Defining Professionalism for Mental Health Services : A Rapid Systematic Review

Background: Efforts have been made to define professionalism across the professions, yet little attention has been paid to the concept in mental health services, where patients’ needs differ to that in other healthcare specialties. Aims: To derive a definition of professionalism for mental health services using the existing literature. Method: A rapid, systematic review was conducted to identify empirical and non-empirical records that described professionalism in a mental health service context from 2006 to 2017. Studies were synthesised narratively using thematic analysis. Results: Seventy records were included in the review. Professionalism was described on two levels; at a societal level, a dynamic social contract between professions and society, and; at an individual level, having intrapersonal, interpersonal, and working professionalism. Utilising emerging themes, an operationalised definition of professionalism, suitable for a mental health service context was derived. Conclusions: Within mental health services, emphasis is placed on the interpersonal aspects of practice such as communication skills, maintaining boundaries and humanity. Themes relating to the vulnerability of patients and the challenge of supporting autonomy and choice whilst maintaining safety and acting in a client’s best interest are also evident. ‘Practical wisdom’ and a flexible approach to working are needed to manage these challenging situations

The association between primary care quality and healthcare utilisation, costs and outcomes for people with serious mental illness: retrospective observational study

Background Serious mental illness (SMI), including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with SMI are treated in primary care by general practitioners (GPs), who are financially incentivised to meet quality targets for patients with chronic conditions, including SMI, under the Quality and Outcomes Framework (QOF). The QOF, however, omits important aspects of quality. Objective(s) We examined whether better quality of primary care for people with SMI improved a range of outcomes. Design and setting We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, Accident & Emergency (A&E) attendances, Office for National Statistics mortality data, and community mental health records in the Mental Health Minimum Dataset. We used survival analysis to estimate whether selected quality indicators affect the time until patients experience an outcome. Participants Four cohorts of people with SMI depending on the outcomes examined and inclusion criteria. Interventions Quality of care was measured with: i) QOF indicators: care plans and annual physical reviews ;and ii) non-QOF indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by GPs). Main outcome measures Several outcomes were examined: emergency admissions for i) SMI and ii) ambulatory care sensitive conditions (ACSCs); iii) all unplanned admissions; iv) A&E attendances; v) mortality; vi) re-entry into specialist mental health services; vii) costs attributed to primary, secondary and community mental healthcare. Results Care plans were associated with lower risk of A&E attendance (Hazard ratio (HR) 0.74, 95%CI 0.69-0.80), SMI admission (HR 0.67, 95%CI 0.59-0.75), ACSC admission (HR 0.73, 95%CI 0.64-0.83), and lower overall healthcare (£53), primary care (£9), hospital (£26), and mental healthcare costs (£12). Annual reviews were associated with reduced risk of A&E attendance (HR 0.80, 95%CI 0.76-0.85), SMI admission (HR 0.75, 95%CI 0.67-0.84), ACSC admission (HR 0.76, 95%CI 0.67-0.87), and lower overall healthcare (£34), primary care (£9), and mental healthcare costs (£30). Higher GP continuity was associated with lower risk of A&E presentation (HR 0.89, 95%CI 0.83-0.97), ACSC admission (HR 0.77, 95%CI 0.65-0.92), but not SMI admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or A&E presentation. None of the quality measures were statistically significantly associated with risk of re-entry into specialist mental healthcare. Limitations There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences. Conclusions Better performance on QOF measures and continuity of care are associated with better outcomes and lower resource utilisation and could generate moderate cost savings. Future work Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning

Impact of family practice continuity of care on unplanned hospital use for people with serious mental illness

Objective: To investigate whether continuity of care in family practice reduces unplanned hospital use for people with serious mental illness (SMI). Data Sources Linked administrative data on family practice and hospital utilization by people with SMI in England, 2007-2014. Study Design: This observational cohort study used discrete-time survival analysis to investigate the relationship between continuity of care in family practice and unplanned hospital use: emergency department (ED) presentations, and unplanned admissions for SMI and ambulatory care-sensitive conditions (ACSC). The analysis distinguishes between relational continuity and management/ informational continuity (as captured by care plans) and accounts for unobserved confounding by examining deviation from long-term averages. Data Collection/Extraction Methods: Individual-level family practice administrative data linked to hospital administrative data. Principal Findings: Higher relational continuity was associated with 8-11 percent lower risk of ED presentation and 23-27 percent lower risk of ACSC admissions. Care plans were associated with 29 percent lower risk of ED presentation, 39 percent lower risk of SMI admissions, and 32 percent lower risk of ACSC admissions. Conclusions: Family practice continuity of care can reduce unplanned hospital use for physical and mental health of people with SMI

Identifying primary care indicators for people with serious mental illness : a systematic review

Background – Serious mental illness (SMI) – which comprises long term conditions such as schizophrenia, bipolar disorder and other psychoses – has enormous costs for both patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. Aim - The objective of this study was to review systematically the literature to create a list of quality indicators relevant to patients with SMI which could be captured using routine data, and which could be used to monitor or incentivise better quality primary care. Design and setting – A systematic literature review, combined with a search of quality indicator databases and guidelines. Methods – We assessed whether indicators could be measured from routine data and the quality of the evidence. Results – 1,847 papers and quality indicator databases were identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. Conclusions – With appropriate adaptation for different contexts, and in line with relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established with improved patient outcomes

Assessing professionalism for the selection of mental health clinicians: the development and validation of a situational judgement test

Patients using mental health services are vulnerable to abuse and exploitation, yet there is no consensus on assessment for values-based recruitment (VBR) in this setting. VBR requires evaluating attitudes, knowledge and traits relevant to the delivery of professional and effective care. Structured interviews are one approach to VBR but are resource intensive to deploy. In contrast, situational judgement tests (SJT) are generally valid predictors of job performance and can be delivered more cost-effectively, and at scale. This project developed and validated a SJT that aimed to assess one’s knowledge of professionalism in a mental health services context.A mixed methods programme of work was conducted, incorporating a rapid systematic review to define professionalism in mental health services, a qualitative study exploring stakeholder perspectives, and a quantitative study that assessed the criterion-related validity of the resulting SJT. The literature review included 70 articles and resulted in two operational definitions of professionalism. The subsequent qualitative study incorporated interviews and focus groups with 56 patients, carers and staff members from a range of professions, who facilitated the development of the SJT. Finally, a pilot study, which involved 170 mental health professionals, was conducted to evaluate the validity of the SJT.The SJT scores validly predicted workplace supervisor ratings of professionalism and effectiveness for nurses and allied health professionals. Its predictive ability was comparable to that previously reported for face-to-face interviews. In conclusion, the SJT can be reliably deployed in mental health services to assist values-based recruitment by identifying candidates who are unable to demonstrate reasonable levels of knowledge related to professional behaviours. This novel tool can support our efforts to reduce the risk of patient abuse and reported instances of malpractice in mental health services

Association Between Antipsychotic Polypharmacy and Outcomes for People With Serious Mental Illness in England

OBJECTIVE: Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality. METHODS: Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality. RESULTS: Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98-1.32), ED visit (HR=0.95; 95% CI=0.80-1.14), or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality. CONCLUSIONS: The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected

Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England. : Analysis of linked longitudinal primary and secondary healthcare records in England

OBJECTIVE: To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS: Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS: Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS: Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation