Why do psychiatrists have difficulty disengaging with the out-patient clinic?: INVITED COMMENTARY ON ... WHY DON'T PATIENTS ATTEND THEIR APPOINTMENTS?

In this issue of APT Mitchell & Selmes present an articledetailing why patients miss appointments and how cliniciansshould respond. Many of the papers quoted relate to the psychiatricout-patient clinic. In this commentary, as well as picking upon some of the themes that emerge from their article, I explorethe attachment that psychiatrists seem to have to this particularmodel of patient contact.

The evidence that non-attendance of patients at psychiatricout-patient clinics is a major problem that is highly wastefulof resources is unequivocal, but evidence-based guidance regardingwhat to do about missed appointments is much less clear. Upto 50% of people with any form of mental health problem missan appointment either in primary or secondary care at some pointduring a treatment episode, around 30% of all psychiatric out-patientappointments are missed and somewhere between a quarter anda half of people who miss an appointment completely disengagefrom mental health services (Killaspy, 2006; Mitchell & Selmes, 2007,this issue). However, the consequences of missing an appointmentare more serious for people with severe and enduring mentalhealth problems such as schizophrenia, schizo-affective disorderand bipolar affective disorder, who are much more likely torequire a subsequent admission than those with common mentaldisorders (Koch & Gillis, 1991; Pang et al , 1996; Killaspy et al , 2000).Most people being seen as follow-up patients have a diagnosisof a severe and enduring mental health problem, whereas newlyreferred patients generally have common mental disorders (Johnson, 1973;Morgan, 1989; Killaspy et al , 2000).

Response to missed appointments

TOP

Response to missed appointments

It follows that the response of services to missed appointmentsshould be in keeping with the seriousness of the consequences,yet current evidence for telephone prompts and other interventionsto encourage attendance is equivocal at best and only relatesto studies in newly referred patients (Macharia et al, 1992;Reda & Makhoul, 2001). Mitchell & Selmes (2007, thisissue) state that ‘Many [patients] who miss appointmentsbecause of slips and lapses later rearrange without adverseconsequences’. If this were true, there would be no indicationfor these authors’ recommendation that further clinicappointments be sent after a non-attendance without first awaitingcontact from the patient. However, the study on which this statementis based (Sparr et al, 1993) was carried out in a military clinicfor combat veterans in the USA and had several methodologicallimitations such that the results have to be interpreted withcaution: the non-attendance rate was particularly low (9%);data were collected retrospectively from the treating clinicianwithout corroboration from the case notes; and no definitionof what was meant by an ‘adverse outcome’ was given.Sparr et al reported that over 70% of patients who missed theirappointment spontaneously contacted the clinic to rescheduleand they concluded that there was no need for the clinic toactively re-engage non-attenders. However, in our prospectivestudy of non-attenders at a psychiatric out-patient clinic inLondon, we found that both new and follow-up patients who misseda single appointment were very unlikely to re-engage with theclinic (Killaspy et al , 2000), and one study from outside theUK found that only half those who missed an appointment re-engaged(Pang et al , 1996).

These ‘slips and lapses’ are a combination of clericalerror on the part of the clinic and, with regard to follow-uppatients, social disorganisation secondary to the executivedysfunction and negative symptoms of the mental illness. Clericalerror accounts for a lower proportion of missed appointmentsin psychiatric clinics (5–12%: Sparr et al , 1993; Killaspy et al , 2000)than in other medical specialties (28–33%: Verbov, 1992;Potamitis et al , 1994) but this is a potentially preventablecause of non-attendance. Although simple systems to remind patientsabout their appointments may appear to have face validity, theycan only be effective for people who are contactable, such asthose who actually have a working telephone (Burgoyne et al, 1983).The associated resources involved also have to be consideredand there are currently no published examples of well-conductedcost-effectiveness analyses of telephone or other prompts toreduce non-attendance at mental health appointments in the UK.Written information leaflets and orientation statements, whichare helpful in reducing anxiety about the appointment for newlyreferred patients, may be more effective at improving attendancerates than prompts (Kluger & Karras, 1983; Swenson & Pekarik, 1988).

