The cost consequences of changing the hospital-community balance: the mental health residential care study

BACKGROUND

Altering the balance of provision between hospital and community care is a key and often contentious component of mental health care policy in many countries. Implementation of this policy in the UK has been slowed by the apparent shortage of suitable community accommodation for people with long-term needs for care and support. Among the consequences could be the silting up of hospital beds by people who could be supported more appropriately elsewhere, in turn denying in-patient treatment to people with acute psychiatric problems and unnecessarily pushing up health service expenditure.

METHODS

Using data collected in a survey of hospital and residential accommodation services and their residents in eight areas of England and Wales, the cost components of today's balance of care were explored. Comprehensive costs were calculated and their associations with resident characteristics examined using multiple regression analyses.

RESULTS

On a like-with-like basis, the costs of hospital in-patient treatment for inappropriately placed patients greatly exceeded the costs of community-based care.

CONCLUSION

Further reduction of hospital beds, however, is not the panacea for an appropriate balance of mental health care, given the unknown but potentially considerable extent of unmet demand, as well as the impact of previous in-patient bed reductions apparent in the services surveyed. Rather, service providers and purchasers should focus on developing community-based care (including increased provision of 24-hour nursed beds) by ensuring that resources released through earlier closure programmes have been redeployed for their intended use and by accessing additional pump-priming or bridging resources.

QALYs and mental health care

Quality-adjusted life year measures (QALYs) have been fervently debated by researchers and decision makers concerned with resource allocation in the health care sector. They have been heralded as important aids to planning and priority setting, but also criticised on technical and ethical grounds. This paper examines these arguments with special reference to mental health care, the intention being to highlight the strengths and shortcomings of QALYs in this context. Issues pertinent to the application of QALYs in health care evaluation more generally are also reviewed. Whilst the rationale and underlying principles of the utility measurement approach are sound, the generic QALY as it is currently constructed represents an insensitive measure of the outcomes of mental health care. In the event of an increasingly QALY-driven priority-setting environment, however, abandonment of QALYs runs the risk of inappropriately marginalising people with mental illnesses in the resource allocation process. This opens up the possibility of developing a mental-health specific measure of utility that, in combination with cost data, would provide useful and appropriate summary information across treatments and programmes of mental health care.

The mental health residential care study: predicting costs from resident characteristics

BACKGROUND

Little information is available on the costs of residential care for people with mental health problems, and there are very few research data on how or why the costs of provision vary.

METHOD

As part of a broader study based on data collected from across the residential care sectors in eight districts and using multiple regression analysis, research has examined whether and which resident characteristics are associated with higher or lower costs.

RESULTS

Resident characteristics account for approximately 21% of the observed variation in inter-resident costs. Separate analyses were conducted for people in the London and non-London districts. The resident characteristics that were found to be significant predictors of cost include: age, gender, ethnic group, history of psychiatric admissions, diagnosis, emotional lability, daily living skills, social interaction and network, aggression, suicidal tendencies, drug abuse and legal status. Examination of the residual ('unexplained') costs found significant differences between facility types, sectors (private and voluntary being less costly than public, other things being equal) and districts.

CONCLUSIONS

The associations uncovered by these analyses can inform commissioners' planning and purchasing activities, at both the macro and micro levels, by revealing those resident needs and circumstances that are associated with higher costs.

The mental health residential care study: classification of facilities and description of residents

BACKGROUND

The NHS is no longer a virtual monopoly provider of mental health residential care. This makes it difficult to assess the volume, range and adequacy of local provision.

METHOD

Local data collectors used standard instruments to collect detailed information about 368 facilities (with 1951 residents) providing mental health residential care in eight districts. Because local definitions were inconsistent, facilities were reclassified on the basis of facility size and extent of day and night cover. The eight categories of accommodation are compared on levels of staffing, staff qualifications and the characteristics of their residents.

RESULTS

There was a nearly threefold variation between districts in the total number of residential places available per unit of population, and even greater variation in the number of places with 24-hour waking cover. Most residents have long-term, severe mental illness and severe impairment. Long-stay wards accommodate people who pose greater risk of violence than do the two types of non-hospital facility with 24-hour waking cover (P < 0.001). The former also employ a much greater proportion of staff with formal care qualifications and, in particular, nursing qualifications than the latter (49% v. 15%, P < 0.001).

CONCLUSIONS

It is suggested that one consequence of the diversification in provision of mental health residential accommodation has been a relative reduction in the proportion of provision available to the most severely disabled. This might apply particularly to those who pose a risk of acting violently.

Two outbreaks of Salmonella enteritidis phage type 4 infection associated with the consumption of fresh shell-egg products

In 1988 there were two outbreaks of infection with Salmonella enteritidis phage type 4 in adjacent local authorities. The first affected 18 of 75 helpers and guests who attended a private function. Investigations revealed that home-made vanilla ice-cream containing uncooked eggs was the vehicle of infection and the causative organism was identified at the premises of the egg producer. The second affected 84 of 422 delegates attending a conference dinner, and 12 of 50 hotel staff at risk. A dessert made with lightly-cooked egg yolk and raw egg white was associated with infection, and the epidemic strain was cultured from the shell of an egg and an environmental sample from the producer's farm. It is of interest that one outbreak involved free-range and one battery-produced eggs, and that in one the vehicle was prepared at home and in the other in commercial premises. In neither incident was any deficiency in standards of egg production or catering practice discovered.

