mental health acts (MHAs). The 1930 MHA legislated for voluntary admissions and outpatient clinics. The 1959 MHA required hospitals to provide local follow- up after discharge, required them to work closely with local social services and obliged social services to help with accommodation and support. An effect of this was to establish highly sectorized services for populations of about 50,000. These were served by multidisciplinary teams (generic CMHTs), which accepted all local referrals from family doctors. Sector CMHTs evolved a pragmatic approach with an emphasis on skill-sharing and outreach, depending heavily on community psychiatric nurses. The NHS is funded by central taxation, with no distortion of clinical practice by per-item service fees. It is highly centrally regulated, with a strong emphasis on evidence-based treatments.Since 2000, generic sector teams have gradually been replaced or enhanced by Crisis Resolution Home Treatment teams, Assertive Outreach Teams and Early Intervention Teams. Assertive Outreach Teams were resorbed into CMHTs, based on outcome evidence. The last decade has seen a major expansion in outpatient psychotherapy (Improving Access to Psychological Treatments (IAPT) services) and in specialist teams for personality disorders and perinatal psychiatry. The traditional continuity of care across the inpatient-outpatient divide has recently been broken. During the last decade of austerity, day care services have been decimated, and (along with the reduction in availability of beds) compulsory admission rates have risen sharply. Mental health care is still disadvantaged, receiving 11% of the NHS spend while accounting for 23% of the burden of disease.