In January the National Confidential Enquiry into Patient Outcome and Death published a report about physical healthcare for people with mental ill-health. This is an issue we looked at through our Focus On: Mental Ill-health and hospital use report in late 2015, so we invited Dr Vivek Srivastava, the new report's co-author, to blog on some of his team's findings.
A middle-aged patient with diabetes and schizophrenia is brought to the emergency department with high blood sugar levels. Believing himself not to be diabetic, he refuses blood tests and insulin. Then, despite medical advice, he self-discharges without any further investigations or treatment.
This story is not uncommon and reflects some of the issues identified in ‘Treat as One’, the latest report from the National Confidential Enquiry into Patient Outcome and Death. In this instance, staff needed to have the confidence to manage the case, to call in a liaison psychiatry team to help de-escalate the situation, collect the required blood tests and obtain consent for treatment. An appropriate mental health assessment and management at this stage would have facilitated better management of diabetes, both immediately and in the long-term.
We looked at 552 cases, across 208 hospitals, of patients with mental ill-health admitted to general hospitals with physical illness. We found good quality care in just 46% of cases reviewed. 23.7% had room for improvement in clinical care and 16.1% had room for improvement in the organisation of care. In 11.7% of cases we found a need for improvement in both clinical and organisational aspects of care.
What are the reasons behind this poor care, and what can hospitals do about it?
Only 95 of the 208 hospitals had mandatory training for staff on managing sick patients with mental health conditions. This lack of appropriate training in many cases points to an issue about staff not having the confidence to care for patients with mental ill-health. Once someone is admitted to hospital it is likely to expose any underlying health issues such as a mental health condition, and staff need to have the confidence to deal with it, and have access to hospital mental health services.
We also found that about 19.6% hospitals did not have a liaison psychiatry service. Where the service was available it was staffed at all times of the day in only 50% of hospitals. Additionally, the service did not cover all the emergency areas and wards in 15% of hospitals.
The majority of patients in the cases reviewed (63.6%) were admitted via the hospital Emergency Department (ED), with a significant minority (14.5%) referred by their GP. We found ED notes to be inconsistent in documenting the mental health condition with only 73 patients having it noted out of the 96 cases where it should have been documented. We also found a similar lack of documentation of a patient’s mental health condition in GP referral letters and in the medical clerking on the ward.
It is now accepted that patients with a severe mental health illness develop medical ill health at least a decade earlier in their lives and die 15 to 25 years younger as a consequence. The rise in mortality is associated with conditions like heart disease at a younger age, often linked to their medications, smoking and obesity.
An example that highlights poor physical treatment in primary and secondary care is the failure to provide stop smoking services routinely to people with mental health conditions. Our study found high levels of smoking among the patients we reviewed - over a third (39.7%) were documented as smokers, compared to 19% of adults in the general population. However, only a minority received effective smoking cessation support.
During in-hospital care some patients need one-to-one mental health observations (sometimes called specialling). But, we found it was inadequate in 68% of cases, primarily because it was given to staff members not adequately trained in that role.
After admission, 22.5% of the patients were referred to the liaison psychiatry team, but lack of timely referral in another 10% compromised their care. Also, ward assessment by liaison psychiatry was significantly delayed in 37.2% cases, which adversely impacted on the quality of care for some patients. The most common reason documented for the delay was “the liaison psychiatry team would not attend until the patient was declared medically fit”. This is a ‘catch-22’ because in many cases physical health and mental health are closely linked. NCEPOD has called for the practice to be discouraged in favour of joint assessment and collaborative management of physical and mental health.
One in four of us will suffer a mental health condition in our lives, and we need to take mental healthcare in hospitals as seriously as physical healthcare, and learn how to provide care for the mind and the body.