It’s time to restore continuity of care in our mental health services

We have long known that a more positive therapeutic relationship predicts better patient outcomes, in both the short and long term. This is true for a variety of mental health conditions, across both inpatient and outpatient settings. Continuity of care strengthens the therapeutic relationship because it allows our patients to build trust with us over time.

In recent years, much of the NHS has transitioned to a functional inpatient/outpatient service model. This means that different teams are responsible for a patient’s care at different points in their journey. It’s designed to provide a practical solution to issues on the ward, like leadership, expertise and throughput. However, it has come at the expense of continuity of care, with the split model leaving patients to navigate a complicated and fragmented system without one consistent team or clinician overseeing their care journey.

The functional model separates inpatient and outpatient services. For our patients, although they may not be aware of the implications, this means a lack of continuity when they are discharged from, or transition between, services. For us, this means it’s harder to establish consistent, trusting relationships with our patients over the long-term. Recently, a consultant who has only ever worked within the functional model told me they couldn’t imagine services working any other way. But the evidence shows us that they can. And I can remember it: when I was first a consultant, I would see my patients continuously, over a number of years and across different settings.

An ongoing relationship

For our patients, continuity of care means they experience an ongoing relationship with us. We are able to deliver coordinated care, which moves them smoothly between different parts of the mental health service. This model is used successfully in many other countries including Sweden, France, Australia and the US. Dr Bhavana Chawda, President of the British Indian Psychiatric Association and proud member of the RCPsych, told me delightedly about the fact that her service never did away with the model. She shares her ward with another consultant and follows her patients all the way through their journey into the community (and if necessary, in rarer cases, back). In addition to ensuring she knows her patients really well, it reduces all that time spent referring to (and arguing with), other services about who’s responsible for who, for what and for when.

Patients often tell us how much they value being looked after by clinicians whom they know, but also who know them and their history too. And, of course, it is equally as valuable for us to be familiar with our patients – to understand the different stages of their illness, see what is impacting on their lives and know what matters most to them. The better we know our patients as individuals, the more equipped we will be to spot their unique warning signs. This is especially vital for patients with severe mental illness (SMI).

A case study

Back when I was a general adult consultant, running both the inpatient unit and a community team, I was able to do this for my patients. For example, I recall a patient I met during his first episode of manic psychosis. He’d been brought into A&E by police after being found trying to throw himself off the top of a car park in the belief that he could fly. He had become aggressive when the car park attendant had tried to intervene. The police who came recognised he was severely unwell. It took about 8-10 weeks to get him well and sort out his rather complex social situation. After leaving hospital, we settled into a routine where he was seen by his care co-coordinator a couple of times a month, and me every three months or so. When he was going through a bit more stress, we would step up the appointments – he knew all he had to do was ring, or text. He knew us well and we knew him well. He stayed out of hospital.

I had left the team by the time we changed to the functional model. Some time later, this patient was referred back to his GP. The community mental health team (CMHT) caseload was too large, and he was deemed too well to require ongoing input. There had been three different consultants and five or six care co-coordinators in his last five years of treatment.

The next time I saw him, he was in prison. It was just less than one year after his discharge to the GP. By then I was working in forensic psychiatry. He had been referred for an assessment after being charged with grievous bodily harm, after committing an assault during a manic psychotic episode. He was admitted to a secure unit and spent the next two years in hospital under a forensic section.

Had he been able to maintain his therapeutic relationships – with a new consultant and a regular care-coordinator – the outcome could have been different. He could have been monitored, better engaged with, and remained on his medication and other treatments. Perhaps the CMHT could have intervened before he reached crisis point.

Continuity of care is preventative care

The evidence shows that this approach reduces the risk of relapse and the likelihood of readmission. In this way, continuity of care is preventative care. It can be key to preventing the exacerbation of an existing mental illness. It facilitates patients in maintaining their relationships, staying in work and living fulfilling lives. This is not only hugely important for their mental health and wellbeing, but it is also a more cost-effective, sustainable model of service delivery.

We know continuity of care works, and works well. It’s not perfect and there were flaws, but frankly, I think it’s better than the situation we have now. It’s time to revisit this approach and investigate how it could work in modern mental health services. When we partnered with the Bipolar Commission to survey our members and patients last year, we all agreed: continuity of care should be a top priority.

Of course, you may disagree that working across the ward and the community is doable. But I think the NHS needs to renew its focus on therapeutic care and put the patient-clinician relationship back at the heart of the mental health system.