Randomised controlled trial of two models of care for discharged psychiatric patients

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Abstract
Objective: To compare the clinical outcome and costs of care of psychiatric patients allocated to community multidisciplinary teams or to hospital based care programmes after discharge from inpatient care. Design: Randomised controlled trial. Setting: Inner London (Paddington and North Kensington) and outer London (Brent) psychiatric services. Subjects: 155 patients with severe mental illness with a previous admission within the past 2 years. Main outcome measures: Ratings of clinical psychopathology, depression, anxiety, and social functioning; comprehensive costs of health care. Results: Clinical outcomes were available for 133 patients and cost data for 144 patients after 1 year. The clinical outcomes of the two models of care were essentially similar, but admission to hospital was more likely in the hospital based care group and the costs of health care were 14% greater per patient than in the community group. This difference, however, was dwarfed by a twofold difference in the costs of care in the outer London services compared with those in inner London. This was explained largely by greater inpatient care for outer London patients (58 median bed days v 18 for inner London patients), more of which was provided by extracontractual referrals to other psychiatric hospitals as Brent had only 0.28/1000 beds available for acute adult patients compared with 0.82/1000 in Paddington and North Kensington over the period of the study. Conclusion: Aftercare by community teams for psychiatric patients with severe mental illness has a similar outcome to hospital based aftercare but with fewer admissions to hospital. When psychiatric bed requirements are insufficient for a population, however, neither form of aftercare is effective as greater use of hospital beds elsewhere swamps any advantage of community care programmes, with disintegration and discontinuity of psychiatric services leading to escalating costs. Community psychiatric care has generally been shown to require fewer beds than more hospital focused care Clinical outcomes in psychiatric patients with recurrent psychotic illness randomised to community focused or hospital focused care after discharge from hospital and followed up for 1 year were similar Costs were lower for patients in the community group, which had fewer admissions to hospital Costs were twice as high in one of the areas covered by the study, mainly because of the insufficient number of beds in the area, with great reliance on psychiatric beds outside the catchment area When the number of psychiatric beds in an area becomes too low there is no advantage in providing better community care because the impact of this is swamped by the disintegrating effects of inpatient care outside the catchment area

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