Health status of the temporarily homeless population and residents of North West Thames region.

OBJECTIVES--To survey the health status of the temporarily homeless population of North West Thames region and make comparisons with regional residents. DESIGN--Direct interview with standardised questionnaires. SETTING--Temporarily homeless people resident in hotels in the London boroughs in the North West Thames region and a random sample of regional residents. SUBJECTS--137 hotels thought to be providing accommodation to homeless people selected at random from a list of 295. 113 (82%) participated in the study, and 319 (61%) of 522 homeless people approached participated. The study was restricted to adults aged 16 and over selected at random. RESULTS--The homeless population was predominantly female (195/319; 61%), young (229 (72%) aged 16-34), and poor, 54% (172/319) receiving income support. 207 subjects (65%) had dependent children aged 16 and under. Rates of acute illness among homeless people (32 cases; 10%) were similar to those reported by regional residents. The prevalence of longstanding limiting illness (108 cases; 34%) was similar to that for regional residents, but the prevalence of mental morbidity was twice that for the region as a whole (145 cases (45%) v 1485 (18%)). Utilisation of general practitioner services, accident and emergency departments, and inpatient admission was much higher by the homeless population than by regional residents. General practitioner registration rates were above 90% for the homeless sample. CONCLUSIONS--Survey data provide empirical evidence about the nature and characteristics of the temporarily homeless population. The high service utilisation recorded may, in part, have resulted from the higher morbidity in this sample of homeless people. The concentration of homeless people into specific locations may suggest that additional funding should be provided to the district which provides care to this group. However, such funding should not necessarily be used for additional acute care but should be used to purchase appropriate services which meet the health needs of this very young, poor and vulnerable group.     

Are elderly people living alone an at risk group?

OBJECTIVE--To test the hypothesis that elderly people living alone are an at risk group with a high level of morbidity that makes high demands on health and social services. DESIGN--Secondary analysis of data from a community survey of 239 people aged 75 and over, identified from general practitioners'' age-sex registers. SETTING--Nine practices in the London boroughs of Brent and Islington. MAIN OUTCOME MEASURES--Scores on the mini-mental state examination; stated satisfaction with life; assessment of mobility; numbers of diagnoses of major physical problems; numbers of prescribed drugs taken; urinary incontinence; alcohol consumption; contacts with general practitioners and hospital outpatient and inpatient services; contact with community health and social services. RESULTS--There were significantly more women among those living alone (93/120 (78%) v 63/119 (53%); p < 0.0005) and the median age of elderly people living alone was higher (81 v 80; p < 0.04). Those living alone and those living with others showed no significant differences in measures of cognitive impairment, numbers of major physical diagnoses, impaired mobility, or use of general practitioner or hospital services. Stated satisfaction with life was somewhat higher in those living alone. Elderly people living alone were significantly more likely to have contact with chiropody, home help, and meals on wheels services and less likely to have someone they could contact in an emergency or at night. Living alone increased the likelihood of contact with one or more community health professionals (district nurses, health visitors, or chiropodists) considered as a group and also increased the likelihood of contact with social services as a whole. There was a tendency for more of those living alone than those living with others to have home visits from their general practitioners, but there were no significant differences in contact with hospital services between the two groups. CONCLUSIONS--Elderly people living alone do not have an excess of morbidity compared with those living with others and do not seem to be an at risk group requiring specifically targeted assessments. More help is needed to provide elderly people living alone with a point of contact in case of emergency.     

Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using capture-recapture analysis.

OBJECTIVES--To use routinely collected data to provide a reliable estimate of the size and psychiatric morbidity of the homeless population of a given geographical area by using capture-recapture analysis. DESIGN--A multiple sample, log-linear capture-recapture method was applied to a defined area of central London during 6 months. The method calculates the total homeless population from the sum of the population actually observed and an estimate of the unobserved population. Data were collected from local agencies used by homeless people. SUBJECTS--Homeless people in north east Westminster residing in bed and breakfast accommodation and hotels or sleeping rough who had contacted statutory or voluntary agencies in the area. RESULTS--2150 contacts by 1640 homeless people were recorded. The estimated unobserved population was 3293, giving a total homeless population for the period of around 5000 (SD 1250). Mental health problems were significantly less prominent in the unobserved compared with the observed population (23% (754) v 40% (627), P < 0.0001). For both groups the prevalence varied greatly with age and sex. CONCLUSIONS--Capture-recapture techniques can overcome problems of ascertainment in estimating populations of homeless and homeless mentally ill people. Prevalences of mental illness derived from surveys that do not correct for ascertainment are likely to be falsely inflated while at the same time underestimating the total size of the homeless mentally ill population. Population estimates derived from capture-recapture techniques may usefully provide a good basis for including homeless populations in capitation calculations for allocating funds within health services.     

Health of prisoners admitted to and discharged from Bedford Prison.