Nucleotide sequence of psbC, the gene encoding the CP-43 chlorophyll a-binding protein of Photosystem II, in the cyanobacterium Synechocystis 6803

The nucleotide sequence for the Photosystem II gene psbC has been determined for the cyanobacterium Synechocystis 6803. The gene overlaps the last 50 bases of the psbD gene, and both genes are transcribed in the same direction, but read in different frames. This arrangement is identical to that found in all chloroplast genomes for which psbC has been sequenced. The Synechocystis nucleotide sequence is 70% homologous to the tobacco gene and the predicted amino acid sequence shows 85% homology. A possible alternative translation start site for psbC has been conserved between seven plant sequences and the cyanobacterial sequence. The hydropathy plot for the cyanobacterial protein is very similar to plots determined for six plant species. Pairs of histidines that may play a role in binding chlorophyll are conserved between the cyanobacterial and plant amino acid sequences.

Recovery of a soybean urease genomic clone by sequential library screening with two synthetic oligodeoxynucleotides

We report the first isolation of a low-copy-number gene from a complex higher plant (soybean) genome by direct screening with synthetic oligodeoxynucleotide (oligo) probes. A synthetic, mixed, 21-nucleotide (nt) oligo (21-1) based on a seven amino acid (aa) sequence from soybean seed urease, was used to screen genomic libraries of soybean (Glycine max [L.] Merr.) in the lambda Charon 4 vector. Twenty homologous clones were recovered from a screen of 500,000 plaques. These were counterscreened with embryo-specific cDNA (15-2 cDNA) made by priming with a second, mixed 15-nt oligo (15-2), based on a Jack bean (Canavalia ensiformis) urease peptide [Takishima et al., J. Natl. Def. Med. Coll. 5 (1980) 19-23]. Five out of 20 clones were homologous to 15-2 cDNA and proved to be identical. Nucleotide sequence analysis of representative clone E15 confirmed that it contained urease sequences. Subclones of E15 homologous to the oligo probes contain a deduced amino acid sequence which matches 108 of 130 aa residues of an amino acid run in a recently published [Mamiya et al., Proc. Jap. Acad. 61B (1985) 359-398] complete protein sequence for Jack-bean seed urease. Using clone E15 as a probe of soybean embryonic mRNA revealed a homologous 3.8-kb species that is the size of the urease messenger. This species is absent from mRNA of embryos of a soybean seed urease-null mutant. However, both urease-positive and urease-null genomes contain the 11-kb DNA fragment bearing urease sequences.

Isolation of multiple genomic sequences coding for chicken myosin heavy chain protein

A genomic bank has been constructed using DNA isolated from a dystrophic strain of chickens. The library was screened for myosin heavy chain (MHC) sequences using a cDNA probe and 11 positive recombinants isolated. Identity of the clones was confirmed by positive RNA selection via hybridization of the clones with muscle RNA and subsequent translation of the hybridizable RNA in vitro. Restriction maps indicate that the clones can be divided into 7 distinct groups; some of these groups do, however, share similar or homologous sequences. Hydridization of the clones to RNA derived from leg, breast, heart, and brain reveals that all of the clones code for the muscle-specific MHC isoforms. These experiments also show that there are at least 3 size classes of MHC mRNA sequences, whose relative amounts appear to be modulated in a tissue- and developmental stage-specific manner.

Insulin and glucagon responses of transplanted intrasplenic pancreatic islets

Two transplant procedures have been investigated in which one third of the pancreas was autotransplanted into the splenic pulp of dogs. The two procedures consist of simple mechanical dissociation of the pancreas or mechanical dissociation followed by collagenase digestion. The ability of the endocrine segment of the transplant to survive and function was assessed by stimulation with arginine and measurement of insulin and glucagon response. The results demonstrate that both transplant procedures result in functioning beta and alpha cells that rapidly secrete both insulin and glucagon in response to arginine stimulation. However, greater insulin responses were obtained when mechanically dissociated but nonenzyme digested pancreatic tissue was used for transplantation. The spleen appears to be an excellent transplant site for the reception of endocrine pancreatic tissue and allowed both beta and alpha cells to survive following transplantation.

Self-regulated methadone detoxification of heroin addicts. An improved technique in an inpatient setting

We used a method of detoxifying heroin addicts involving a self-regulated schedule of methadone hydrochloride detoxification in an inpatient setting. This method allows the addict to receive methadone on an "as needed" basis within specified guidelines, thus permitting him to regulate his own detoxification. For this study, 30 chronic heroin addicts were detoxified using this self-regulated detoxification procedure. Measures of length of stay, amount of methadone required, and degree of patient satisfaction indicate that this is a practical means of withdrawing chronic heroin addicts that may have advantages over fixed withdrawal schedules.

A comparison between the gastric and salivary concentration of iodide, pertechnetate, and bromide in man

The concentration of iodide (I(-)) and pertechnetate (TcO(4) (-)) and bromide (Br(-)) has been measured simultaneously in gastric juice and parotid saliva. The combined gastric and salivary clearance for iodide and pertechnetate is more than twice the clearance of these ions by the thyroid gland. The concentration of the ions was in the order I(-)>TcO(4) (-)>Br(-) in both gastric juice and saliva. Differences exist between the secretion of iodide, pertechnetate, and bromide. Bromide, in contrast to iodide and pertechnetate, was found to be more concentrated in gastric juice than in saliva. The ratio of the iodide to pertechnetate clearance was greater in gastric juice than in saliva.