This paper discusses the advantages and disadvantages of case management systems for the co-ordination of care of people with long-term mental illness living in the community. Many of the principles are equally applicable to other client groups with long-term needs, eg elderly people or people with learning difficulties. Some of the historical background to the emergence of case management concepts is discussed, culminating in the recent White Paper on Community Care. The underlying concept of case management is examined, together with a number of fundamental questions concerning who should act as case managers, what kinds of training they will require, problems of inter- and intra-agency co-operation, and the empirical evidence regarding its effectiveness. It is concluded that case management could be an important element in a comprehensive range of mental health services, but it is not a substitute for basic community provisions.
In 108 open-entry full marathons held in Great Britain in 1983 (35 incorporating shorter races) the number of static first-aid posts varied from 0 to 28 (median 9). In 54 (50%) the first of these was within 3 miles of the start but in 11 (10%) there were none in the first 10 miles. Mobile first-aid arrangements did not compensate for the absence of static posts. The numbers of qualified first-aid staff ranged from 1-250 in events with fewer than 1,000 entrants (67%), and 18-930 in larger events. Intravenous infusion facilitates were available in 59 (55); defibrillators in 34 (31%). Drink stations were provided in all events but in at least 40 they were spaced more than 2 1/2 miles apart on average. Oral and intravenous fluid replacement facilities were available to no greater extent in summer events than at other times of the year; 25 of the 57 summer events started at or after 11.00 hrs. Races with fewer than 10 first-aid posts had mean contact rates of 75 per 1,000 entrants (S.E. 15.4); those with 10 or more, 107 per 1,000 (S.E. 14.4). Only 160 runners were taken to hospital from all events combined (2 deaths). The mean hospital contact rate was 1.6 per 1,000 entrants, and was not related to the size of entry, density of first-aid posts nor sophistication of the first-aid offered. The inadequacy of arrangements in some marathons for preventing dehydration and treating collapsed runners on the course suggests that marathon organizers should be required to apply consistent, high standards to their arrangements for preventing and treating medical problems.
We have studied the outcome of geriatric patients with lengths of stay exceeding 180 days. In 1985 there were 77 of these patients (37 discharges and 40 deaths) representing 2.8% of all discharges and deaths in that year. Female long stay patients survived longer than their male counterparts. Forty six per cent of patients were discharged to their own homes or local authority residential homes and 46% to private care. Elderly patients may be successfully discharged from hospital despite a protracted hospital stay.
We present a comparison of data from two morbidity surveys conducted in 1970-71--the Second National Morbidity Study (subsequently referred to as NMS) and the General Household Survey (GHS). In the NMS 115 general practitioners recorded for one year details of the utilization of services by and the morbidity in their patients; and in the GHS the same sort of information was obtained from interviewing members of approximately 15,000 households. Differences in consultation and home visiting rates are examined. For this purpose, data in the NMS which were based on the verified population (population linked to the National Census for 1971) are contrasted with findings from the GHS (with telephone contacts excluded). Apart from small differences in home visiting rates especially among old people, the overall consultation rates are extremely close. We suggest that the losses to both studies, which occur especially among young mobile people in urban populations, need to be considered carefully when interpreting the data. Nevertheless, the doctor-generated NMS data matches well with the patient-generated GHS. Ways are suggested whereby the surveys might be more closely linked.
This paper is based on work which has been in progress for the past 13 years. Longitudinal data are presented on doctors who graduated from United Kingdom schools in 1974 and 1977 who reported periods of unemployment of at least three months' duration each, or who have worked part-time. The results reveal how their patterns of non-employment and part-time work have changed over the years. As expected, women were more likely to have been unemployed or to have worked part-time and these differences were strongly linked to marriage and child-bearing. Finally, some of the implications for the career prospects of women doctors are discussed.
Patients undergoing amputation and who are considered to be suitable for an artificial leg are referred to the Disablement Services Centres (formerly called the Artificial Limb and Appliance Centres). This article reviews the referrals to the 23 centres in England, Wales and Northern Ireland over the five-year period 1981-85. The results show that there has been a decrease in the number of both upper and lower limb referrals and a 4% increase in the primary cause of amputation, arteriosclerosis. Centres that are the busiest, those seeing the greatest and fewest number of arteriosclerosis and diabetic referrals and those being referred the largest numbers of above, below and knee level amputations are identified.
