History and development of the out-patient model

The first mention of any form of psychiatric out-patient service in the UK can be traced back to the 18th century, when Edward Tyson, a physician at the Bethlem Hospital in London, convinced the hospital Governors of the benefits of apothecary prescriptions to discharged patients to prevent relapse:

As with many service developments, the establishment of psychiatric out-patient clinics evolved as a response to service pressures. One major factor was the difference in admission criteria between registered hospitals and asylums. The latter were considered a last resort: after the parish doctor declared a person insane, the individual was placed on a compulsory reception order by a local magistrate under the Lunacy Act 1890 and taken to the asylum, where the medical officer classified them as ‘curable’ or ‘incurable’ (Reference Hunter and MacAlpineHunter & MacAlpine, 1974). In contrast, registered hospitals such as the Bethlem stopped admitting parish patients in 1857, and from the late-19th century the Bethlem prided itself on being one of the pioneers of uncertified cases. By 1900, only 3% of Bethlem patients were certified, compared with 97% of the asylum population (Reference Andrews, Briggs and PorterAndrews et al, 1997).

In 1917, John Porter-Phillips, Physician Superintendent of the Bethlem, suggested the need to develop an out-patient service to encourage early detection of psychiatric illnesses. This was seen as progressive policy, in keeping with the growing interest in psychoanalysis and psychological treatments for those returning from the First World War and it was hoped that it would allow

The first specialist psychiatric out-patient department in the UK subsequently opened in 1918 in Lambeth Road, London, as the Hospital for Nervous Diseases. It was so named in order to encourage attendance, since any overt association with the Bethlem was acknowledged to be stigmatising for patients. It was initially considered successful and was widely acclaimed but, owing to financial problems, it was closed in 1927 ‘having failed to attract suitable cases’ (Bethlem Hospital Governors’ Report, 1927). Its optimistic aims had not been achieved, since most patients who attended had been previously treated and were not easily cured.

However, as a result of the exponential rise in the asylum population, the Mental Treatment Act 1930 extended the voluntary admission procedure to asylums and encouraged some form of out-patient service to assess patients for their suitability for voluntary treatment prior to admission. In 1925 there were 25 psychiatric out-patient departments in the UK and by 1935 this figure had increased to 162 (Reference Andrews, Briggs and PorterAndrews et al, 1997).

The social and political climate of the following decades and the introduction of phenothiazine drugs fuelled dramatic changes in mental health service provision, with the closure of the asylums and the relocation of services to district general hospitals within the newly established National Health Service.

Psychiatry began to become accepted as a medical specialty and the model adopted for the organisation of services was the same as for other hospital disciplines, namely in-patient wards and out-patient clinics. Gradually, community psychiatric nurses were added to out-patient services, relocating into community bases outside of the hospital and eventually evolving into multidisciplinary community mental health teams (CMHTs), integrated with colleagues in social services (Department of Health, 2002). The National Service Framework for Mental Health (Department of Health, 1999a ) outlined the development of further specialist community mental health services, such as assertive outreach teams, crisis resolution and early intervention services, which have now been implemented nationally (Department of Health, 2004). Out-patient services have therefore been somewhat usurped by other community service provision and there is therefore a need to reflect on whether they still have a place within modern mental health services.

Use of out-patient services

In 1995 the National Audit Office estimated that around 40 million out-patient consultations were booked per year in England and Wales and that 12% of out-patients failed to attend their appointments in 1993–1994 (National Audit Office, 1995). At the time, the cost of each missed appointment was estimated at around £50, giving a total waste of £240 million per year. The rates of out-patient non-attendance at psychiatric clinics have consistently been found to be greater than in most other hospital specialties, ranging from 20% to 57% (Reference Baekland and LundwallBaekland & Lundwall, 1975). National ‘league tables’ published by the Commission for Healthcare Improvement (http://www.chi.nhs.uk/Ratings/home.asp) for 2003–2004 showed that the non-attendance rate at first psychiatric out-patient appointments reported by all 83 mental health trusts in England ranged from 7.5% to 40.1%, with a national average of 18%. The cost of this wasted medical and clerical time and associated overheads will have increased well above £50 per appointment.

A number of studies (Reference JohnsonJohnson, 1973; Reference MorganMorgan, 1989; Reference Killaspy, Banerjee and KingKillaspy et al, 2000) have shown that the majority of new referrals to psychiatric out-patient clinics have a diagnosis of a common mental disorder such as depression or anxiety. In contrast, the majority of follow-up patients (who make up around 90% of the clinic population) have diagnoses of severe and enduring mental health problems such as schizophrenia, schizoaffective disorder and bipolar affective disorder (Reference Killaspy, Banerjee and KingKillaspy et al, 2000). This suggests that individuals with severe mental illness do not generally access out-patient services by direct referral from the general practitioner (GP) but are seen as follow-up patients, usually after an in-patient admission. It also suggests that the majority of psychiatrists assess patients with common mental disorders but do not necessarily offer ongoing follow-up appointments to them. This trend appears to be growing (Table 1) and illustrates that the role of out-patient clinics has evolved from its original ‘triage for admission’ function towards assessment of less severe conditions and follow-up of people with longer-term problems.

Table 1 Diagnoses of new and follow-up patients at psychiatric clinics

Diagnosis	New: n = 456 (Reference JohnsonJohnson, 1973) %	New: n = 106 (Reference MorganMorgan, 1989) %	New: n = 57 (Reference Killaspy, Banerjee and KingKillaspy et al, 2000) %	Follow-up: n = 167 (Reference Killaspy, Banerjee and KingKillaspy et al, 2000) %
Depression	34	47	53	26
Neurosis	11		21	10
Personality disorder	30	19	5	7
Functional psychosis, bipolar affective disorder	4	17	9	56
Other, including substance misuse	8	13	7	2
Organic disorder	5	0	0	0
No psychiatric problem	8	3	5	0

Reasons for non-attendance

Review of the literature identifies a number of factors associated with out-patient non-attendance across medical specialties: younger age; lower socioeconomic status; lack of family support; greater waiting time between referral and appointment; poor understanding of the reason for referral; and clerical error (Reference Caldwell, Cobb and DowlingCaldwell et al, 1970; Reference Baekland and LundwallBaekland & Lundwall, 1975; Reference SkuseSkuse, 1975; Reference Deyo and InuiDeyo & Inui, 1980; Reference McGlade, Bradley and MurphyMcGlade et al, 1988; Reference Frankel, Farrow and WestFrankel et al, 1989; Reference Koch and GillisKoch & Gillis, 1991; Reference Lloyd, Bradford and WebbLloyd et al, 1993; Reference VerbovVerbov, 1992; Reference Potamitis, Chell and JonesPotamitis et al, 1994). Along with ear, nose and throat and dermatology clinics (Reference McGlade, Bradley and MurphyMcGlade et al, 1988), psychiatry has very high non-attendance rates and individuals with a diagnosis of substance misuse or personality disorder are least likely to attend (Reference Baekland and LundwallBaekland & Lundwall, 1975; Reference Smyth, Vostanis and DeanSmyth et al, 1990).

Studies that have investigated the reasons patients give for non-attendance have found differences between psychiatric and non-psychiatric clinics. Patients who miss appointments at non-psychiatric clinics are more likely to report that they were unwell with symptoms unrelated to the condition for which they were due to attend or that they were away on holiday (Table 2). In contrast, both new and follow-up psychiatric patients’ reasons suggest that active symptoms of the illness are a major contributor to non-attendance (e.g. ‘too paranoid that day’ or ‘too depressed to get out of bed’). Reasons given by patients who miss follow-up appointments at psychiatric clinics also appear to be a function of the psychiatric illness itself. For example, lack of insight (e.g. ‘no need to attend as not unwell’), apathy (‘couldn't be bothered’) and reduced organisational skills (e.g. ‘forgot’ or ‘lost appointment card’) (Table 3). For those newly referred to a psychiatric clinic, previous out-patient treatment increases the chance of attending (Reference Carpenter, Morrow and Del GaudioCarpenter et al, 1981), but previous psychiatric admission reduces it (Reference Smyth, Vostanis and DeanSmyth et al, 1990). This could be because admission is a negative experience that alienates patients from services or, perhaps a more likely explanation, because those who have required an admission are more unwell and less likely to manage attendance at the out-patient clinic for reasons directly related to their illness, as outlined above. This explanation is supported by the finding that, although some patients cite unhappiness with treatment as their reason for non-attendance, a large study of follow-up psychiatric patients failed to show any difference in satisfaction with treatment or out-patient services between attenders and non-attenders (Reference Killaspy, Gledhill and BanerjeeKillaspy et al, 1998).

Table 2 Reasons that patients give for missing appointments at non-psychiatric and psychiatric clinics

	Non-psychiatric clinics			Psychiatric clinics
Reason for missing appointment	Dermatology, UK: n = 100 (Reference VerbovVerbov, 1992) %	Ophthalmology, UK: n = 224 (Reference Potamitis, Chell and JonesPotamitis et al, 1994) %	General medical, UK: n = 162 (Reference Frankel, Farrow and WestFrankel et al, 1989) %	New + follow-up patients, USA: n = 101 (Reference Sparr, Moffitt and WardSparr et al, 1993) %	Follow-up patients, Hong Kong: n = 56 (Reference Pang, Lum and UngvariPang et al, 1996) %	New patients, USA: n = 103 (Reference Carpenter, Morrow and Del GaudioCarpenter et al, 1981) %
Physical illness unrelated to presenting complaint	28	22	9	6
Feeling better	6	8	12		40	28
Away on holiday	5		28
Forgot	9	18		25
Unable to take time off work	10	3	12
Time to appointment too long						12
Appointment not received	6	15
Appointment altered by clinic			9	5
Appointment cancelled by clinic		8
Lost appointment card	3
Mistook appointment time or date	5			9
Other commitment	10	4		6	5	6
Family reason	8	1		1
Transport problem	2	7		4		2
Could not remember reason	4			22	20
Overslept				7
Too worried about appointment		3				3
Received treatment in another clinic					10	25
Admitted to in-patient unit				1		14
Went to casualty						2
Stigma of psychiatric treatment					5
Moved away					7
Unhappy with treatment					13

Table 3 Reasons given for missing appointments (from Reference Killaspy, Banerjee and KingKillaspy et al, 2000)

Reason for missing appointment	New patient non-attenders (n = 29) n (%)	Follow-up non-attenders (n = 74) n (%)
Active symptoms of psychiatric illness	4 (14)	10 (14)
Clerical error	4 (14)	8 (11)
Forgot	3 (11)	20 (27)
Felt better	1 (3)	1 (1)
Afraid of admission	3 (11)	0 (0)
Unhappy with referral	5 (17)	0 (0)
Physical illness	1 (3)	1 (1)
Lost appointment card	1 (3)	3 (4)
Other commitment	3 (11)	6 (8)
Travel problem	0 (0)	3 (4)
Unhappy with treatment	1 (3)	6 (8)
No need to attend as no problem	0 (0)	5 (7)
Poor weather	1 (3)	0 (0)
Couldn't be bothered	1 (3)	5 (7)
Overslept	1 (3)	6 (8)

Clinical implications of non-attendance

Prospective studies of follow-up patients at psychiatric clinics have demonstrated that non-attenders are more severely unwell, more socially impaired and have a greater chance of admission within 12 months of the missed appointment than attenders (Reference Pang, Lum and UngvariPang et al, 1996; Reference Killaspy, Banerjee and KingKillaspy et al, 2000). Rates of readmission for patients discharged from the in-patient unit who miss their follow-up appointments have been shown to be three times higher than for those who attend (Reference Koch and GillisKoch & Gillis, 1991; Reference Nelson, Maruish and AxlerNelson et al, 2000). One interpretation of these findings is that attendance at the clinic maintains stability of mental health. Alternatively, psychiatrists are perhaps only seeing those who are well enough to attend.

