Dedicated psychiatric care within general practice: health outcome and service providers' views

Dedicated psychiatric care within generalpractice: health outcome and serviceproviders' views

Julie Bruce RGNN BSc MSc

Research Assistant, Department of Public Health, University of Aberdeen, UK

Diane Watson RMNRMN

Community Psychiatric Nurse, CPN Department, Royal Cornhill Hospital,

Aberdeen, UK

Edwin R. van Teijlingen MA PhDMA PhD

Lecturer, Department of Public Health, University of Aberdeen, UK

Ken Lawton MBChBMBChB FRCGPFRCGP

Clinical Senior Lecturer, Department of General Practice and Primary Care,

University of Aberdeen, UK

M. Stuart Watson MBChBMBChB MRCGPMRCGP

Lecturer in Public Health Medicine, Department of Public Health,

University of Aberdeen, UK

and Alastair N. Palin MBChBMBChB MRCPsychMRCPsych

Consultant Psychiatrist, Royal Cornhill Hospital, Aberdeen, UK

Accepted for publication 1 July 1998

BRUCE J, WATSON D, VANBRUCE J, WATSON D, VAN TEIJLINGENTEIJLINGEN E.R., LAWTON K., WATSON M.S. &E.R., LAWTON K., WATSON M.S. & PALINPALIN A.N.A.N.

(1999)(1999) Journal of Advanced Nursing 29(5), 1060±1067

Dedicated psychiatric care within general practice: health outcome and service

providers' views

Health service reforms have led to relocation of care of the chronic mentally ill

from institutions to the community, with subsequent demands on the primary

health care team. Few studies have attempted to identify satisfactory models of

care for this patient group. This study explores the impact of the employment of

a community psychiatric nurse (CPN) by a general practice in Aberdeen city to

co-ordinate care of discharged long-stay psychiatric patients resettled in hostels.

A similar general practice with a comparable group of registered patients was

selected as a control group. Patient health outcome was measured using the

Health of the Nation Outcome Scales (HoNOS) and service providers' views on

dedicated psychiatric care within general practice were explored using qual-

itative methods. Improvements in communication, liaison and drug manage-

ment were reported in the intervention practice. A primary care-based CPN

Correspondence: Ms. J. Bruce, Department of Public Health, University of

Aberdeen, Polwarth Building, Medical School, Foresterhill, Aberdeen,

Scotland AB25 2ZD, UK.

Journal of Advanced Nursing, 1999, 29(5), 1060±1067 Issues and innovations in nursing practice

1060 Ó 1999 Blackwell Science Ltd

service dedicated to the care of the chronic mentally ill promoted a smooth

transfer of care from long-term institutionalized care to the community setting.

Keywords: community psychiatric nursing, qualitative research, Health of the

Nation Outcome Scales, evaluation, general practice, psychiatry

INTRODUCTION

Since the 1970s there has been an attempt to shift the

location of patient care from the hospital setting to

the community. The National Health Service reforms

of the early 1990s led to changes at the interface between

primary and secondary health care services that consol-

idated this process (Department of Health 1989). This

trend has been particularly predominant for psychiatric

care where, throughout the United Kingdom (UK), pa-

tients with chronic mental illness have been discharged

to the community. An infrastructure of hostels, group

homes and supported accommodation has developed to

accommodate them. Many such patients receive care

from the social services with signi®cant input from

community mental health and primary health care

professionals. Recent studies have recognized that the

supervision of this care tends to fall to general practitio-

ners, with subsequent greater demands on their time and

resources (Kendrick et al. 1991, Strathdee 1994). How-

ever, the General Medical Services Committee (GMSC)

refutes that general practitioners should be the key

workers in this ®eld and suggests they should relinquish

care to specialist or social services once need has been

identi®ed (GMSC 1996, Kendrick & Burns 1996). Studies

to date have not yet identi®ed the optimal model of

management of the chronic mentally ill in the

community.

BACKGROUND

In Grampian Region, North-east Scotland, long-stay psy-

chiatric wards were closed between 1990 and 1994 and

replaced with group hostels in the community to accom-

modate patients with chronic and severe mental illness.

The Aberdeen city general practice in this study accepted

medical responsibility for 23 discharged chronic mentally

ill patients housed at three nearby hostels. Following the

transfer of care from secondary to primary services,

practice staff perceived an increase in workload. This

was subsequently supported by internal audit, where

yearly consultation rates were found to be nine times

greater for resettled chronic mentally ill patients when

compared to other patient groups. In 1994, this fundhold-

ing practice employed a `G' grade community psychiatric

nurse (CPN) for 15 hours per week, at a cost of £10 000 per

annum, to dedicate care to patients with severe and

chronic mental illness discharged from long-term psychi-

atric care. Independent evaluation of this service was

conducted to assess patient health outcomes and explore

views of service providers' on this alternative model of

community care.

