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Alternatives to acute in-patient care: safety and efficacy

Published online by Cambridge University Press:  02 January 2018

Frank Röhricht*
Affiliation:
East London NHS Foundation Trust, London, UK; email: frank.rohricht@elft.nhs.uk
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Abstract

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Creative Common License - CCCreative Common License - BY
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Copyright © Royal College of Psychiatrists, 2016

Hunt et al Reference Hunt, Appleby and Kapur1 discuss implications of recent findings regarding high rates of suicide in patients under crisis resolution home treatment. Their obvious conclusion points towards improving safety in this setting. There is, however, in my opinion, another important consequence – reconsidering other evidence-based models that provide treatment as an alternative for in-patient admission at times of acute mental health crisis. The NHS Plan policy mandate appears to have been too one-sided in favouring one model of care over other evidence-based services.

The acute day hospital (ADH) model – somewhat out of fashion, partially because most services provide step-down day care rather than acute crisis care – is an interesting alternative model worth considering because of its established safety track record and hence its relevance to this debate. In contrast to the home treatment team model, the ADH (‘virtual community ward’) provides individuals who experience an acute mental health crisis with an intensive group therapy programme including psychological therapies and social activities, as well as multidisciplinary daily monitoring of their mental state and associated risks.

According to a Cochrane review, 25-40% of all voluntary patients can be treated in an ADH with significant cost reductions, Reference Marshall, Crowther, Almaraz-Serrano, Creed, Sledge and Kluiter2 and the treatment is associated with higher patient satisfaction and better efficacy in reducing psychopathology. Reference Priebe, Jones, McCabe, Briscoe, Wright and Sleed3 Most importantly, suicide incident rates were reported as being low. Reference Jones, Gavrilovic, McCabe, Becktas and Priebe4 Furthermore, unpublished data from the East London ADH indicate an average length of stay close to that of in-patient wards.

There appears to be renewed interest in alternative models for in-patient care in the context of financial constraints, and it might be worth comparing the various models directly in terms of their clinical efficacy and cost-effectiveness.

References

1 Hunt, IM, Appleby, L, Kapur, N. Suicide under crisis resolution home treatment – a key setting for patient safety. BJPsych Bull 2016; 40: 172–4.Google Scholar
2 Marshall, M, Crowther, R, Almaraz-Serrano, A, Creed, F, Sledge, W, Kluiter, H, et al. Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev 2003; 1: CD004026.Google Scholar
3 Priebe, S, Jones, G, McCabe, R, Briscoe, J, Wright, D, Sleed, M, et al. Effectiveness and costs of acute day hospital treatment compared with conventional in-patient care. Br J Psychiatry 2006; 188: 243–9.Google Scholar
4 Jones, G, Gavrilovic, J, McCabe, R, Becktas, C, Priebe, S. Treating suicidal patients in an acute psychiatric day hospital: a challenge to assumptions about risk and overnight care? J Ment Health 2008 17: 375–87.Google Scholar
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