The aetiology, presentation and management of fractured mandibles were investigated in a major accident and emergency department in 1983 and 1993. Demographic features of patients in both years were similar: most injuries were in males (89%), most were a result of an assault ( > 75%), and 50% of the patients presented for treatment between the hours of 10pm and 5am. There were striking reductions in the numbers of patients who waited more than 24-hours for an operation (60% in 1983; 34% in 1993), and out-of-hours operating (60% in 1983; 41% in 1993). There was an increase in the number of patients for whom consultants were the principal operator (13% in 1983; 32% in 1993). Changes in the methods of treatment included a decrease in the use of postoperative intermaxillary fixation (98% in 1983; 56% in 1993) and an increase in internal fixation using bone plates (2% in 1983; 53% in 1993). Total inpatient stay was the same in both study years (mean = 3 days), and there was no difference in duration of stay between treatment modalities (internal versus intermaxillary fixation).
The legal documentation and hospital case-notes of all patients detained during 1989 in Nottingham and Lincoln under Section 5(2) of the Mental Health Act 1983 (empowering the emergency detention of a voluntary inpatient who wishes to leave), were audited to establish if there were any predictors of conversion to longer-term restraint under that Act. Of the 146 Section 5(2) orders, 80 were converted to a Section 2 or 3; the conversion rate in people detained outside normal working hours and those detained within 12 hours of admission was significantly lower; and the conversion rate was significantly higher in people with a mental illness, compared with those with personality disorders, substance abuse and stress reactions. No differences existed in the overall conversion rates of people managed by senior or junior doctors, but junior doctors who did not seek the advice of a senior doctor had a significantly lower rate of conversion than those who did. These results indicate that Section 5(2) may have been inappropriately used in up to 45% of cases, and underline the need for appropriate consultation.
Between 1 January 1983 and 31 December 1985, 72 complaints concerning the management of patients attending Accident and Emergency (A & E) Departments in South Glamorgan were received. This represents an incidence of 1 in 3,390 new patient attendances (0.029%). Thirteen cases have to-date involved legal action (1 in 22,895 new attendances). An analysis is made of the nature and management of these cases.
Formulation of business plans by National Health hospitals requires information on likely demands for the services they provide. Two cohorts of patients admitted to the Nottingham hospitals in 1983 and 1989 with suspected myocardial infarction were sampled to determine the workload implications due to initial in-hospital tests, subsequent readmission and outpatient investigations. The results show that attendance in the first year after discharge related principally to cardiac problems, while in subsequent years non-cardiac problems predominated. An estimation of the total workload, based upon 1,000 patients admitted in 1989, suggests that demands for hospital services in the following year include over 4,000 electrocardiographs, 1,400 chest X-rays and 18,000 laboratory tests, and only 118 exercise tests and 37 cardiac catheterisations. Admission with suspected myocardial infarction makes great demand on hospital services in the year after discharge. Any change in practice, which increases the potential demand for cardiac investigations, could have important financial implications for Nottingham hospitals.
The Mental Health Act 1983 substantially modified Guardianship, a previously little used facility for the compulsory care of mentally ill and mentally handicapped people in the community. This paper describes the results of a survey of information based on the annual returns from Local Authorities to the Department of Health and Social Security, and examines the impact of the new legislation upon the use of Guardianship in psychiatric practice. Although the number of Guardianship Orders in force remains relatively small compared to hospital admissions, recent trends indicate a significant increase in its application to people with a mental illness, and a decline in its use for people with a mental handicap. Despite the overall increase in use, the Regional differences of cases in England remain essentially unchanged and reflect the differing attitudes and policies of Local Authorities towards Guardianship Orders.
One of the aims of the Mental Health Act 1983 was to discourage the use of emergency orders; the criteria for using the emergency provisions provided by Section 4 of the Act are stricter than those of the corresponding Section 29 of the previous Mental Health Act 1959. In 1986-87 the Mental Health Act Commissioners found a comparatively high level of admission under Section 4 in Cambridge. This study was undertaken to examine the hospital careers of all Section 4 admissions in Cambridge over a two-year period, and to compare these with admissions for assessment by two doctors under Section 2 of the 1983 Act and informal admissions. Almost 50% of all the Section 4 admissions were not continued on a compulsory admission by the end of the 72 hour duration of the Section. The findings suggest that these patients might have been more appropriately admitted informally or not at all.