In contrast, some groups of patients may become particularly difficult to discharge from the clinic. For example, Reference Pomeroy and RickettsPomeroy & Ricketts (1985) found an overrepresentation of people with a diagnosis of personality disorder among long-term out-patient attenders. This may, of course, have been because the individuals found this form of regular contact helpful and containing. However, in recent years, specialist interventions such as dialectic behavioural therapy (Reference Linehan, Armstrong and SuarezLinehan et al, 1991) and partial hospitalisation (Reference Bateman and FonagyBateman & Fonagy, 1999) for people with cluster B personality disorders have been shown to be effective and may promote a more encouraging longer-term prognosis for this client group than years of out-patient review.

Encouraging attendance

The evidence in support of prompts aimed at encouraging attendance at first appointments have been summarised in a Cochrane review (Reference Reda and MakhoulReda & Makhoul, 2001). The authors concluded that written prompts (such as ‘orientation statements’, which give an introduction to the clinic and what to expect at the appointment) received 1 or 2 days before the appointment are effective at encouraging new patient attendance but that telephone prompting is not. This is mainly because those with higher social function are more likely to have a telephone and more likely to attend anyway (Reference Burgoyne, Acosta and YamamotoBurgoyne et al, 1983).

A meta-analysis of approaches to increase treatment adherence (defined as appointment attendance and taking medication as prescribed) of people with schizophrenia and other severe mental disorders supported two interventions: pre-discharge contact between in-patient services and the community team; and psychoeducation about medication and other treatments (Reference Nosé, Corrado and GrayNosé et al, 2003). The first of these approaches could be considered an essential component of good discharge planning within the framework of the care programme approach (CPA; Department of Health, 1990, 1999b ). In addition, Standard four of the National Service Framework for Mental Health (Department of Health, 1999a ) states that patients discharged from hospital should be reviewed in the community within 7 days. Contact from the community team prior to this initial review would seem highly appropriate (e.g. during the admission and/or at a discharge CPA meeting in the in-patient setting). Various forms of psychoeducation for patients and their families are recommended in the National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of schizophrenia (National Institute for Clinical Excellence, 2002) and again could be considered essential components of good care planning for people with serious mental illness.

Out-patient commitment

A statutory system of out-patient commitment is in operation in the USA that involves a

The statute is applicable only to patients being discharged from an in-patient unit and specifically prohibits forced medication in the community but allows for enforced attendance at a mental health facility. At present there is no evidence of any benefit for out-patient commitment over standard care in terms of readmission, taking medication as prescribed, arrests or homelessness. In fact it has been estimated that it would take 238 out-patient commitments to prevent one arrest, 27 to prevent one episode of homelessness and 85 to prevent one readmission (Reference Kisely, Campbell and PrestonKisely et al, 2005). There is currently no equivalent to out-patient commitment in England but the proposed amendments to the Mental Health Act (1983) may include community treatment orders with similar powers.

Alternatives to the out-patient clinic

If, on the basis of the evidence presented so far, one accepts that the out-patient clinic may not be the best model within which to review the community treatment and care of people with longer-term mental health problems, the next step is an exploration of feasible alternatives.

