Dear Editor,
The Louth Meath Mental Health Service is in the process of relocating its inpatient units to a single centre in Drogheda. This process has raised an important issue in relation to the model of consultant care delivered for inpatients. Two potential models of care have been proposed: a continuity model of care, in which the same consultant is responsible for both inpatient and outpatient management; and a split model of care, in which two consultants are involved, one responsible for inpatient and the other for outpatient care. There are several examples internationally of health services moving from a continuity model of care to a split model of care, and vice versa (Giacco et al. Reference Giacco, Bird, McCrone, Lorant, Nicaise, Pfennig, Bauer, Ruggeri, Lasalvia, Moskalewicz, Welbel and Priebe2015). There does not appear to be strong evidence that either model result in better outcomes for patients, however, and there is currently a large international multi-centre study underway to investigate this issue (Giacco et al. Reference Giacco, Bird, McCrone, Lorant, Nicaise, Pfennig, Bauer, Ruggeri, Lasalvia, Moskalewicz, Welbel and Priebe2015). In the context of limited and inconclusive evidence, how can mental health service planners make decisions in relation to consultant models of care?
It is worth reflecting on the reported benefits of each model of care outlined in the literature, as summarised by Giacco et al. (Reference Giacco, Bird, McCrone, Lorant, Nicaise, Pfennig, Bauer, Ruggeri, Lasalvia, Moskalewicz, Welbel and Priebe2015). Proposed advantages of the split model of care include quick clinical decision making; positive risk management; specialisation of interventions; enhancement of clinical leadership; and development of specialised expertise. In contrast, the proposed benefits of the continuity model of care include avoiding fragmentation of services; increased engagement with patients who are less likely to actively seek treatment; continuity of care; and establishment of a stronger therapeutic relationship with patients. It is worth noting that continuity of care is a difficult concept to define, and that continuous consultant care represents only one aspect of this construct. However, a systematic review performed by Puntis et al. (Reference Puntis, Rugkasa, Forrest, Mitchell and Burns2015) found that greater continuity of care may be associated with improved social functioning for those patients involved.
The National Health Service in the UK has moved towards a split model of inpatient psychiatric care over the last couple of decades and Tom Burns describes his concerns in relation to this development (Burns, Reference Burns2010). Although some viewed the split model of care as having the potential to deliver more effective bed management and reducing service costs, Burns cites the high bed numbers in split services, for example, Germany or Switzerland compared with continuity services, for example Italy. Many different factors are likely to influence the level of utilisation of inpatient resources, however, and consultant models of care are only one such factor. Burns describes his reservations about the therapeutic impact of community psychiatrists handing over care of patients at their time of greatest distress and vulnerability. Furthermore, having experience in both models of care, he also describes the polarisation of professional styles of care, with the inpatient model more medical and the outpatient model more psychosocial in approach. Burns also highlights the increased mortality risk associated with recent discharge from hospital, and discusses the potential relevance of continuity versus split models of care in this regard.
Although it is unclear whether patient outcomes are influenced by different models of consultant care, it may be that patients’ preference is for a continuity model of care. Begum et al. (Reference Begum, Brown, Pelosi, Crabb, McTaggart, Mitchell, Julyan, Donegan and Gotz2013) reported in their survey of Scottish mental health service users that a significant majority of patients (76%) indicated a preference for a continuity model of care. In addition, it is possible that aspects of patient satisfaction with consultant care is higher in those receiving care in continuity models than in a split model (Laugharne and Pant, Reference Laugharne and Pant2012). Patient preference is an important component of decision making for health services, although any service-level decision should include multiple stakeholders and be based on best available evidence or guiding principles. A Vision for Change remains the guiding document in relation to the development of mental health services in Ireland and it has continuity of care as a core guiding principle for care of those with mental illness.
In the absence of a clear evidence base to guide service planning in relation to this issue, there are nonetheless several guiding principles for service planning around models of consultant care. The process of change management includes service evaluation, consultation with key stakeholders, guidance from national strategy documents, learning by proxy from others’ experience and applying lessons learned in a manner appropriate to the local context. Most importantly, change management in health services should adopt a patient-centred approach.
