consultation document) on introducing out of hospital teams and closing GP community hospitals. This follows a pilot in the Lowestoft area which reduced emergency admissions compared to the previous year (see evidence), whereas nationally figures increased.
The case for change document includes an appendix on the clinical evidence base from national initiatives. Health policy has encouraged a greater range and volume of care to be delivered outside hospital for some time now. Implementation of this policy has been tentative and the SeeSaw simulation by the Kings Fund looked at the reasons why. Primarily this is about commissioning and HealthEast do seem set on making integrated out of hospital care a reality.
The implementation of home based treatment was different for mental health services. It proceeded before that for physical health care. The evidence for Crisis Resolution and Home Treatment (CRHT) in psychiatry came from several major controlled research studies (see Tyrer & Creed, 1995, for a summary of this evidence). CRHT teams were then implemented as part of a national service framework that modernised services.
There does not seem to be the same controlled research evidence for physical health care. National policy is also more piecemeal with each area being expected to 'reinvent the wheel'. Data from the Lowestoft pilot project is anecdotal. It may be valuable nonetheless but it is limited. The mental health studies did not really show much improvement for clinical symptoms for home care over hospital care, although there was some evidence of greater satisfaction, perhaps particularly for relatives. Bed reduction was possible, although there is evidence over recent years that this has gone too far (Tyrer, 2011).
It is important to be clear about what can be achieved with out of hospital care, particularly for clinical symptoms. It's just that I would have felt more confident about it succeeding, if there had been the controlled research studies to back it up. Nonetheless, I don't think there's any turning back (except, as I said, perhaps on mental health service beds) and its nice to see this initiative leading the field in the area where I work.
A new epistemology for psychiatry
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