Over recent decades there has been increasing interest in the establishment of psychiatric liaison services. Reference Strathdee and WilliamsStrathdee & Williams (1984) showed that 19% of general adult psychiatrists in England and Wales and 50% of those in Scotland had established primary care liaison clinics since the late 1970s. These services vary from the ‘shifted out-patient model’, where the psychiatrist sees patients in the GP's surgery for assessment and short-term management, to longer-term liaison with the primary care team. This approach appears to be more acceptable to some patients than the psychiatric out-patient clinic (Reference TyrerTyrer, 1984) and encourages joint management of people with serious mental illnesses by the GP and psychiatrist (Reference Darling and TyrerDarling & Tyrer, 1990). This is clearly advantageous, since the quality of communication between primary and secondary care has been shown to be particularly poor for individuals with severe and enduring mental health problems who fail to attend their out-patient appointments (Reference Killaspy, Banerjee and KingKillaspy et al, 1999). The GP's active involvement is also especially relevant for the physical health monitoring of this group, treatment of associated conditions such as diabetes and weight gain, and health promotion such as smoking cessation initiatives. Moreover, cardiovascular risk screening in primary care has been shown to be acceptable to people with serious mental illnesses (Reference Osborn, King and NazarethOsborn et al, 2003).

Do we need out-patient services at all?

For newly referred individuals who do not meet criteria for care coordination by the CMHT and are not in crisis, the out-patient clinic may provide an appropriate setting for assessment, referral to more appropriate agencies, initial monitoring of response to any medication prescribed and/or brief psychological interventions. Although data in Table 1 suggest that an increasing proportion of newly referred out-patients have common mental disorders, no recent studies have been published that could confirm whether psychiatric out-patient services in the UK are becoming more consultative. Older studies demonstrated a great reluctance on the part of psychiatrists to refer patients back to the GP within 3 months of assessment, irrespective of the severity of their condition (Reference Kaesar and CooperKaesar & Cooper, 1971; Reference JohnsonJohnson, 1973). Further exploration of the reasons for this reluctance to consult and discharge is needed since (a) this is in contrast to the consultative role provided by secondary out-patient services in other specialties, (b) it is wasteful of scarce consultant psychiatrist resources, (c) it is clinically illogical for the most qualified member of the multidisciplinary team to treat and review patients whose needs are not complex enough to require management under the CPA, and (d) it is outwith recent guidelines on new roles for consultant psychiatrists (British Medical Association, 2004).

The central role of the CMHT

A single point of entry into secondary mental health services may help to discourage parallel systems within community mental health services by routing all assessments through the CMHT. Medical assessment and primary care liaison would be part of this, following which a team decision is made about whether the individual requires ongoing care from the CMHT under the CPA (Fig. 1). Such a system can incorporate in-patient and out-patient referrals and allows some flexibility in the exact nature of primary care liaison and medical input to assessments.

Fig. 1 The community mental health team (CMHT) as the single point of entry to secondary community mental health services. CBT, cognitive–behavioural therapy; CPA, care programme approach.

This model, which is described in detail in the policy implementation guide for CMHTs (Department of Health, 2002), helps services to deliver on important aspects of the National Service Framework for Mental Health. For example, Standard two of the latter states that:

‘Any service user who contacts their primary health-care team with a common mental health problem should … be offered effective treatments, including referral to specialist services for further assessment, treatment and care if they require it’ (Department of Health, 1999a : p. 28).

The policy implementation guide for CMHTs outlines the need for primary care liaison that includes increased training of the primary care health team to recognise and treat common mental disorders and their increased liaison with secondary mental health services through ‘link workers’. The role of the CMHT is clearly detailed as including: advice to primary care health teams; triage of referrals; assessment of referrals; treatment and care for people with time-limited conditions who can benefit from specialist care (such as those with common mental disorders); and longer-term treatment and care of those with more complex and enduring needs (certainly people with psychoses, bipolar affective disorder and severe personality disorder, and possibly also those with common mental disorders whose conditions are not time-limited and who have complex needs). This document suggests that doctors should be involved in the assessment of people with severe mental illness in the majority of cases but that other members of the CMHT should be able to adequately assess those with common mental health problems.