AIMS OF THE STUDY

The aims of this study were to quantify and compare

health outcomes of chronic mentally ill patients,

registered with a general practice who employed a `ded-

icated' part-time CPN, to a comparable group of patients

registered with a similar general practice which did not

employ a `dedicated' CPN. The comparison practice

employed traditional, generic CPN services within a

community mental health team. Exploration of views of

service providers was also undertaken to evaluate wider

aspects of the two models of care.

Study practice

The fundholding study practice, situated in the west end

of Aberdeen city, consisted of six full-time general prac-

titioners responsible for approximately 10 000 registered

patients (Table 1). Three practice nurses were responsible

for administration of depot medication to patients

including those with chronic mental illness. This practice

cared for the highest number of patients in Grampian

discharged from long-term psychiatric care between 1990

and 1994.

Psychiatric services were provided by a community

mental health team which comprised a consultant psychi-

atrist, junior medical staff, a psychologist, an occupational

therapist, social workers and two CPNs, one of whom was

Table 1 Practice characteristics

Study practice

Comparison

practice

No. of registered

patients

10 000 10 000

Location West end West end

No. of general

practitioners

6 6

Funding status Fundholding Non-fundholding

Depot administration Practice nurse Practice

nurse/CPN

CPN model of care Dedicated CPN Generic CPN

Issues and innovations in nursing practice Psychiatric care in general practice

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1060±1067 1061

the intervention CPN. Although the intervention CPN was

employed for 15 hours a week to provide dedicated care to

resettled mentally ill patients, the remainder of her

working time was as a generic CPN working with the

community mental health team. Psychiatric consultations,

both with new patients and follow-up appointments, were

held in the general practice rather than the psychiatric

hospital.

Comparison practice

A comparison practice, which employed the traditional,

generic model of CPN care, was selected for the study.

This non-fundholding general practice cared for the

second highest number of patients in Grampian dis-

charged from long-term care between 1990 and 1994. Five

full-time and one part-time general practitioner were

responsible for approximately 10 000 registered patients.

This practice was also situated in the west end of

Aberdeen. Practice nurses shared responsibility for

administration of depot medication with CPNs.

Psychiatric care was provided by one of 16 community

mental health teams in Grampian, which cover on average

four general practices each. This mental health team

comprised two generic CPNs with mixed caseloads of

patients with neurotic and psychotic disorders. Referral to

CPN services was via a formal written request procedure

except for emergency situations. Psychiatric consultations

were conducted at the psychiatric hospital rather than in

general practice, partly due to lack of space within the

practice.

METHODS

A combination of quantitative (standardized question-

naire) and qualitative approaches (face-to-face interviews

and focus groups) was undertaken. Ethical permission

was obtained from the local Joint Ethical Committee and

local General Practitioner Sub-Committee to conduct

interviews with 40 patients who had been discharged

from long-term psychiatric care.

Health outcome measurement

Health outcome was measured using the Health of the

Nation Outcome scales for severe mental illness

(HoNOS-SMI), a recently designed generic instrument

that incorporates mental, physical and social compo-

nents of health. It was felt important to obtain an

indication of the environment in which the patient lived

rather than to focus purely on clinical symptoms of

mental health state. The HoNOS consists of 12 items,

each of which is rated from zero to four `no problem' to

`very severe problem' giving a ®nal score between 0 and

48. Two items measure impairment, three behaviour,

three symptoms and four measure function within a

social context. The total score gives an overall indica-

tion of current health. Although a single score allows for

comparison between individuals or groups, groupings of

items can also be compared. Initial reports suggest that

the scale is sensitive to change and can be administered

before and after an intervention to assess change over

time (Curtis & Beevor 1995).

A trained rater completes the HoNOS following either

an interview or a team assessment of a patient. The

researcher (JB), having a clinical nursing background,

received training in HoNOS administration from a con-

sultant psychiatrist. For the purposes of this study, an

information sheet was given to each patient, followed by

a short explanation of the study. The information was

then left with the patient and their key worker for several

days to allow the patient time to consider whether or not

they would participate. A signed consent form was

obtained from each patient before interview. Patient

interviews were conducted in familiar surroundings, in

private, and lasted on average 50 minutes. The HoNOS

form was then completed by the researcher in the

presence of the patients' key worker. Key workers were

consulted to clarify and con®rm the recent mental and

physical health of the patients for whom they were

responsible.