Baseline data on screening and health education were collected in 1984 from a national survey of general practitioners (GPs), and two groups of GPs who responded to this first survey were followed-up by a second postal questionnaire sent out in July 1990. One group comprised doctors who previously had a low involvement with screening and health education in 1984 (low-involvement group [LIG]), and the other doctors with high involvement (high-involvement group [HIG]). The results from the 1990 survey indicated that the HIG were still more committed to screening and health education than the LIG, but the differences between the two groups had greatly diminished. In 1990 similar proportions of both groups were expecting to receive payments for screening, child health surveillance and health promotion clinics under the new GP contract.
This study looked at recent changes in Wales in four health-related behaviours: smoking, alcohol consumption, diet and physical activity. Data are drawn from three large-scale surveys conducted across Wales in 1985, 1988 and 1990. The results show a reduction in smoking prevalence between 1985 and 1990 among men and women, and a growing trend towards healthier eating, with reduced frequent consumption of salt and foods high in saturated fats. Encouraging progress towards healthier living has been made, but the results also indicate the extent of the remaining challenge: greater progress is particularly needed to encourage participation in exercise, and to reduce the numbers of people who drink alcohol in excess of recommended sensible limits.
Recent years have seen a reduction in the number of psychiatric hospital beds available in central London. A survey was carried out to investigate the effects of bed losses without upgrading community facilities on one inner-city service. The problems highlighted are discussed in relation to patient needs and service provision.
This longitudinal survey of elderly people examines morbidity and service usage. 705 elderly people who lived in their own homes were interviewed as part of the Gospel Oak project in 1987/88, and in 1990, 524 (74.3%) were re-interviewed--90 (12.8%) had died, 51 (7.2%) had moved and 40 (5.7%) refused a follow-up interview. The results indicate that 60% of residents (1987/88 and 1990) had been in contact with community services within the month before the survey. Respondents with depression were mostly in contact with the health service, those with dementia were in contact with social services. Long-term activity-limited people had high contact with both services, although this finding was less likely among newly activity-limited people. Multiple service-users from the first survey were likely to be either dead, or high service-users in 1990. Low service-users tended to continue to be low service-users. New users were generally living alone, aged around 70 years and had been relatively healthy previously. Respondents who stopped using services were generally younger, mostly women, and possibly depressed. People who had never been service-users, were generally younger and healthier. Information on community services performance is inadequate to ensure targeted, efficient services, and this survey gives detailed information to help planning and resource allocation.
The Medical Manpower and Education Division of the Department of Health publishes information in this journal each year on the current state of medical and dental manpower in England and Wales, to assist medical and dental students and newly-qualified doctors and dentists in their career choices. Additional information can be obtained from the national and regional census tables which are usually published by the Department of Health each spring. These are circulated widely to all health authorities, postgraduate deans and clinical tutors.
The increasing sophistication of enteral and total parenteral nutritional support techniques has resulted in improvements in the clinical practice of such support in recent years. This survey was designed to establish current clinical practice in the management of nutritionally-compromised hospital patients in 206 districts in the United Kingdom. However, despite recent developments in these techniques, the response revealed a wide variation in the practice of clinical nutritional support. The results also indicate that in each district there should be a group of people, with an interest in clinical nutrition, to monitor and advise on nutritional support. It is suggested that, a national multidisciplinary group should be formed, similar to the American and European Societies of Parenteral and Enteral Nutrition. The group would promote the appropriate use of, and research into, nutritional support specifically for the nutritionally compromised patient in the United Kingdom.
The demand for, and provision of, primary dental care was investigated in a teaching hospital setting in 1989 and 1993 - a period which saw the introduction of the new dental contract and the publication of the Poswillo report on general anaesthesia and sedation. Five hundred patients who attended the primary care department for the first time at the University of Wales Dental Hospital were interviewed in May/June 1989, and a further 520 patients were interviewed in May/June 1993. Self-referrals increased from 260 patients (52%) in 1989 to 352 patients (68%) in 1993. The proportion of patients who did not have a general dental practitioner (GDP) increased from 32% (160) in 1989 to 39% (202) in 1993. More patients registered with a dentist self-referred in 1993 compared to those in 1989, reportedly because of inability to obtain an appointment with their own GDP (88), rather than because of cost (17). Over the four-year period there was an increase in demand for treatment of early stage (pulpitic) dental infection from 32% to 40%, and a decrease in relation to end-stage infection (dentoalveolar abscess) from 11% to 6%. This 'safety net' role of dental hospitals needs to be taken into account when contracting for services.