The age, smoking and drinking habits, active health problems, and occupational fitness of prisoners entering Bedford prison, and the health and willingness of prisoners being discharged from prison to take a letter to their general practitioner were surveyed. This group of men had a high level of illness, neglected their health, and had a high alcohol intake. Fewer problems were found than in a survey in New York City. Many prisoners with active medical problems on discharge from prison were unwilling to take a letter to their own general practitioner.     

Relationship between Body Mass Index and the Use of Healthcare Services in Australia

Objective: To examine the relationship between body mass index (BMI) and the use of medical and preventive health services. Research Methods and Procedures: This study involved secondary analysis of weighted data from the Australian 1995 National Health Survey. The study was a population survey designed to obtain national benchmark information about a range of health‐related issues. Data were available from 17,033 men and 17,174 women, ≥20 years or age. BMI, based on self‐reported weight and height, was analyzed in relation to the use of medical services and preventive health services. Results: A positive relationship was found between BMI and medical service use, such as medication use, visits to hospital accident and emergency departments (for women only); doctor visits, visits to a hospital outpatient clinics; and visits to other health professionals (for women only). A negative relationship was found in women between BMI and preventive health services. Underweight women were found to be significantly less likely to have Papanicolaou smear tests, breast examinations, and mammograms. Discussion: This research shows that people who fall outside the healthy weight range are more likely to use a range of medical services. Given that the BMI of industrialized populations appears to be increasing, this has important ramifications for health service planning and reinforces the need for obesity prevention strategies at a population level.     

Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries

Objective To establish whether reinstitutionalisation is occurring in mental health care and, if so, with what variations between western European countries.Design Comparison of data on changes in service provision.Setting Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s—England, Germany, Italy, the Netherlands, Spain, and Sweden.Outcome measures Changes in the number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 and 2002-3.Results Forensic beds and places in supported housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds has been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. The general prison population has substantially increased in all countries.Conclusions Reinstitutionalisation is taking place in European countries with different traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.     

Addressing long-term physical healthcare needs in a forensic mental health inpatient population using the UK primary care Quality and Outcomes Framework (QOF): an audit

Objectives This audit aims to evaluate the effectiveness of delivering an equivalent primary care service to a long-term forensic psychiatric inpatient population, using the UK primary care national Quality and Outcomes Framework (QOF).Method The audit compares the targets met by the general practitioner with special interest (GPwSI) service, using local and national QOF benchmarks (2005-2006), and determines the prevalence of chronic disease in a long-term inpatient forensic psychiatry population.Results The audit results show that the UK national QOF is a useful tool for assessment and evaluation of physical healthcare needs in a non-community based population. It shows an increased prevalence of all QOF-assessed long-term physical conditions when compared to the local East London population and national UK population, confirming previously reported elevated levels of physical healthcare need in psychiatric populations.Conclusions This audit shows that the UK General Practice QOF can be used as a standardised instrument for commissioning and monitoring the delivery of physical health services to in-patient psychiatric populations, and for the evaluation of the effectiveness of clinical interventions in long-term physical conditions. The audit also demonstrates the effectiveness of using a GPwSI in healthcare delivery in non-community based settings. We suggest that the findings may be generalisable to other long-term inpatient psychiatric and prison populations in order to further the objective of delivering an equivalent primary care service to all populations.The QOF is a set of national primary care audit standards and is freely available on the British Medical Association website or the UK Department of Health website. We suggest that primary care workers in health economies who have not yet developed their own national primary care standards can access and adapt these standards in order to improve the clinical standards of care given to the primary care populations that they serve.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Making access to health care more equal: the role of general medical services.

The Resource Allocation Working Party (RAWP) recognised the need to consider both health authority and primary care services in achieving its objective. RAWP and the subsequent Advisory Group on Resource Allocation (AGRA) found (but did not publish) considerable variation in resources used by both services but could not find a clear relation between them. Statistics provided by the DHSS were used to compare spending by 80 area health authorities in 1980-1 with expenditure per head on general medical services by their corresponding family practitioner committees. There was considerable variation in the provision of resources for both services and no clear relation between the variations in spending on each service. Only 40 of the 80 areas had both health authority and family practitioner committee spending levels within 10% of "target." Subregional inequalities in resources tend to be related to variations in admission rates, which in turn are related to general practitioners'' referral behaviour. These results emphasise the importance of finding out more about inequalities in the provision of general medical services and their relation to the use of hospital services. They also suggest that RAWP''s aim of equality of opportunity of access to health care resources may be achieved only if general medical services are brought into the equation as well.     

Mortality and Life Expectancy in Homeless Men and Women in Rotterdam: 2001–2010

Background

Data on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city.

Methods

Based on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy.