Interviews with general practitioners

Four general practitioners, two from the study and two

from the comparison practice were selected randomly and

invited to participate in the study. Face-to-face interviews

were conducted with individual practitioners in their

own consulting rooms. The mean interview time was

65 minutes. Each interview was taped and transcribed on

completion. Issues for discussion had been developed

from an earlier pilot study with general practitioners

independent from the study. At the end of each interview,

the researcher summarized key points with practitioners

to highlight the main themes. This was conducted in an

attempt to validate the researcher's interpretation of the

interaction (respondent validation).

Focus groups with carers

Focus groups were held with staff from four separate

hostels in Aberdeen city, two of which housed patients

registered with the study practice and two that housed

patients registered with the comparison practice. Project

managers from each hostel were approached and invited

to participate. It was hoped that focus groups with staff

would encourage open discussion of the advantages and

J. Bruce et al.

1062 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(5), 1060±1067

disadvantages of each model of care. At the close of each

focus group, the researcher fed back emerging themes to

the staff in an attempt to validate responses.

Data analysis

The HoNOS scores were entered onto the Statistical

Package for the Social Sciences (SPSS) for Windows

database version 6.1 (Norusis 1997). Due to small study

numbers the Mann±Whitney non-parametric test was used

to compare HoNOS scores between groups. Taped infor-

mation from interviews and focus groups was transcribed

within 24 hours to avoid incorrect interpretation. Each

transcript was analysed (JB) in detail to identify the

substance of each interaction. Recurring categories within

the data were identi®ed, classi®ed and coded into themes

following a grounded theory approach, which permits the

emergence of concepts from the interaction. These con-

cepts are thus `grounded' within the obtained data (Do-

well et al. 1995, Mason 1996).

RESULTS

Patient characteristics

There were no differences in age, sex or diagnostic

distribution between the two groups of patients

(P � 0á6). The study group comprised of 23 patients, 14

of whom were male (61%). The comparison group com-

prised of 19 patients, 13 of whom were male (68%). The

median age of the study was 55 years (range 35±72 years)

and the median age of the comparison group was 52 years

(range 28±75 years). The commonest diagnosis within

both groups was schizophrenia (study group 65%; com-

parison group 68%; P � 1á0). Although the exact time

spent in psychiatric hospital for each patient was not

calculated, each patient had spent a minimum of 1 year in

any 3-year period in such a hospital. Similar proportions

of patients had spent more than 20 years in hospital at any

time (study group 22%; comparison group 21%).

Health outcome measurement

A HoNOS score was completed for 22 (96%) patients from

the study group and 18 patients (95%) from the compar-

ison group. Two patients, one from each group, were in

psychiatric hospital with acute exacerbation of their

illness, which made interview inappropriate.

No differences were found in total HoNOS scores

between the two groups (median values study group 6;

comparison group 5; P � 0á21 Mann±Whitney U-test).

One comparison group patient had a high total score of 19

due to a recent relapse of delusional symptoms. Each of

the 12 HoNOS domains were analysed separately with no

signi®cant differences found between groups (Table 2).

Qualitative ®ndings

(a) General practitionersFour general practitioners, two from the study practice

(identi®ed as SP1 & SP2) and two from the comparison

practice (identi®ed as CP1 & CP2) were interviewed.

Access. Study practice: access to on-site specialist ad-

vice and support from the intervention psychiatric nurse

was perceived by general practitioners as bene®cial, both

for patients and practice base health care professionals.

The CPN attended the general practice at least twice

weekly but was also accessible by radiopager: Ìt's a

tremendous advantage in accessibility and just the overall

ef®ciency of the system' (SP1). This predominantly

informal and regular contact allowed practitioners the

opportunity to discuss aspects of management of patients

with chronic mental illness. Hostel staff and discharged

patients who had progressed to living alone had direct

access to the intervention CPN.