Coordination and continuity of community mental healthcare

A sea change is therefore required to modernise out-patient services and bring them into line with an integrated and comprehensive approach to community mental health service provision. This might involve a ‘spring clean’ of the out-patient clinic to prevent unnecessary and wasteful duplication of patient reviews and ultimately a gradual devolution of the clinic altogether. This would involve a review of all out-patients to decide whether their needs would be better met and led by the care coordination offered by the CMHT, with episodic consultant review at CPA review meetings. For patients who do not meet criteria for CMHT care, a judgement has to be made as to whether their illness could be adequately managed in a primary care setting. Obviously, the development of primary care liaison services would make this option easier.

A sudden discharge of all out-patients to CMHTs and primary care would clearly be inappropriate. Indeed, for patients with histories of self-harm who have required admission, reduction in the amount of care offered in the community has been shown to be associated with a greater risk of suicide (Reference Appleby, Dennehy and ThomasAppleby et al, 1999). Therefore any reorganisation of out-patient services needs to be undertaken within the context of a well-coordinated strategy supported by service managers and commissioners who can facilitate meaningful links between primary and secondary care services.

Community coordination

With this in mind, the government's recent encouragement of increased community coordination of all healthcare (Department of Health, 2006) could be used to promote shared coordination and delivery of mental healthcare between primary and secondary services. Secondary community mental health services are already well-developed. Mental health skills within primary care teams will benefit from the introduction of graduate mental health workers, supported self-help programmes, and primary care liaison teams offering specialist advice, assessment and short-term medical and psychological treatments for common mental disorders and review of people with stable longer-term problems managed in primary care (Department of Health, 1999a , 2006). For people with more complex and enduring mental health problems, the CMHT provides longer-term care coordination and referral to other specialist mental health services. Figure 2 shows this as a proposed ‘community coordination model’ that incorporates the possible demarcation and overlap of primary and secondary mental health services, with specialist teams such as crisis resolution, primary care liaison and early intervention providing a clear bridge between the two.

Fig. 2 Community coordination model of mental healthcare.

Conclusions

I have attempted here to outline the origins of the psychiatric out-patient model, to question its relevance to modern community mental health service provision and to suggest a feasible alternative. Accepting that there will always be individual patients who are exceptions to any strategic reform of services, the proposed community coordination model for primary and secondary mental healthcare is capable of providing appropriate assessment and treatment for those who require both short- and longer-term management of their mental health problems. Its implementation would, over time, invalidate the need for a separate consultant-led out-patient service.

Declaration of interest

None.

MCQs

1. 1 The psychiatric out-patient model originated from:

   1. a a need to triage people before admission to asylums

   2. b a duplication of other specialties’ approaches

   3. c the recognition that continuity of care could prevent relapse

   4. d a government initiative.

2. 2 Factors associated with missing out-patient appointments include:

   1. a female gender

   2. b family responsibilities

   3. c lower socio-economic class

   4. d lower age.

3. 3 Factors associated with missing psychiatric out-patient appointments include:

   1. a greater severity of psychiatric illness

   2. b greater social disorganization

   3. c dissatisfaction with the out-patient service

   4. d lack of a telephone.

4. 4 Evidence-based alternatives to out-patient clinics include:

   1. a home visiting

   2. b primary care liaison services

   3. c out-patient commitment

   4. d CPA review.

5. 5 The best response to a missed first appointment by a patient with no history of risk to self or others is:

   1. a to send another appointment

   2. b to telephone the patient

   3. c a home visit with the CMHT

   4. d to ask the GP to visit.

MCQ answers

1		2		3		4		5
a	T	a	F	a	T	a	T	a	F
b	T	b	F	b	T	b	T	b	F
c	T	c	T	c	F	c	F	c	F
d	T	d	T	d	F	d	T	d	F