A large questionnaire survey of general practices in England to determine the most recent policies, perceptions, and procedures for influenza immunisation, and the extent to which individual practice characteristics were related to levels of vaccine distribution, was conducted during January and February 1992. The results indicate that the proportion of practices with influenza immunisation policies has increased considerably since the mid 1980s. However, some notable shortcomings remain and practice characteristics appear to have little influence on vaccine delivery, suggesting that other factors may also be important.
This article offers some background information to help junior doctors, and those who advise them, to make decisions about their future careers. Further information can be obtained from the Regional tables, which the Department of Health circulate to Regional Postgraduate Deans, Health Authorities and clinical tutors. All the information presented here is retrospective. Comparing this with the previous annual articles in this series may help you to assess the likely future prospects in your particular specialty.
This annual article is intended to help young doctors and dentists make informed decisions about their career paths, in the light of the current prospects of obtaining a career post in any specialty. Regional details of the national figures presented here may be obtained through individual Regional postgraduate deans, Health Authorities and clinical tutors. This article summarises the most recent figures available, and comparison with previous articles in this series may help to identify employment trends.
This article provides a brief update on current national policies affecting medical education and training, and information on the present medical and dental workforce. Although of general interest, senior medical students and doctors in the training grades may find it particularly helpful when considering choices of future career. As there may be marked local variations in career prospects for any one specialty, further information and advice is available from Regional Postgraduate Medical and Dental Deans, specialty advisors (through Royal College and specialty associations) and clinical tutors. The information in this article relates to the present situation only and a review of previous articles in this series may be useful to observe certain trends.
Information obtained from 3 questionnaires circulated to British gastrointestinal endoscopists has been used to trace the development of endoscopy services during the 1970s. Oesophagogastro-duodenoscopy became available in most hospitals; colonoscopy services were slower to develop and endoscopic retrograde cholangio-pancreatography was performed in under 50% of hospitals. Various therapeutic techniques followed the diagnostic procedures and by the end of the decade constituted one of the major areas of growth. The impact of gastrointestinal endoscopy on other disciplines, diagnostic radiology, surgery, pathology and general practice is reviewed. Organizational aspects of endoscopy services with emphasis on staff, premises, instrumentation and finance are discussed. Analysis of the trends during the 70s has allowed some predictions of the likely developments in the 1980s.
This paper reports the results of a retrospective review which analysed emergency admissions and readmissions of elderly patients to a district general hospital. All patients received standard after-care allocated by the community health and social services departments following referral by hospital staff. In addition, half of the cohort was randomly allocated to receive care attendant support for a maximum of 12 hours a week for two weeks following the first and any subsequent discharge from hospital. The effect of this additional community support on emergency readmissions was also reviewed. The findings show that the patients randomly allocated to receive the modest domiciliary after-care service were less likely to have another emergency readmission or multiple readmissions. The results suggest that patients over 75 years-of-age, living alone, or having two or more emergency admissions within six months, should have a domiciliary assessment and follow-up after hospital discharge.
Two hundred and fifty one people aged 75 and over, and living in their own homes in South Glamorgan, were interviewed about their knowledge of the health and social services available to them, and their satisfaction with those they had received. Heavy service use was the exception rather than the rule, but the pattern of service provision was comparable with that of Great Britain as a whole. The most frequent health service contact was with the General Practitioner (GP) Service, and the service most frequently provided by the Social Services Department (SSD) was the Home Help Service. There were low levels of awareness of some services, and, for some, considerable uncertainty about their functions. Those who had received services reported high levels of satisfaction with them, but for some services there was a higher level of specific criticism.
Attempts to reduce the number of children born with congenital malformations may be seen as part of the programmes for rubella immunization and for screening for neural tube defects and chromosome anomalies. The rubella immunization programme in England and Wales has not been accompanied by any appreciable decline in the overall incidence of heart or eye malformations detected at or soon after birth. However, the decline in the incidence of babies born with defects of the central nervous system, and of babies born with Down's syndrome to elderly mothers, indicates that interventive methods of control are achieving changes.
With increasing numbers of child sexual abuse referrals in 1985, professionals in an inner city health district recognised the limitations of existing child abuse guidelines for the sensitive investigation of such cases. A multi-disciplinary working party was set up under the auspices of the District Child Abuse Review Committee to develop more flexible guidelines, particularly for suspected cases. New guidelines were implemented which involved early consultation with a specialist multi-disciplinary team to allow a specific co-ordinated approach for the investigation and management of each case. The guidelines, the cases and the difficulties encountered by the different professionals involved are described.
