There are many different ways to organise care for people who use mental health services. We use the term “integration” to describe how services work with each one another. In the COFI study, we were looking at one way of organising mental health care to provide integration. We studied the best way to organise care between the hospital (when a person is an inpatient) and in the community (when the person is an outpatient).
There are two main ways to organise mental health between the hospital and the community:
1. Personal Continuity – the same psychiatrist see the service user in hospital and in the community.
2. Specialisation – the service user is seen by one psychiatrist in hospital, and a different psychiatrist in the community.
Although many people may be involved in a person’s care, the two systems focus on the psychiatrist as they often make decisions about the person’s treatment, including their medication.
In the UK and Italy, whether a person has the same or different psychiatrist (i.e. received personal continuity or specialisation) depends on where the person lives. Each hospital provides either personal continuity or specialisation. In Belgium, Germany and Poland the service user and staff member decides whether a person sees the same or a different psychiatrist when the person is ready to leave the hospital. This means both personal continuity and specialisation can happen within the same hospital.
Policymakers – who are the people who make decisions about the type of care mental health services provide, are currently discussing whether personal continuity or specialisation is better. However, changing the organisation of mental health care can be expensive and disruptive to both staff and service users. We therefore need high quality research evidence to help us decide which approach is best. We designed the COFI study to answer this question.
2) What did we do?
The COFI study took place in five countries in Europe. These were UK, Belgium, Italy, Germany and Poland. In all of these countries, both personal continuity and specialisation are already in place. This meant that we did not have to change anything in the study and did not ask clinicians or service users to do anything new. As we did not change anything, COFI is called a “natural experiment”.
The COFI study wanted to see whether personal continuity or specialisation was best for people who use mental health services. To do this we included people who had been admitted to a psychiatric hospital ward over a 14 month period. People were asked to fill in a questionnaire that asked them about themselves and their experience of mental health care. We then asked the same questions one year later to see if anything had changed. We also looked to see whether the person had been readmitted to the hospital and counted the number of days they spent in hospital over the year. Finally, we were interested in how satisfied people were with their care in the hospital and in the community and checked on the safety of mental health care by measuring whether people had experienced any incidents called “untoward events”.
We included 57 hospitals in the study and 7,302 people filled in our questionnaire. This makes COFI one of the biggest studies including people in hospital ever!
We also wanted to make sure that people had the chance to tell us about their experiences of mental health care. To do this we held interviews with service users and staff who took part in the study. The interviews asked people about worked well and what worked less well in each system. We conducted nearly 200 interviews with service users and over 60 with staff members.
Throughout the study, we had a panel of people with lived experience called SUGAR (Service User and carer Group Advising on Research) who helped us to make sure that all the questionnaires and interview questions made sense to people who use services.
3) What did we find?
After one year, we were able to complete the questionnaires with 6369 out of the 7304 service users. This means we followed up nearly 90% of people who took part in the study.
We found that more than one in three people who leave hospital have to go back to hospital within one year (around 40%). We did not find any differences in the number of people who had to go back into hospital between personal continuity and specialisation. We also did not find any differences in the number of days people spend in hospital.
We checked to see if personal continuity or specialisation worked better for different types of people who use hospital. To do this we looked at “subgroups”. This meant comparing people with certain mental health conditions, people over or under 40 years of age, and people who had previously been in hospital to those who had not been in hospital before. We did not find any differences between personal continuity and specialisation for any of the “subgroups” we looked at.
We did find that people were more satisfied with their hospital treatment if they received personal continuity compared to specialisation. This means people who have the same psychiatrist in the hospital and in the community are more positive about their experience of hospital care.
Although people who had the same psychiatrist were more satisfied with their hospital care, there was no difference in how satisfied they were with their overall care in the community. We also did not find any differences in their quality of life and in the safety of mental health care between personal continuity and specialisation.
We looked at the interviews to see what people said about their experience of mental health care. Service users and staff members identified a number of good and bad points about both personal continuity and specialisation.
4) What does this mean?
Whether or not the person sees the same or a different psychiatrist between the hospital and the community is a hotly debated question. However, we did not find it made any difference to service users after one year on the questionnaires. Service users preferred their hospital treatment when they receive personal continuity (i.e. the same psychiatrist) but this did not make a difference in the longer term. We found that service users and clinicians named advantages and disadvantages of both systems.
The COFI study is a large and important study for people who use, work in and make decisions about mental health services. From the findings of the study, we were able to recommend:
1. Costly reorganisations of mental health care systems should not focus on changing from specialisation to personal continuity of care or vice versa, if the aim is to improve long-term outcomes for people.
2. If we want to improve the experience of people using inpatient services, personal continuity may be better.
3. Both personal continuity and specialisation have strengths and weaknesses – the individual experiences in a local context may favour one or the other.
4. Research and policy should focus less on the organisation of care but should instead focus on improving the content of care.
COFI website: http://cofi.qmul.ac.uk/projectoverview/