Comparison practice: all requests for CPN contact were

made via the general practitioner, therefore hostel staff or

Table 2 Comparison of HoNOS scores

Study

group

n = 22

Comparison

group

n = 18

Health of the Nation

Outcome Scales

Median

(range)

Median

(range)

1. Overactive, aggressive,

disruptive behaviour

0

0±1

0

0±3

2. Non-accidental self-injury 0

0±1

0

0±2

3. Drinking or drug taking 0

0±2

0

0±4

4. Cognitive 0

0±2

0

0±2

5. Physical illness or disability 0

0±4

0

0±2

6. Hallucinations & delusions 0

0±4

0

0±4

7. Depressed mood 0

0±1

0

0±3

8. Other mental & behavioural

problems

0

0±3

0

0±4

9. Relationships 0

0±2

0

0±3

10. Activities of daily living 0

0±3

0

0±3

11. Living conditions 0

0

0

0±1

12. Occupation & activities 0

0±1

0

0±2

Total HoNOS score 5

0±10

6

0±19



patients had no direct access to psychiatric services.

General practitioners acted as a gateway and ®lter to the

community psychiatric team. Practitioners reported infre-

quent contact with CPNs and the community mental

health team: `We used to have monthly meetings¼but for

the last six months there's been no meetings' (CP2).

Practitioners were unable to identify which chronic men-

tally ill patients had input from a CPN: I'am not sure

exactly which cases she does visit¼but I'am sure that she

must visit some of the cases once they're discharged from

hospital¼I'am not sure how much they are let go totally

from the psychiatric team' (CP1). General practitioners

controlled access to the psychiatric team, but were

unaware of who received input or regular follow-up from

the psychiatric services.

Identity. Study group: practitioners perceived the inter-

vention nurse as a team player, an integral member of the

practice staff: Ìt is much better when you have an

identi®able team and you see her on a regular basis and

get problems sorted out,' (SP2). Although operating within

a multi-disciplinary setting, this staff member was viewed

as a central contact to the care and management of

registered patients with severe mental illness.

Comparison practice: practitioners viewed the CPN as a

member of the community mental health team who cared

for patients in the community. Any requests for care were

directed at the team rather than at individual CPNs: Ìt's

passed to the team¼I don't know quite how they allocate

it but a request goes to whoever is most appropriate for the

job and is not up to us' (CP1). The CPN, therefore, was not

a discernible member of the primary care team.

Communication. Study group: practitioners reported a

noticeable improvement in communication between

primary care, secondary care, social services and commu-

nity staff. The process of transition from hospital to

community was ameliorated by the intervention CPN:

`Well she sort of came in and smoothed things over¼it's

just running amazing smoothly now'(SP1). This was

particularly important because patients were often disori-

entated and bewildered when adjusting to life in the

community setting. General practitioners felt that the

mixed background and experience of hostel staff added to

this period of instability: `Before she was employed the

social work team were always on the phone about things,

anything that they couldn't handle and it seemed to be

they couldn't handle very much¼lets face it¼because it

was new for them' (SP2).

Comparison practice: general practitioners had made an

elective decision for the CPN not to have direct access or

regular involvement with hostel residents. They felt,

however, that high staff turnovers within hostels did

hamper communication and continuity of care: `The

trained nurse went away and they've been left with people

that have no real experience of working in a psychiatric

hospital or looking after long-term mentally ill people'

(CP2). Although communication could be improved by

regular input from a CPN or community mental health

team, this would take services away from the chronic

population who lived alone or without hostel support.

They expressed a fear that if CPNs visited hostels, their

time would be `tied up' and they `would never be out of the

place' (CP1). This could only change with additional

funding: `There's been no additional funding given to the

community psychiatric services¼so it's where you decide

that the resources are more appropriately used' (CP2).

Drug management. Practitioners from both general

practices thought that primary care nurses (practice nurs-

es) should administer depot medication. This would allow

the CPN to concentrate on assessment and counselling of

patients. The practice nurses from the study practice held

a `depot clinic' which patients attended whereas the

comparison practice shared depot administration between

staff (CPN and practice nurses). The practitioners believed

it was bene®cial for patients to attend the general practice

rather than have a CPN visit to administer intra-muscular

injections: ÔIt gives the patient responsibility¼and by and

large most come up to the practice on their own'(SP2).

Study group practitioners highlighted the additional ad-

vantages of liaison between the intervention CPN and

local pharmacist, who was responsible for preparation and

dispensing of repeat prescriptions. Any discrepancies or

failure to collect a prescription was dealt with by the CPN.

(b) Hostel staffFour focus groups were held with a total of 25 staff from

four different hostels. Focus groups took place before

weekly staff meetings when most staff, including project

managers, were in attendance. Study hostels are identi®ed

as SH1 and SH2, comparison hostels are identi®ed as CH1

and CH2.

