BackgroundThe functional split model of consultant psychiatrist care for inpatients has been one of the major service redesign that has occurred in the NHS in the last decade. It is unclear if this new split model offers any advantages over the previous sectorised model of working. More recent evidence has suggested that patients, carers and professionals have varied views regarding the benefits of this model.This survey of patient’s views on models of consultant working is the first in Scotland and we have attempted to include a large sample size. The results suggest that after providing sufficient information on both models, the majority of patients from various Scottish health boards have opted for the traditional sectorised model of working.MethodDuring a four week period consecutive patients across 4 health boards attending the General Adult consultant outpatient clinics and those who were admitted to their inpatient ward were offered a structured questionnaire regarding their views on the functional split versus traditional sectorised model. Space was provided for additional comments. The study used descriptive statistical measures for analysis of its results. Ethical approval was confirmed as not being required for this survey of local services.ResultsWe had a response rate of 67%. A significant majority (76%) of service users across the four different health boards indicated a preference for the same consultant to manage their care irrespective of whether they were an inpatient or in the community (Chi-squared = 65, df = 1, p < 0.0001). In their unstructured comments patients often mentioned the value of the therapeutic relationship and trust in a single consultant psychiatrist.ConclusionsOur survey suggests that most patients prefer the traditional model where they see a single consultant throughout their journey of care. The views of patients should be sought as much as possible and should be taken into account when considering the best way to organize psychiatric services.

Objective-To measure needs for care of patients aged 18-65 years with major mental illness.Design-Identification of everyone in one area seen by a health professional within the previous five years because of a psychotic disorder. Interview of a one in three sample of patients and their main carers with the cardinal needs schedule.Setting-Hamilton, a socially deprived district of Scotland.Subjects-71 subjects were interviewed from the original sample of 263 patients.Main outcome measures-"Cardinal problems" in seven clinical and eight social areas of functioning; these are defined as problems requiring action. "Needs"-cardinal problems for which suitable interventions exist but have not been tried recently.Results-High levels of morbidity were found. 30 interviewed patients (42%; 95% confidence interval 31% to 54%) had one or more clinical needs. 35 (49%/6; 38% to 61%) had one or more social needs. Skills to deal with all but seven needs in the sample were available at the time of investigation. Patients not being seen by the community mental health team were similar in severity and levels ofneed to those who were on the community team's caseload. Care was unequivocally and severely inadequate for four patients. Shortcomings in service delivery usually arose from failure to monitor some patients at home. Problems were not due to shortage of acute psychiatric beds nor the absence of an elaborate assertive community care team.Conclusions-Systematic assessment of needs with research instruments can give valuable insights into the successes and failures of community care ofpeople with major mental illness. Most needs could be dealt with in these patients but in our area (and probably most other parts of the United Kingdom) this would entail diversion of resources from people with less severe disorders.

BackgroundChronic diseases result in significant morbidity and costs. Although medications and lifestyle changes are effective for improving outcomes in chronic diseases, many patients do not receive these treatments, in part because of financial barriers, patient and provider-level knowledge gaps, and low patient motivation. The Assessing outcomes of enhanced chronic disease care through patient education and a value-based formulary study (ACCESS) will determine the impact of two interventions: (1) a value-based formulary which eliminates copayment for high-value preventive medications; and (2) a comprehensive self-management support program aimed at promoting health behavior change and medication adherence, combined with relay of information on medication use to healthcare providers, on cardiovascular events and/or mortality in low-income seniors with elevated cardiovascular risk.MethodsThe ACCESS study will use a parallel, open label, factorial randomized trial design, with blinded endpoint evaluation in 4714 participants who are over age >65 (and therefore have drug insurance provided by Alberta Blue Cross with 30 % co-payment); are at a high risk for cardiovascular events based on a history of any one of the following: coronary heart disease, prior stroke, chronic kidney disease, heart failure, or any two of the following: current cigarette smoking, diabetes mellitus, hypertension, or hypercholesterolemia; and have a household income

Background: One in eight people with heart disease has poor medication adherence that, in part, is related to copayment costs. This study tested whether eliminating copayments for high-value medications among low-income older adults at high cardiovascular risk would improve clinical outcomes. Methods: This randomized 2x2 factorial trial studied 2 distinct interventions in Alberta, Canada: eliminating copayments for high value preventive medications and a self-management education and support program (reported separately). The findings for the first intervention, which waived the usual 30% copayment on 15 medication classes commonly used to reduce cardiovascular events, compared to usual copayment, is reported herein. The primary outcome was the composite of death, myocardial infarction, stroke, coronary revascularization, and cardiovascular-related hospitalizations over a three-year followup. Rates of the primary outcome and its components were compared using negative binomial regression. Secondary outcomes included quality of life(EQ-5D index score), medication adherence, and overall healthcare costs. Results: 4,761 individuals were randomized and followed for a median of 36 months. There was no evidence of statistical interaction(p=0.99) or of a synergistic effect between the two interventions in the factorial trial with respect to the primary outcome, which allowed us to evaluate the effect of each intervention separately. The rate of the primary outcome was not reduced by copayment elimination, (521 vs 533 events, incidence rate ratio(IRR) 0.84, 95%CI 0.66 to 1.07, p=0.162). The IRR for non-fatal MI, non-fatal stroke, and cardiovascular death (0.97; 95% CI 0.67 to 1.39), death (0.94 (95%CI 0.80 to 1.11) and for cardiovascular-related hospitalizations (0.78 (95%CI 0.57 to 1.06) did not differ between groups. No significant between-group changes in quality of life over time were observed(mean difference 0.012, 95%CI -0.006 to 0.030, p=0.19). The proportion of participants who were adherent to statins was 0.72 vs 0.69 for the copayment elimination vs usual copayment groups, respectively(mean difference 0.03, 95% CI 0.006-0.06, p=0.016). Overall adjusted health care costs did not differ ($3,575, 95%CI -605 to 7,168, p=0.098). Conclusions: In low-income adults at high cardiovascular risk, eliminating copayments (average $35 a month) did not improve clinical outcomes or reduce healthcare costs, despite a modest improvement in adherence to medications.