Relevance of the out-patient model in contemporary mental health services

TOP

Relevance of the out-patient...

Last year I was invited to write a review article for APT onthe origins and future of the out-patient clinic in contemporarymental health services (Killaspy, 2006). This article detailedthe history of how the model developed some 300 years ago froma vehicle to triage new admissions to asylums and later becamea replica of the approach used in other medical specialtiesfor patient assessment and review. Given the consistently highnon-attendance rates and evidence of poor outcomes for non-attenderswith severe and enduring mental health problems, I suggestedthat it might be time to review the usefulness of the clinicmodel for this client group. I explored an alternative approachthat could be integrated within our existing and highly developedcommunity mental health services to facilitate assessment andbrief interventions for newly referred patients with commonmental disorders and that would provide appropriate triage forpatients requiring longer-term care from secondary mental healthservices.

New Roles for Psychiatrists (National Working Group on New Roles for Psychiatrists, 2004)and the Mental Health Policy Implementation Guide: CommunityMental Health Teams (Department of Health, 2002) have far reachingimplications and contain detailed guidance on the delivery ofassessment services for patients newly referred to mental healthservices and on ongoing treatment for patients with severe andenduring mental health problems. Both documents describe a secondarymental health service that appears to have no out-patient clinics.So why, despite the relevant policy to support a new direction,are psychiatrists still inclined to use the clinic model? Isit because we see ourselves as hospital doctors whose activityis measured in the familiar approach of the out-patient clinic?Is it that we enjoy the only part of the job where we get toform a one-to-one therapeutic alliance with our patients, providinga welcome relief from our usual role of multidisciplinary teamwork? Are we under-confident in our non-medical colleagues’skills in assessment and one-to-one interventions? Are theresome more-challenging patients that we feel only we have theexperience to contain?

None of these possible explanations has been researched, butin exploring the issue of the therapeutic alliance, Mitchell& Selmes suggest that the patient’s perception ofthe therapeutic alliance with the clinician and of the latter’shelpfulness is important in preventing disengagement from theclinic (‘Attendance at follow-up appointments is morea reflection of the patient’s satisfaction with care thanof the perceived need for further help’). However, thetwo large studies that have investigated satisfaction with psychiatricout-patient services have not found a statistically significantrelationship between dissatisfaction with care and drop-out(Killaspy et al , 1998; Rossi et al , 2002), although considerablepatient dissatisfaction has been expressed about being seenby the junior doctor rather than the consultant (Killaspy et al , 1998;McIvor et al , 2004). In fact, the content of the interactionbetween patients with psychosis and their psychiatrists appearsto be rather unsatisfactory at out-patient appointments (McCabe et al , 2002).

The report on proposed new roles for consultant psychiatristshighlighted the problems of the out-patient clinic model:

‘There was almost universal dissatisfaction with out-patientclinics. The doctor is isolated from the team and patients frequentlydo not attend. Patients may present very differently in theartificial environment leading to differences with staff whosee the patient at home. Patients are brought back routinelyso as not to lose touch with them rather than out of necessity’(National Working Group on New Roles for Psychiatrists, 2004:p. 12).

Since out-patient non-attendance is no longer a Healthcare Commissionperformance indicator, it is likely that managerial attentionon the out-patient clinic will fade. The evidence currentlysuggests that the out-patient model is best targeted at peoplewho are most able and likely to keep appointments and that alternativeapproaches are indicated for those with more complex mentalhealth problems, including assertive outreach for particularly‘difficult-to-engage’ clients. A more radical reviewof the model could allow the integration of assessment and briefinterventions for newly referred patients, and multidisciplinarytriage of those requiring longer-term care under the care programmeapproach within the full range of community mental health services.Alternatively, we could continue to organise our services sothat the most expensive member of the team sees the patientswith the least complex problems and accept the resultant wasteof resources when 1 in 3 do not attend.

Declaration of interest

TOP

Declaration of interest

None.

Footnotes

See pp. 423–434, this issue.

References

TOP