Access to psychiatric services. Study groups hostels:

direct access to the intervention CPN was a major theme

for discussion. Access to support and advice was now

available where, prior to CPN employment, hostel staff

had to refer problems to the general practitioner. He or

she, it turn, would then contact psychiatric services: `Well

you could get the GP but then the would come in and then

try and get hold of the psychiatrist¼and that would take

just as long' (SHI). Staff felt at ease contacting the CPN

rather than the psychiatrist or general practitioner: `You

might feel a bit¼that you're wasting their precious time'.

Furthermore, the CPN had access to other mental and

occupational health professionals without involving the

general practitioner.

Comparison group hostels: staff perceived a number of

problems with access to specialist support, which was via

J. Bruce et al.


the general practitioner: `The dif®culty is getting hold of

them, you can say I would like to speak to Dr X¼ but it really

depends on whether the receptionist from hell is going to let

you through or not' (CH1). For non-emergencies, staff often

had to wait days before they could get patient appoint-

ments. General practitioners called to attend a patient were

often unfamiliar with patients and staff.

Communication. Study group hostels: staff had noted

changes in communication patterns after the employment

of the dedicated CPN. Many comments suggested that

direct contact with the CPN and thereby with medical and

related health professionals (i.e. occupational therapist,

pharmacist) was preferred to the traditional route of access

via general practitioner referral: `By and large we tend to

bypass the GPs¼only because we have the service, the

contact¼and we know the CPN can relay our concerns

directly to the psychiatrist and that she has her own

contacts with the hospital services' (SH1). Most patients

were reviewed, at least annually, by a consultant psychi-

atrist in the presence of the intervention CPN so any

concerns could be relayed and discussed. Similarly,

followed assessment, the CPN could feedback medication

changes or management decisions, made during the

review, to hostel staff and general practitioners.

Comparison hostels: there was no regular input from a

CPN or other members of the community mental health

team at either of the comparison hostels and staff had been

actively discouraged from contacting them: `The rule is

always to contact the GP ®rst' (CH1). `We don't expect

support from the community mental health team so we

have to work around it¼it would be an awful lot easier if

we had that' (CH2). Most patients attended the psychiatric

hospital for review appointments. Staff thought this was

anxiety-provoking for patients who were under pressure

to `perform' in front of the psychiatrist: Ìts quite daunting

for them¼there's often the fear that they're going to be

whisked back in' (CH1). Medications were altered or

discontinued at review assessments without consultation

with hostel staff. There was also a consensus among staff

that psychiatric professionals should see patients in their

own environment to observe how they were coping in the

community: `They are not really getting a true picture of

how well they've done or what problems they've had¼it's

a case of a snapshot which doesn't accurately represent

how they've been (CH2). `We get no feedback from the

hospital apart from what the residents tell us' (CH1). In

general, comparison hostel staff were critical of the review

system, as they were neither contacted before or consulted

after review appointments.

Familiarity. Study hostel: familiarity with the CPN was

thought to have led to improved relationships between the

different parties. The CPN saw patients and staff ùsually

every week' and often up to `three times a week' on an

informal basis. She was, therefore, a familiar face to all the

hostels and knew of patients' previous medical histories,

medication and recent progress: `We do use her as a

sounding board if we're not sure about anything or if we

think things aren't going right for a resident' (SH1). The

hostel staff also felt that their own familiarity with the

CPN was bene®cial as she could judge which situations

they were able to cope with: Ìt is important that people

remember that we are giving the social care side of things

rather than medical¼and when we say we need help it's

usually because we need help and not just being awkward'

(SH2).

Comparison hostels: the different organization of psy-

chiatric services in the comparison practice resulted in

infrequent contact between hostel staff and CPNs. One

hostel staff member stated: `We don't really know or have

a clear understanding of what the CPN does in

the community' (CH2). Staff, however, were keen to

communicate with staff from the psychiatric services.

One manager explained Òften we are just looking for a bid

of support and a bit of guidance' (CH1).

DISCUSSION

There has been an increase in the number of CPNs

attached to general practice, whose role it is to care or

counsel those with non-psychotic illness (Gournay &

Brooking 1994, King & Nazareth 1996, Gask et al. 1997).

This project examined the impact of CPN employment by

a general practice to dedicate care of chronic mentally ill

patients resettled in the community using quantitative and

qualitative methods. Jones (1996) highlighted the dif®cul-

ty of conducting psychiatric research in the community

setting because of the uncontrolled nature of the environ-

ment. This research, however, attempted both to study

patients and carers in their own environment, and to ®ll

the gap in qualitative approaches recognized in the

psychiatric literature (Cohen 1993, Jones 1996).

