Slower than anticipated recruitment resulted in the achieved practice sample being smaller than the original target: 64 practices in 51 different Primary Care Trusts across England were recruited. The median practice size was 9,011 [IQR (6,345, 13,757)]: 48 (75%) were training practices. 18% of practice nurses reported that they had some form of mental health training. The median number of patients on practices’ mental health registers was 66 [IQR (43, 105)] and the median number of those eligible for the study was 50 [IQR (26, 71)].
Each practice was provided with a list of random numbers for the purpose of sampling 20 eligible patients from their register. Some smaller practices did not have 20 eligible patients hence data were extracted for a total of 1,150 patients (practice mean
Locus of Care
The results presented in the tables provide comparative data on demography, health and medication details for those seen only within primary care and those who were in contact with secondary care mental health services over the period 1/4/2008 – 31/3/2009. The results are further divided between those with schizophrenia and those with bipolar disorder.
Of the total patient sample 30.8% (354 out of 1150) were seen only in primary care over the 12 month period (ie had no evidence for any secondary care contacts); the other 69.2% (796) had at least one secondary care contact during the period. 56.3% (647) of patients had a diagnosis of schizophrenia and 37.7% (433) bipolar disorder. After weighting for practice register sizes and socioeconomic deprivation indices, the estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%).
The average age of the 1,150 patients was 52.7 years (standard deviation, SD
14.7) and 53.1% were male. 13.2% were reported to be non-white, although information on ethnic origin was missing for 17.4%. A third (33.3%) of the sample lived alone and 26.4% lived with their spouse/partner. Just 12.6% were reported to be in employment, but employment status was unknown for 22.8%. The average duration of a patients’ illness was 17.3 years (SD
Demographic characteristics, weighted means and percentages.
Direct comparisons between patients with secondary care contacts and those without did not find any differences in gender, age of diagnosis, ethnic group or living situation (p>0.05 in all cases), but did find that the former group were younger on average (by 5.5 years; t
5.66; p<0.001) and likely to have been diagnosed more recently (3.6 years on average; t
Mental Health Status
Most people were in receipt of prescriptions for mental health medication (89.7%), with 7.7% not in receipt of medication and another 2.6% where this information was not recorded (). People seen in secondary care had slightly fewer health morbidities on average (mean 1.3 versus 1.5; χ2(1)=
0.054), but much more likely to have a dual diagnosis (21.8% versus 12.2%; χ2(2)=
0.013) and to have a greater number of prescribed mental health medications compared to those seen only in primary care (mean 1.9 versus 1.4; χ2(1)=
Health and medication details, weighted percentages.
Health Service Use
In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (representing 20% of total contacts) during the period (). Most consultations in primary care were with a GP (62%) or a nurse (28%). Most of the secondary care consultations were with a psychiatrist (67%).
Contacts in primary and secondary care, unweighted counts.
Most patients had one or more consultations with a general practitioner during the year (88.7%) (). The mean consultation rate for all 1,150 patients was 4.3 and was higher for those seen in secondary care (4.6 compared to 3.7 for those seen in primary care only; χ2(1)=
0.008). Secondary care patients also saw a greater number of different GPs on average (1.9 versus 1.5; χ2(1)=
0.012). Almost two thirds of patients had one or more consultations with a practice nurse during the year (59.1%). The mean nurse consultation rate for all 1,150 patients was 2.1.
GP face to face consultations and relational continuity of care, weighted percentages.
Physical health problems were cited more frequently than mental health problems as reasons for contacts regardless of locus of care or mental illness diagnosis (67.5% of all patients reported consulting a GP for a physical problem; 41.5% for a mental health problem). However, patients in contact with secondary mental health services were more likely to consult a GP for a mental health reason compared to those seen only in primary care (46.9% vs. 29.7% respectively; χ2(1)
23.91; p<0.001). Health education was a component in 17.1% of all consultations, and was borderline significantly different between loci of care (14.9% versus 22.0%; χ2(1)
Of the 69% of patients seen in secondary care, 61% had at most two contacts over the year with secondary mental health services (). Almost 12% of this cohort had a mental health admission (8% voluntary; 4% compulsory) during the 12 months. Most patients (96%) were seen by a community mental health team, outpatient psychiatry, rehabilitation/ recovery, or other non-intensive teams. 6% were in contact with home treatment teams/ crisis resolution, assertive community treatment, early intervention services or forensic services or outreach services.
Contacts with mental health professionals, weighted percentages.
Continuity of Primary Care
Calculation of relational continuity of primary care was restricted to patients with a minimum of three GP contacts (n
697) (). One-fifth (20.6%) of these patients had poor continuity. Patients who had five GP contacts over the year were the most likely to have poor continuity (45.3%), whilst patients with seven or more GP contacts were the least likely (9.9%).
There was no significant difference in the rates of poor relational continuity between patients who were seen in primary care alone and patients who were also seen in secondary care (p
Informational continuity, the timely availability of information, also appeared to be poor. Data relating to all patients who had a new referral to a mental health service over the year (n
266) indicated that no information was recorded in primary care about the outcome of the referral for 28.7% of patients, 5.1% of patients were not seen by the mental health services and a further 1.7% were seen according to free text notes, but no documentation had been received.
Cross-boundary continuity, which we have measured as transitions and fragmentations in care, was poor for a substantial proportion of patients. Of those who were discharged from a mental health service in the period of study (n
111), 8.1% were either lost to follow up for no apparent reason or did not attend the appointment and a further 14.9% did not have a reason recorded for their discharge.
Patient and Practice Predictors of Locus of Care
Univariate and multivariate logistic analysis identified a number of patient and practice characteristics associated with being seen by secondary care mental services (). Examined individually, factors predictive of being seen in secondary care were: younger age (p<0.001); fewer years since diagnosis (p<0.001); a dual diagnosis (p
0.013); and economic activity status (p<0.001), in particular being unemployed. After multivariate adjustment only years since diagnosis (p
0.006) and economic activity (p<0.001) remained significant.
Summary of weighted univariate and multivariate regressions for locus of care and poor relational continuity of care.
Patient and Practice Predictors of Poor Relational Continuity
In both univariate and multivariate models the strongest single predictor of poor continuity of primary care was number of GP contacts (; p
0.003 and p
0.017 respectively): patients with 5 to 6 GP contacts were most likely to have poor relational continuity, whilst those with 7 or more contacts were least likely. Although poor continuity was also associated with practice size (p
0.009) and economic activity status (p
0.047) in the univariate models, both relationships ceased to be significant under multivariate analysis.