VOL: 100, ISSUE: 22, PAGE NO: 38
Lawrence Mountford, BA, RMN, DipN, is community psychiatric Nurse, Hull and East Riding Community Health Care Trust
Many mental health teams across the UK have found problems with the appropriateness and quality of the referrals they receive. Various independent reports have highlighted a failure to focus services on the most vulnerable patient groups (Audit Commission, 1994; House of Commons Select Committee, 1994; Mental Health Foundation, 1994). The referral information received is often brief and uses subjective terminology such as ‘very distressed’ or ‘depressed and down’. Receiving this kind of information puts community mental health teams in a dilemma as, although receiving a referral with information such as ‘very distressed, has just split up with boyfriend’ suggests a problem best treated in primary care, without assessing the situation it is impossible to be certain that the person is not suffering from severe mental illness. The Department of Health (2002) acknowledges that the skills required to recognise mental illness vary among GPs. They also point out that assessment in order to confirm that people are not suffering from a psychiatric disorder is a core function of a mental health team.
This lack of accurate assessment data was one of several problems faced by a community mental health team working in a mixed rural and urban area of East Yorkshire. Another problem was the variety of professional and social backgrounds within the team - and with no formal set referral threshold different practitioners used different criteria for entry into the service. Therefore, someone could be seen by a member of one discipline and taken onto their caseload, and then seen by another and refused access to the service.
In addition, unclear referrals present a problem in the amount of time it takes to process them. Completing paperwork after an inappropriate referral takes time away from providing direct care to clients who have severe mental health problems.
The DoH (2002) acknowledges this need to ‘protect direct patient care time’. And the problem of targeting services towards those with severe mental illness is not exclusive. The Audit Commission (1994) found community psychiatric nurses across the UK were not consistently targeting those with severe mental illness. One reason that has been found is that there is no agreement on how to define severe mental illness or how it should be identified (Slade et al, 2000).
Improving referral management
Faced with the identified problems, a small project group of practitioners was set up to determine the properties an assessment tool would need to provide to improve the management of referrals. These tools include:
- The Health of the Nation Outcome Scales;
- The Camberwell Assessment of Needs;
- The Threshold Assessment Grid (TAG).
The Health of the Nation Outcome Scales (Wing et al, 1996) was useful at identifying national and local mental health needs but was not specifically aimed at identifying access to mental health services. It was considered to be open to different interpretations and, at times, the scoring could be fairly subjective.
The Camberwell Assessment of Needs (Phelan et al, 1995) was found to be a very thorough assessment tool. However, the assessment was more focused towards the needs of clients who already had a diagnosis of mental illness. There were also concerns that using such a thorough tool would take longer to complete than our current assessment procedure.
TAG was developed by the Institute of Psychiatry at King’s College London (Slade et al, 2000). It is a brief (single page, seven tick) standardised assessment of the severity of mental health problems. It can be used by primary and secondary care staff to assist decision-making about who to accept/refer into secondary care mental health services. The TAG assessment rates the severity of a client’s difficulty in three areas (Box 1), split into seven domains. On each domain the assessor scores between ‘zero’ (meaning no problem present) and ‘four’ (representing a very severe problem). It also offers an evidence based checklist offering the clinician guidance on the issues to consider when assessing each domain;
The project group were particularly impressed with this tool as:
- It provided a thorough assessment;
- It was evidence based;
- It assessed risk and safety;
- It provided a holistic assessment of needs;
- It could be completed quickly;
- It could be developed at a later date as an audit tool to assess caseloads;
- It may be possible for GPs to use the tool to gauge the appropriateness of referral to the integrated mental health team.
The objectiveness of the tool leaves practitioners in little doubt as to whether the client’s needs were best met by mental health services or within the primary care sector.
Training and implementation
The tool was presented to the management of the trust and after several representations and a few small additions to the original document had been made its use in a pilot form was approved.
The Institute of Psychiatry (2003) assert that training in the TAG assessment is not essential. However, training offers several other purposes such as increasing staff confidence and acting as a launch event. Therefore, a method of training staff to use the tool was investigated. The King’s College website (www.iop.kcl.ac.uk/iopweb/virtual/?path=/hsr/prism/tag) gives some examples of case scenarios to be assessed using the tool. We then set up several training sessions to give practitioners a chance to examine, discuss, and score these fictitious assessments using the TAG tool.
During the training the scores at which individual practitioners from a variety of disciplines - including nurses, occupational therapists, social care staff, and a psychiatrist - assessed clients were all fairly similar and did not significantly differ from suggested scores from the TAG development team. The reliability and validity of TAG had already been tested with 600 users from 10 mental health teams in London. Results from this testing conclude TAG has adequate reliability and both internal and external validity (Institute of Psychiatry, 2003).
The Institute of Psychiatry TAG development team suggest a cut-off score of five or over to access services and it was decided that this was appropriate to adopt. It was also agreed that individual practitioners could show some flexibility over entry to services.
As Morgan (1998) argues, despite the use of any assessment tool, ‘gut feeling’ can often be the best guide to a client’s needs. Therefore, occasionally it may be that if circumstances dictated a person scoring less than five may be offered a service. Similarly a person scoring more than five may find her or his needs better met in another service. Slade et al (2003) acknowledge problems such as this exist and therefore advocate that a rigid threshold for referrals should not be recommended.