Although this study was undertaken opportunistically,

the methodological design was weakened by the lack of

baseline HoNOS data before patient discharge. However,

this would entail prospective studies and it is unlikely

that such work could be undertaken, as the majority of

long-stay patients in Grampian have been discharged and

rationalization of psychiatric wards is now complete.

There were no differences in total HoNOS scores between

the two groups of patients nor between individual

domains. One item, domain 11, which measures problems

with living conditions (functioning in a social context)

was not found to be wholly applicable to a group hostel

environment where basic necessities such as heat, light

and hygiene are provided. A more comprehensive

measure of autonomy and coping within residential set-

tings in the community would be achieved using speci®c

functioning indices, e.g. the Environmental Index (Gib-



bons & Butler 1987). However, the HoNOS proved to be a

brief, acceptable and concise measure of health outcome

of this group of patients with chronic and enduring mental

illness.

General practitioners from the study practice welcomed

the dedicated CPN's role in communication and liaison

between practice staff, hostel staff and secondary psychi-

atric services. The CPN could provide support and advice

on the management of problems, speci®c to the chronic

mentally ill, to hostel staff. This was particularly

important as staff had diverse backgrounds and training.

Practitioners were satis®ed with the service, as they

perceived less overall contact with both hostel staff and

patients for mental health reasons, which relieved the

burden of care on general practice staff.

Practitioners from the comparison practice felt that CPN

time should be used primarily for the support of chronic

mentally ill living alone or those relying upon family

input. A dedicated CPN service, if provided, should be

proactive rather than reactive. The lack of training and

mixed background of hostel staff was an issue raised by

all. Practitioners criticized the lack of funding to cope

with the discharged chronic population and the failure to

redirect resources from secondary services to primary care

teams who were now responsible for their care.

The focus groups successfully generated many interest-

ing views from staff members, most of whom heartily

participated in discussion. In general, staff were keen to

air opinions to an independent researcher. Study group

hostel staff stated access to assistance had improved and

communication with the primary and secondary services

was facilitated by the dedicated CPN. Familiarity, which

had developed over time with regular visits, was viewed

as a bene®t to patients and staff. Management of medica-

tions was perceived to be safer and simpler for practitio-

ners and hostel staff. Furthermore, the dedicated CPN

could communicate the concerns of hostel staff to the

consultant psychiatrist at patient reviews.

Comparison group hostel staff identi®ed a number of

problems related to access and communication. Hostel

staff felt isolated and excluded from decisions made

during patient reviews and had no input from the CPN or

other members of the mental health team. They welcomed

any feedback from the review process and from general

practitioners. The transfer of care from hospital to hostel

was hampered by the lack of trust and stilted communi-

cation between different parties.

CONCLUSION

This study has a number of limitations, namely its small

sample size and retrospective study design. Ideally,

prospective randomized controlled studies would be

required to reduce bias and improve generalizability.

However, as local long-stay ward closures are now com-

plete, it is of value to capitalize on the information

generated from studies such as this where the opportunity

for a similar study of prospective design will not present

itself. Although the study and comparison practices were

comparable in terms of location, population and catch-

ment area, they had different models of funding. The

autonomous fundholding status of the study practice

provided the ¯exibility to purchase a dedicated service.

This was not an option to the non-fundholding compara-

ble practice. It may be dif®cult to attribute any changes

solely to the intervention of the dedicated CPN as the

whole organization of care of at the study practice is

innovative. Furthermore, the boundaries between primary

and secondary care teams were blurred at the study

practice because of the shift in operational base.

CPN was both welcomed and bene®cial. However, it

may be that the main bene®ciaries are the general

practitioners and hostel staff rather than the service

users, who had similar quality of life scores. It is a

noteworthy point that the whole thrust of political

policy has been to return the management of the long-

term mentally ill to primary care. Nevertheless, it is

apparent from the ®ndings of this study that both

primary care teams and carers welcome liaison with

hospital psychiatric services for the management of

these patients. A dedicated CPN based within primary

care would seem to ®ll this role.

Acknowledgements

The authors extend grateful thanks to all the patients

(hostel residents) who kindly participated in this study

and to staff from the general practices and community

hostels for their time and co-operation throughout the

duration of this project. Thanks are due to Ms Jill Mollison

for valuable statistical advice.

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Documents

Dedicated psychiatric care within general practice: health outcome and service providers' views