A new model for the delivery of psychiatric services for general hospital inpatients: the development and delivery of a psychiatric service model for older, acutely admitted general hospital inpatients

Thesis

Background

Current psychiatric services for general hospital inpatients have limitations in meeting the needs of increasingly elderly and multimorbid populations. New service models are emerging, but lack evidence of effectiveness from randomised trials. I aimed to establish the evidence for current psychiatric services for general hospital inpatients, and develop, operationalise and deliver a new service model for delivery and evaluation in a randomised trial, The HOME Study.

Methods

A systematic review of randomised trials of psychiatric services for general hospital inpatients was completed. A new service model was developed by reviewing relevant literature, obtaining feedback from clinicians and patients, and iterative piloting. The new model was operationalised for consistent delivery in the trial. The delivery of the resultant model in the trial was evaluated using the RE-AIM framework.

Results

The systematic review identified eight eligible randomised trials. No trial reported evidence that the psychiatric service was more effective than usual care. A new psychiatric service model for older general hospital inpatients, Proactive Integrated Psychological Medicine (PIPM) was developed. The model was described in a service manual, and a checklist and quality assurance process were developed to maximise consistent delivery. PIPM was implemented in three hospitals in southern England, over two years. 1,373 (99%) of patients randomised to PIPM received the intervention. PIPM was delivered in accordance with the service manual, with six out of seven measures of concordance with the service manual over 94%. Interviews were conducted with patients (n = 26) and carers (n = 18), ward professionals (n = 55), and all PIPM clinicians (n = 15). Thematic analysis identified an appreciation of the increased psychiatric presence on the ward, common among all interviewee groups. However, PIPM clinicians and ward professionals were concerned PIPM may blur professional responsibilities on the ward, potentially resulting in confusion for patients.

Conclusions

There is no randomised evidence that current psychiatric services for general hospital inpatients are effective. A new service model, PIPM, has been developed with clinicians and patients, based on the best available evidence. PIPM was delivered largely as intended in a large randomised trial, The HOME Study. The outcome of The HOME Study will provide further information on the effectiveness of PIPM and indicate the value of further implementation.

Authors: Toynbee, M

• DOI: 10.5287/ora-qmddexvvo
• Type of award: DPhil
• Level of award: Doctoral
• Awarding institution: University of Oxford
• Language: English
• Keywords: service development; systematic review; psychological medicine; RCT; general hospital; proactive integrated psychological medicine; liaison psychiatry; psychiatry
• Subjects: Consultation-liaison psychiatry; Psychiatry