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Improving Care in Longer Term Mental Health Facilities International Differences in Quality and Service User Experience of Care

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Improving Care in Longer Term Mental Health Facilities International Differences in Quality and Service User Experience of Care Improving Care in Longer Term Mental Health Facilities International differences in quality and service user experience of care Tatiana Taylor Salisbury UCL PhD in Psychiatry I, Tatiana Taylor Salisbury, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. 2 Acknowledgements The work that has gone into this thesis would have been inconceivable without the support of so many. To my supervisors, Helen Killaspy and Michael King, their unwavering support and encouragement has meant so much over the years. To the DEMoBinc team, without whom this thesis would have been impossible. I especially would like to thank Sarah White from St George’s University of London for her statistical advice and encouragement. To my colleagues in the UCL Mental Health Sciences Unit, Department of Primary Care and Population Health and Department of Statistical Sciences for their support, feedback and advice. Special thanks to Alexandra Pitman, Baptiste Leurent, Emma Cassidy-Ingles, Farah Hamidi, Henry Llewellyn, Melanie Lean, Rachael Hunter and Rachel McCrea for providing adequate distractions when the stress levels rose. To Don Salisbury, for sacrificing his Olympic viewing schedule to read the completed draft. To Sam Salisbury, for always believing in me and making me believe too. Some would say he’s perfect. This thesis is dedicated to my mother. 3 Abstract Background Although mental health problems are highly prevalent across the world, relatively little is spent on mental health care and a large number of individuals with mental health problems go untreated. Although the World Health Organization has pressed for countries to increase mental health expenditure and deinstitutionalisation of care in the hope of improved care, there is limited evidence regarding the relationships between national characteristics of mental health care provision and quality of care. Aim The aim of this study was to evaluate, in a European sample, the association between national mental health expenditure and the deinstitutionalisation of care and 1) the quality of longer term psychiatric and social care and; 2) service user ratings of care. Method Facility managers were interviewed using the Quality Indicator for Rehabilitative Care (QuIRC). Service users in each facility provided ratings of autonomy, life satisfaction, experience of care and therapeutic milieu. Mental health expenditure and deinstitutionalisation were measured using national mental health budgets and a novel quantitative tool, respectively. Multilevel models were developed to evaluate relationships between expenditure, deinstitutionalisation, quality of care and service user ratings of care. 4 Results Increased mental health expenditure and deinstitutionalisation were significantly, positively associated with all QuIRC domains, except social interface. Increased expenditure and deinstitutionalisation were also significantly associated with more positive service user ratings of autonomy and experience of care. No associations with service user ratings of life satisfaction or therapeutic milieu were found. Conclusions Results suggest that financial investment in and deinstitutionalisation of longer term mental health care are integral to the provision of higher quality care. Lack of available data on country-level variables and the cross-sectional nature of the study design limit generalisability. Future work should include a variety of national, facility and service user variables in order to build more robust models with improved generalisability. 5 Table of Contents List of Abbreviations....................................................................................................... 14 Introduction ..................................................................................................................... 15 Scope of the thesis ....................................................................................................... 15 Description of original work ....................................................................................... 17 Chapter 1: Review of the Literature ................................................................................ 19 1.1 Defining the population of interest ................................................................... 19 1.2 The provision of institutional care for those with longer term mental health problems ............................................................................................................ 21 1.2.1 Early provision of mental health care ........................................................ 21 1.2.2 Deinstitutionalisation ................................................................................. 25 1.2.3 The current state of mental health care provision ...................................... 29 1.3 The Cost of Mental Health Care ....................................................................... 57 1.3.1 Measurement of costs ................................................................................ 57 1.3.2 Estimates of the costs of mental health problems ...................................... 60 1.3.3 Current expenditure on mental health ........................................................ 66 1.4 The Measurement of Quality of Care ............................................................... 69 1.4.1 Definitions of quality care ......................................................................... 69 1.4.2 The measurement of quality ...................................................................... 70 1.4.3 Evidence on the association between deinstitutionalisation and quality of longer term care ......................................................................................... 74 1.4.4 Evidence on the association between mental health expenditure and quality of longer term care ..................................................................................... 78 1.5 Summary ........................................................................................................... 83 Chapter 2: The Components of Effective Care ............................................................... 87 2.1 Introduction ....................................................................................................... 87 2.1.1 Aims ........................................................................................................... 87 2.2 Method .............................................................................................................. 88 2.2.1 Eligibility ................................................................................................... 88 2.2.2 Search strategy ........................................................................................... 89 2.2.3 Assessment of methodological quality ...................................................... 89 6 2.2.4 Domain allocation ...................................................................................... 91 2.2.5 Analysis ..................................................................................................... 91 2.3 Results ............................................................................................................... 92 2.3.1 Key domains of care .................................................................................. 92 2.3.2 Strength of the evidence ............................................................................ 94 2.3.3 Living environment .................................................................................... 96 2.3.4 Interventions for the Treatment of Schizophrenia ..................................... 97 2.3.5 Physical Health .......................................................................................... 99 2.3.6 Restraint and Seclusion ............................................................................ 100 2.3.7 Therapeutic Relationship ......................................................................... 101 2.3.8 Autonomy and Service User Involvement ............................................... 101 2.3.9 Staff Training and Support ...................................................................... 102 2.3.10 Clinical Governance ................................................................................ 102 2.4 Discussion ....................................................................................................... 103 2.5 Conclusions ..................................................................................................... 104 Chapter 3: Development of the Quality Indicator for Rehabilitative Care ................... 105 3.1 Introduction ..................................................................................................... 105 3.2 Toolkit preparation.......................................................................................... 106 3.3 Testing and refinement ................................................................................... 108 3.4 The relationship between QuIRC and service user ratings ............................. 112 3.5 Summary ......................................................................................................... 118 Chapter 4: Aims and Hypotheses .................................................................................. 120 4.1 Aims and objectives ........................................................................................ 120 4.2 Rationale
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