Results

During follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95–7.82) as compared to men (RR 3.31, 95% CI 2.91–3.77), and decreased with age (RR 7.67, 95% CI 6.87–8.56 for the age group 20–44 and RR 1.63, 95% CI 1.41–1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1–12.9) and 15.9 (95% CI 10.3–21.5) years lower for homeless men and women compared to men and women in the general population respectively.

Conclusion

Homeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.     

Treatment needs of prisoners with psychiatric disorders.

OBJECTIVE--To describe the prevalence of psychiatric disorder and the treatment needs of sentenced prisoners in England and Wales. DESIGN--Population survey based on a 5% sample of men serving prison sentences. SETTING--Sixteen prisons for adult males and nine institutions for male young offenders representative of all prisons in prison type, security levels, and length of sentences. SUBJECTS--406 young offenders and 1478 adult men, 404 and 1365 of whom agreed to be interviewed. MAIN OUTCOME MEASURES--History of psychiatric disorder, clinical diagnosis of psychiatrist, and required treatment. RESULTS--652 (37%) men had psychiatric disorders diagnosed, of whom 15 (0.8%) had organic disorders, 34 (2%) psychosis, 105 (6%) neurosis, 177 (10%) personality disorder, and 407 (23%) substance misuse. 52 (3%) were judged to require transfer to hospital for psychiatric treatment, 96 (5%) required treatment in a therapeutic community setting, and a further 176 (10%) required further psychiatric assessment or treatment within prison. CONCLUSIONS--By extrapolation the sentenced prison population includes over 700 men with psychosis, and around 1100 who would warrant transfer to hospital for psychiatric treatment. Provision of secure treatment facilities, particularly long term medium secure units, needs to be improved. Services for people with personality, sexual, and substance misuse disorders should be developed in both prisons and the health service.     

PSYCHIATRIC INPATIENT SERVICES IN GENERAL HOSPITALS

Traditional asylum care of psychiatric patients leads to the isolation, confinement, and restraint of the patients, and to isolation of psychiatric practice from the rest of medicine. Modern psychiatric advances have demonstrated the disadvantages to both patients and their families of such isolation, confinement and restraint. It is in the best interests of patients and professional workers that inpatient psychiatric services be continuous with, and contiguous to, other medical services and to rehabilitation services of all kinds.Examination of currently available information reveals a shortage of psychiatric beds in California, particularly for diagnosis and brief treatment. Thus, not only is there a need to develop psychiatric inpatient facilities, but also an opportunity to develop them along several different lines. Since both the Hill-Burton Act (federal) and the Short-Doyle Act (state) give financial assistance to only those psychiatric services established in general hospitals or affiliated with general hospitals, this requirement calls for examination in the light of experience with services so operated.At first, the Short-Doyle Act was perceived as a panacea for the psychiatric ills of the state. Now it is beginning to be recognized as one method of providing additional mental health resources, rather than the exclusive method. As more short-term cases are treated in local, tax-supported, psychiatric units in general hospitals, an impact can be expected on the state hospital program.In its administration of the Short-Doyle Act, the Department of Mental Hygiene attempts to respond to community needs as locally determined. It tries to insure local option and encourage local responsibility while furthering high standards of staffing and of service.     

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE--To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN--Multicentre randomised controlled trial. SETTING--51 general practices linked to nine Scottish maternity hospitals. SUBJECTS--1765 women at low risk of antenatal complications. INTERVENTION--Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES--Comparisons of health service use, indicators of quality of care, and women''s satisfaction. RESULTS--Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION--Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.     

Prevalence of Mental Illness among Homeless People in Hong Kong

MetholodogyThis study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.FindingsThe point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.ConclusionThe low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.     

Homelessness and dog ownership: an investigation into animal empathy,attachment, crime,drug use,health and public opinion

Abstract

A sample of 51 homeless people in Cambridge, UK completed a questionnaire featuring adapted Animal Empathy and Companion Animal Bonding Scales. Concepts of crime, drug use, and health matters amongst the homeless, both dog owning and non-dog owning, were investigated, as well. Ninety members of the general public completed a similar questionnaire which sought their opinions on homeless people who own dogs. There was a highly significant difference (p < 0.01) between the homeless and the securely housed on their animal empathy and attachment scores, with the homeless sample displaying higher values. Gender and dog ownership status had no effect on these scores. A near significant result (U = 2, n₁ = 13, n₂ = 58, p = 0.06) was revealed for animal empathy scores of those who gave money to dog-owning homeless people and those who gave to non-dog owning homeless people. Of the public respondents, women were significantly more likely to show concern for a homeless person's dog's welfare than men (X²₍₁₎ = 8.5, p < 0.01), and of the homeless respondents, non-dog owners were significantly more likely than dog owners to believe that having a dog helped initiate conversations with the public (X²₍₁₎ = 4.0, p < 0.05). Highly significant differences (U = 10, n₁ = 31, n₂ = 20, p < 0.01) were found for medical care use between the dog-owning and non-dog owning homeless, and health scores showed a reversed trend compared to that expected for the general population, with dog owners scoring lower than non-dog owners.     