Previous studies of day-case laparoscopy have indicated considerable post-operative morbidity, with high incidences of nausea, vomiting and pain, often resulting in overnight admission. These studies also indicate that 30% of patients would have preferred an overnight stay. Changes in day surgery anaesthetic practice since then have included the wider use of non-steroidal analgesics and the specific use of propofol, a new short acting anaesthetic drug, with improved recovery and anti-emetic properties. We audited 74 patients who had day-case laparoscopy for diagnosis or sterilisation, and found that the incidence of nausea and vomiting was lower than any previously recorded, and mean pain scores were minimal. No patient was admitted for recovery problems, despite the inclusion of afternoon procedures; two patients only were admitted for surgical complications. Despite considerable morbidity after their return home, only 8% of patients said they would have preferred an overnight stay. Changes in anaesthetic practice would seem to make day-case laparoscopy a more acceptable procedure than previously reported.
A survey of attendances in one year at a community hospital accident and emergency department in Redcar was undertaken to determine the clinical conditions treated and their severity, the number of cases referred to the major accident centre or to an appropriate specialist, and the reasons why patients chose to attend for treatment at the community hospital. Minor trauma accounted for many of the 7,557 attendances (4,916 patients); 5% were medical and non-traumatic surgical cases. One third of the patients had hand injuries. There were 1,765 patients (36%) referred for specialist care or follow-up. Nearly half of the patients gave no reason for choosing to seek treatment at the community hospital and most of the remainder attended because of difficulty in getting access to their general practitioner or practice surgery when the injury/illness occurred.
This paper describes the results of a survey in 1990 which examined the practice of general anaesthesia in Accident and Emergency Departments. Data were obtained concerning the anaesthetics induced during the previous year, specifically the number of procedures undertaken, the equipment, the facilities and the personnel involved, including any complications. These findings are discussed in relation to recommendations for minimum standards in anaesthetic practice.
Accident and Emergency Departments are increasingly becoming major providers of primary health care to the elderly. The attendance of an elderly person at an Accident Department may be associated with loss of independence and this may lead to admission to hospital. Such admissions, may sometimes, be avoided by the provision of immediate social support in the community. For five years, we have worked with the Age Concern after-care officer who is able to provide such assistance by liaison with the Social Services. To provide longer-term help, she works closely with the community-based Age Concern network. The Community and Social Services, as well as the Hospital-based services, have benefited from her presence.
In order to assess the impact of changes in the Licensing Laws in England, a prospective study was undertaken of patients attending the Accident and Emergency Department of the Newcastle General Hospital. Patients were breathalysed in October 1986, before the liberalisation of the Licensing Laws in England and Wales and again in October 1988, after this change. A blood alcohol level of greater than 50 mg/100 ml was detected in 13% of all attenders in 1986 and 14% in 1988. A comparison of the two years revealed no significant change in the number of patients who had ingested alcohol prior to attendance, although there was a trend towards increased frequency of alcohol ingestion in nighttime attenders.
This paper describes the development of a comprehensive, practical audit by the medical staff at the Accident and Emergency Department at Guy's Hospital. The audit has enabled a comprehensive systematic review of clinical care and its documentation. The results shows that audit of Accident Emergency medicine is possible when channelled by proforma. Junior doctors in this specialty exercise great autonomy, and the audit highlights their need for proper training and guidance from senior medical staff in the review of major and minor cases.
There has been great variation between District Health Authorities in the proportion of attenders at Accident and Emergency Departments who reattend for further care. Eight Accident and Emergency Departments were studied during 1987 to ascertain the extent to which this reflects different medical policies. Information extracted from a random sample of 4,682 first attendances found that the sample reattendance rates lay closer together than the reported ones, with only a three-fold, rather than a six-fold variation between departments. Important causes of the exaggerated variation in the reported rates were different ways of organising follow-up clinics, and differences in hospital and departmental practices of aggregating and reporting statistics on activities in these clinics. The variation between departments in their booked reattendance rates could not be explained by differences in case-mix or treatment practices. The results of this study suggest that differences in medical and organisational policies produce different reattendance rates. However, it is not known which of the different management policies on reattendance are the most cost-effective.
This paper describes the process involved in establishing the nurse practitioner services at Oldchurch Hospital, Essex. It also contains an evaluation of the safety of such a practice and outlines the current operational guidelines.