It was also decided that not all clients would receive a TAG assessment. If from the initial referral it was obvious that the client would need a mental health service, then it seemed pointless to put her or him through an initial TAG screening assessment only to follow it immediately with a full mental health assessment. Examples of this could be when a client with a severe psychotic disorder moves into our area or when a client is admitted as an emergency into an acute admission bed.
Primary care liaison practitioner
Having studied the national service framework guidelines (DoH, 1999) we realised that our team had become somewhat remote from the primary care services. Members of the team were aware they were not providing advice, health education, and an informal linkage between primary and secondary care.
One-quarter of routine GP consultations are for people with a mental health problem and around 90 per cent of mental health care is provided solely by primary care (DoH, 1999). With this in mind a primary care liaison practitioner was identified from the team to undertake a role that included attending practice meetings, liaising, and giving advice to primary care practitioners such as health visitors, midwives, GPs, and the voluntary sector.
Each GP was visited to explain how the TAG assessment worked and referrers were encouraged to spend more time providing better quality, objective information on clients’ problems and reasons for referral.
As well as working as a link between primary and secondary care the liaison practitioner also started to provide clinics in the surgeries and offer advice on recommended treatment regimes for clients with mental health problems who were treated in primary care. This role has led to:
- Increased confidence in primary care services managing less severe mental health problems;
- More understanding of secondary care services’ role;
- Better quality, more objective referrals from general practice to our service.
Use of the TAG assessment began as a pilot in our area in April 2003. Practitioners, clients, and primary care services have on the whole found its use to be advantageous. Due to the fact that our health and social service mental health teams became integrated during this period, it is impossible to provide a direct comparison of any changes to client care that have occurred as a result of the implementation of the TAG assessment.
The advantages and opportunities arising from the TAG assessment include:
- The TAG assessment has provided a faster, less bureaucratic method of assessing a person’s mental health needs and offering appropriate treatment options. The process of completing a TAG assessment can comfortably be achieved in one hour as opposed to a minimum of two hours using our previous assessment procedure. The speed of response from receiving a referral to seeing the client has been cut from an average of 20 days in 2002 to six days in 2004;
- In speeding up the assessment process the TAG assessment has led to increased input for clients with severe mental health problems. During the last year the average full-time practitioner’s caseload has decreased from 32 in January 2003 to 21 in January 2004. This is not entirely due to the implementation of the TAG assessment - clinical supervision and the development of primary care mental health services have also played a part (Box 2);
- The TAG process has increased practitioners’ skills and confidence in recognising mental health problems;
- The combination of the TAG assessment and the development of the role of the primary care liaison practitioner has improved cooperation and relationships between primary and secondary care teams;
- The quality of GPs’ referrals has improved;
- Practitioners feel more confident in returning any inappropriate referrals back to primary care for more appropriate treatment;
- Staff have become more interested in assessment tools and many have begun to incorporate further specialist evidence-based assessment tools into their everyday practice;
- Records of TAG scores are recorded allowing for future research and auditing of referral trends (such as any seasonal variations). It is hoped this will allow our team to target local service interventions more effectively towards identified clients’ needs;
- It has allowed community psychiatric nurses (CPNs) and social service care staff to adopt a more holistic overview when assessing a client.
Some problems and challenges were also identified:
- When the pilot began no clear criteria were established to distinguish which clients should receive a full assessment and which a TAG assessment. As many clients who were obviously suffering from severe mental health problems bypassed the TAG assessment procedure, it led to artificially low average scores when auditing referrals to our service;
- Certain administrative problems emerged in the early stages of the pilot. These included uncertainty about whether all clients needed to be registered under the care programme approach and how one-off assessments were registered;
- Occasionally, although a client may have scored very low on a TAG assessment, other clinical guidelines necessitated that they continue to receive a service from the integrated mental health team. Examples of this include clients on the local authority home link scheme, a client who had section 117 (Mental Health Act, 1983) entitlement (DoH and the Welsh Office, 1999) and a client admitted to an inpatient psychiatric facility.
CPNs are often the initial point of contact for mental health service users. Historically their assessments have been criticised as unstructured and subjective (Reed, 1999; Royal College of Psychiatrists, 1997). The TAG assessment offers a structured unbiased assessment procedure if used more widely.
Gamble and Brennan (2002) assert that effective assessment is the cornerstone of effective intervention. They also argue that the aim of assessment is as much to engage clients in the process of treatment as it is to identify their problems and needs. The TAG assessment offers a standardised system of assessment.
The Royal College of Psychiatrists (1997) argue that a standardised system of recording CPNs’ assessments is required to form the basis of a national audit of the CPN’s role in mental health services. Previous assessment tools have tended to focus on a medical model - concentrating on clients’ symptoms rather than social difficulties in their lives. However, government guidelines (DoH, 2001) focus on clients with mental health problems achieving basic standards of daily living. The TAG assessment is more holistic in its approach with a section focusing on clients’ social needs as well as their psychological difficulties and symptoms.
Despite these problems the introduction of the TAG assessment has been a great success locally. Informal canvassing of the integrated mental health team revealed no one wanted to return to the previous assessment process and no one could see any clinical problems with the TAG assessment.
Slade et al (2003) suggest that GPs should complete TAG assessments as part of their practice and a copy should accompany any referral to specialist mental health teams. Discussions on the integration of TAG assessment into primary care and extending the use of the TAG scoring system to improve caseload audit would be useful in future.
Although some practitioners see TAG assessment as a purely gate-keeping tool, its main strength is in ensuring clients with emotional and mental health problems receive appropriate, best quality care in the most applicable setting.
- This article has been double-blind peer-reviewed.