The elderly mentally ill--whose responsibility?

The elderly mentally ill make considerable demands on health and social services. To evaluate the need for these services a one-day census of all people aged 65 and over was carried out in an area containing 220 000 people (40 000 over 65). Data were obtained on the nursing needs and psychiatric state of the 2162 elderly people in hospital or local authority residential homes for the elderly, or living at home receiving care from the community nursing service. One-third were classified as having psychiatric problems, more than half of them being outside hospital. Residential homes and community nurses play a significant part in caring for the elderly mentally ill, and an integrated but flexible manpower policy is important.     

Use of hospital services by homeless families in an inner London health district.

Over the past decade the number of families in London who were considered officially to be homeless appreciably increased. In response to this many families have been given temporary accommodation, usually in bed and breakfast hotels, while awaiting permanent rehousing. About 200 of the roughly 600 hotels in London that provide such accommodation are located in the area of the former Paddington and North Kensington Health Authority, now part of Parkside Health Authority. The use made by the homeless population of hospital services was studied by finding out the numbers of inpatients admitted to hospital and the numbers presenting to the walk in paediatric clinic and the casualty department at one hospital. These figures were compared with those for local residents and the overall workload. The bed and breakfast population were high users of inpatient beds, the casualty department, and the paediatric clinic. Overall, about one tenth of the beds were used by these people. The health authority receives no additional funding for this group of patients. Further research is needed to find out if the high use of hospital services made by these patients reflects their increased morbidity or their inability to obtain primary care services.     

Lithium treatment: prescribing and monitoring habits in hospital and general practice.

OBJECTIVES--To define current clinical practice of lithium prescribing and monitoring and to compare hospital based practice with general practice. DESIGN--Prospective study of doctors'' practice. SETTING--Psychiatric hospital day and outpatient facilities and general practices in Edinburgh and Midlothian district (population 600,000). SUBJECTS--458 patients taking lithium who had been stabilised and who remained as outpatients during the year of study. 219 were treated by their general practitioner and 190 by the hospital; 49 had shared care or care transferred during the study. MAIN OUTCOME MEASURES--Daily dose, duration of treatment, psychiatric diagnosis, mean annual serum lithium concentration, frequency of occurrence of and response to raised serum concentrations. RESULTS--Compared with hospital doctors general practitioners were more likely to prescribe lithium three or more times daily (43/219 (general practice) v 10/190 (hospital); chi 2 = 18.6, p = 0.001) and to estimate serum concentrations less frequently (4.5 v 5.3 measurements/year; t = 3.04, p = 0.003), and their patients were more likely to experience raised lithium concentrations (39/219 v 17/190; chi 2 = 6.8, p = 0.01). One third of doctors made no response to raised lithium concentrations in the next six weeks. CONCLUSIONS--General practitioners and hospital doctors care for similar types of patients and the stringency of lithium surveillance varies greatly among doctors. Certain aspects of practice give cause for concern and could be improved by following more uniform guidelines.     

The outcome of targeting community mental health services: evidence from the West Lambeth schizophrenia cohort.

OBJECTIVES--To report outcome of targeting community mental health services to people with schizophrenia in an inner London district who had been shown, one year after discharge, to have high levels of psychotic symptomatology and social disability but very low levels of supported housing and structured day activity. DESIGN--Repeat interview survey of symptoms, disability, and receipt of care four years after index discharge. SETTING--Inner London health district with considerable social deprivation and a mental hospital in the process of closure. SUBJECTS--51 patients originally aged 20-65 years who satisfied the research diagnostic criteria for schizophrenia. MAIN OUTCOME MEASURES--Contact with services during the three months before interview, levels of symptoms (from present state examination), global social disability rating. RESULTS--65% (33/51) of the study group had been readmitted at least once in the three years between surveys. Recent contacts with community psychiatric nurses and rates of hospital admission increased (8 at one year v 24 at four years, p < 0.01; 5 v 13, p < 0.06). Conversely, fewer patients were in contact with social workers (17 v 7, p < 0.03). Proportions in supported housing, day care, or sheltered work did not change. Unemployment rates remained very high. A considerable reduction (almost a halving) in psychiatric symptoms was observed, but there was no significant change in mean levels of social disability. CONCLUSIONS--The policy of targeting the long term mentally ill resulted in significant increases in professional psychiatric input to the cohort but failed to improve access to social workers or suitable accommodation. Improvements in social functioning did not follow from reductions in the proportions of patients with psychotic mental states. Social interventions are likely to be crucial to achieving the Health of the Nation target of improving social functioning for the seriously mentally ill, as improving mental state seems in itself to be insufficient.