Relaciones entre componentes

episode. As som e patients had more than one admission their support status m ay change

from admission to admission. Therefore the following analyses refer to admissions not to individual patients.

Table 2 Types of accommodation and level of support pre- and post-admission

P re-adm ission P ost-adm ission

T ype o f a c c o m m o d a tio n

Hostels and night shelters 2 2

Residential care ho m e 3 5

S u ppo rted acco m m od atio n 10 11

In d e p e n d e n t housing 14 12

Living w ith parents 4 3

NFA 2 2 T o tal 35 35 Level o f s u p p o rt HIGH 5 7 LOW 10 13 NONE 20 15 To tal 35 35

Number of hours per week was used to define ‘support’. Clients in supported accommodation typically received 2-12 hours a week from a floating support worker, comparatively little compared to support in residential care homes. Those that received none were all living in independent accommodation such as council flats (Appendix F).

Level of support analysis revealed a similar trend towards greater input needed post-admission (Figure 1). There were increases in high support housing (24 hour residential care, 14% to 20%), and low support (2-12 hours per week floating support, 29% to 37%), whereas no support decreased (57% to 43%) (Table 2).

N u m b e r of a d m is si o n s NO SUPPORT LOW SUPPORT HI SUPPORT

Level of support following admission

Figure 1. Levels of accommodation support pre and post admission

The hypothesis that service-users would need less support after admission was not supported. Wilcoxon signed-rank test of marginal homogeneity confirmed there was a significant, but modest increase in level of support required post-admission (7=0, p < .05, r= -.28).

Psychology referrals

Table 3 shows that most clients had been offered psychological treatment (69.23%), with 57.69% of those resulting in a formal referral to psychology. A further 11.54% were receiving psycho-social interventions (PSI) from another team member. Nearly a fifth of clients (19.23%) were not offered psychological treatment because the team felt it was inappropriate. A

common reason was the client’s lack of psychological mindedness, and in one case the care coordinator felt the client was relatively well and that psychology input may destabilize him (Appendix D). However, even those clients without individual psychological interventions had access to the unit’s weekly mental health promotion group delivered jointly by nursing staff and psychology.

Table 3 Reasons for non-referral to psychology

Psychology re fe rra ls Clients

Referred 15

Not referred (PSI from other staff) 3

Not offered (team felt inappropriate) 5

Referral offered (client refused) 3

26

DISCUSSION

Summary of results

Contrary to the study’s hypothesis, people needed more, not less, support after admission to the unit. Bed-blocking was fairly rare and normally caused by funding delays. NICE (2002) recommendations for the offering of psychological interventions were partially met. While most people were offered some form of psychosocial input, there were significant numbers not offered formal psychological treatment.

Strengths and limitations

In an area lacking previous research, this study adds to our knowledge about prevalence of bed-blocking in rehabilitation units. It also highlights a strength of this particular CNS service: fewer inpatients experienced delayed discharge compared to other studies (Koffman & Fulop, 1999; Shepherd et al., 1997). This may reflect the relative affluence of the catchment area, rather than a particularly proactive approach taken by the MDT in placing clients. It is notable that most delayed discharge clients were NFA on admission. Indeed, in a national study of acute beds Shepherd et al. (1997) linked social deprivation to delayed discharge.

This present study successfully highlights how the current system is masking an unmet level of needs. Level of support in accommodation required by service-users increased after discharge, and in at least one case this was because carers had been previously absorbing much of the unmet need. However, looking after a person with mental illness is stressful, and in this case lead to breakdown in family relations. Most other clients pre-admission were living in unsupported independent housing. How long they had been struggling before admission to the rehabilitation unit is difficult to know. It appears their need for greater support was only identified when breakdown

occurred and they were admitted, a particularly inefficient and costly way to assess needs. Early identification and provision of support has both financial and human benefits. Admission can be a stigmatising and traumatic process, leading to further disablement for some people.

This study could be criticised for not covering other areas of care such as supported employment, a social inclusion issue considered key by NICE (2002) and the National Service Framework (Department of Health, 1999). However, data on occupational status of patients is not routinely collected by the CNS. If future evaluations are to address this issue, adjustments to the screening process could include questions on employment. Some continuing needs services (Meddings et a/., 2007) are already in line with NICE (2002) recommendations for regular assessment of quality of life and use adapted forms of the Lancashire Quality of Life (Gaite et a/., 2000, Appendix G) to routinely audit specific measures of social inclusion such as social networks or daytime activity.

A second limitation is that psychological interventions and PSI are poorly defined. Whether the client was offered family work or CBT is not recorded. Furthermore, it is unclear what constitutes the PSI delivered by non­ psychology staff. Therefore, only a relatively crude audit of NICE (2002) implementation has been conducted.

Thirdly, regarding the inferential analysis on level of accommodation support, a small sample meant the study was underpowered to find anything other than a large effect. Care must be taken therefore when drawing conclusions as this study revealed only a small effect size. Furthermore, Robson (2002) comments that the pre-post single group design used here, commonly seen in clinical service evaluations, is vulnerable to various validity threats such as maturation and statistical regression.

Socio-political context

Proximal factors like patient aspirations affected bed-blocking. For example, one delayed discharge patient preferred to live permanently in the unit, resisting attempts to move him on. Are we making such units too attractive and thus creating dependency? Leighton (2002) prefers a more distal analysis by suggesting that those patients who seek a more collective, pastoral and spiritual lifestyle are neglected by services. The concept of individualised care within psychiatric services has been counterproductive for some client groups, sometimes leading to frustration, alienation, and bed-blocking. However, even those clients both ready and eager to move on are sometimes frustrated by distal factors such as funding hold-ups, possibly due to poor working relationships between health and social services.

Other distal influences include governmental pressures for accountability which place staff in contradictory positions, sometimes resulting in non- therapeutic outcomes for patients. For example, potential tensions exist between care coordinators and the unit manager. Care coordinators may desire longer inpatient stays for ease of risk management, whereas unit managers may feel pressured to move people on as quickly as possible because they are monitored by the trust on delayed discharges. Just as staff fears of trust evaluation act as proximal influences on patient discharge, so too can these fears interfere with the research process. In this service evaluation, the researcher had to tread very sensitively so as to avoid staff perceiving the study to be an evaluation of their practice, which could cause threatened and defensive feelings.

Proximal factors acting on psychology referrals are staff attitudes to recovery and mental illness. Unless staff hold hope of recovery for people with a SEMI, they are unlikely to understand how psychological interventions can be useful

in relapse prevention, promoting medication adherence, increasing insight6, and reducing symptoms as NICE guidance (2002) suggests. A staff member lacking appreciation of how psychology can help even those service-users with persistent symptoms is unlikely to refer.