Psychiatric out-patient services: origins and future

Abstract

Psychiatric out-patient services originated in the early-20th century to enable triage of new referrals to the asylum in order to differentiate between treatable and untreatable cases. They evolved to provide community follow-up of patients discharged from hospital and assessment of those newly referred to psychiatric services. Non-attendance at out-patient appointments represents an enormous waste of clinical and administrative resources and has potentially serious clinical implications for those who are most psychiatrically unwell. The place of out-patient clinics in modern community mental health services is explored with reference to the reasons for, and clinical and cost implications of, missed appointments. An alternative model is described that incorporates recent UK government guidance on the roles and implementation of community mental health teams, liaison with primary care and new roles for consultant psychiatrists.

Why don't patients attend their appointments? Maintaining engagement with psychiatric services

“…The purpose of this article is to review the extent and predictors of non-attendance in people with mental disorders presenting in primary and secondary care. Although one approach may be to fundamentally question the merits of out-patient clinics (Killaspy, 2006), our approach is to examine essential predictors and solutions within current models of care. In considering the classification of missed appointments it is important to distinguish between those who do not attend their first appointment and those who do not attend follow-up appointments.…”

Optimising outpatient efficiency – Development of an innovative ‘Did Not Attend’ management approach

“…Killaspy ' s review explains that clinician response to a missed appointment is important in infl uencing future nonattendance; she suggests that the need for a further appointment should be carefully considered and only made if clinically appropriate (Killaspy 2006 …”

“…Th e NHS Institute of Innovation and Improvement recognises that missed appointments are wasteful and ineffi cient, and promotes the eff ective management of outpatient clinics (NHS Institute for Innovation and Improvement 2008). Review of psychiatric outpatient services has identifi ed the reasons people give for not attending appointments (Killaspy 2006). Th ese included symptoms (e.g.…”

Why do psychiatrists have difficulty disengaging with the out-patient clinic?

“…Up to 50% of people with any form of mental health problem miss an appointment either in primary or secondary care at some point during a treatment episode, around 30% of all psychiatric out-patient appointments are missed and somewhere between a quarter and a half of people who miss an appointment completely disengage from mental health services (Killaspy, 2006;Mitchell & Selmes, 2007, this issue). However, the consequences of missing an appointment are more serious for people with severe and enduring mental health problems such as schizophrenia, schizoaffective disorder and bipolar affective disorder, who are much more likely to require a subsequent admission than those with common mental disorders (Koch & Gillis, 1991;Pang et al, 1996;Killaspy et al, 2000).…”

“…Last year I was invited to write a review article for APT on the origins and future of the out-patient clinic in contemporary mental health services (Killaspy, 2006). This article detailed the history of how the model developed some 300 years ago from a vehicle to triage new admissions to asylums and later became a replica of the approach used in other medical specialties for patient assessment and review.…”