Many people with schizophrenia are still not getting the high quality psychological and medical treatment they deserve, according to the new National Audit of Schizophrenia, published today.

In December 2012, the first report from the National Audit of Schizophrenia highlighted areas of concern, particularly the management and coordination of physical healthcare, some aspects of prescribing practice and the availability of psychological therapies like CBT and family therapy. We blogged about the 2012 audit here.

The second audit has re-examined these areas and looked in more depth at service users’ perception of their care.

Areas of concern

The reports calls attention to the following areas of concern:

• Poor monitoring of the physical health of people with schizophrenia and a lack of action when warning signs are identified
• People who are not responding to standard antipsychotic medications are waiting too long to be prescribed clozapine
• CBT and family interventions are not widely available
• There is not enough information and support for carers

Methods

Data was gathered for this audit in two ways:

1. All 64 Mental Health Trusts in England and Health Boards in Wales were asked to submit a random selection of anonymous records for 100 people being treated for schizophrenia or schizoaffective disorder in their area. The response rate was good with 88% of the requested data coming back, which amounted to over 5,500 records.
2. Questionnaires were also developed for people using community mental health services. In total the team heard from 3,379 people using mental health services and 1,119 carers.
3. The team also set up a service user reference group, made up of people with direct experience of schizophrenia. This group contributed ideas and views on how to engage people with lived experience of mental illness in the process and encouraged them to fill in the questionnaire. The reference group also provided feedback on the findings and audit standards.

Results

Experiences of people with schizophrenia

• The majority (88%) of people using mental health services said they were ‘very’ or ‘fairly’ satisfied with their care and only 4% said they were ‘not satisfied at all’
• Less than half (44%) of NHS Trusts met the standards set for overall patient satisfaction
• Less than half (48%) of people looking for a job said they were getting support from mental health services to find one

Experiences of friends and family

• Only 1 in 10 (9%) NHS Trusts met expected standards for carer satisfaction with information and support
• 1 in 4 (24%) carers said they hadn’t been given enough information about how the illness (of the person they are caring for) will progress in the long term
• 1 in 4 (26%) carers said they were dissatisfied with their attempts to get support for themselves
• 80% of carers were ‘somewhat’ or ‘very’ satisfied with the information and support they received. However, the response to this question varied considerably across different NHS Trusts, with the proportion of carers who said they were ‘somewhat’ or ‘very’ satisfied ranging from 56% to 100%

Physical health

• Only a third (33%) of people with schizophrenia have had their physical health monitored properly (compared with 29% in 2012)
• When abnormal blood glucose levels were found, nothing was done about it in 64% of cases
• Just over half (52%) of people had their weight (BMI) checked (compared with 51% in 2012)
• Rates for monitoring people’s BMI were as low as 5% in one NHS Trust and as high as 92% for others. For the monitoring of glucose control, rates varied from 16% to 99%

Medication

• It’s good practice for professionals to give people information about medication. Despite this, less than half (48%) of people surveyed said they were given this information (compared with 52% in 2012)
• Only 4 out of 10 (41%) people with schizophrenia say they were definitely involved in decisions about the medication they were prescribed
• Only 54% of Trusts said they involved people in decisions about prescribing (compared with 62% in 2012)
• 1 in 10 people are being prescribed antipsychotics at a higher than recommended dose. The percentage of people prescribed a higher dose of antipsychotics than recommended by the British National Formulary ranged from 1%-22% across different NHS Trusts
• Possible alcohol or substance abuse was investigated in 62% of cases, when people did not show improvement after 4 weeks of antipsychotics (excluding clozapine) (compared with 78% in 2012)
• Possible alcohol or substance abuse was investigated in 56% of cases, when people did not show improvement after 4 weeks of clozapine (compared with 81% in 2012)

Psychological therapy

• 39% of people have been offered CBT
• Only half (48%) of people who were offered CBT took the offer up
• Only 12% of people said they had received family intervention

Care and crisis planning

• According to NHS records 95% of people with schizophrenia have a care plan, but only 75% of people using services say they have one
• 1 in 4 (26%) people said they do not have a phone number to call in a crisis

National Audit of Schizophrenia recommendations

The full report contains detailed recommendations for different groups (Department of Health, NHS England, Professional bodies, Commissioners, Mental Health Trusts, Medical Directors, Directors of Nursing, Mental Health Teams and their Managers, GPs, Psychiatrists and Pharmacists).

The areas covered by the recommendations are:

• The need to implement new NICE guidelines which set out how the system should take care of the physical health of people with schizophrenia. These guidelines make clear that mental health professionals are responsible for doing these checks for the first year of treatment. Responsibility then passes to the person’s GP
• The need to change the existing culture within the NHS which sees mental and physical health as separate
• The need to improve the way antipsychotics are prescribed, including making sure health professionals provide information about medications and involve people in decisions
• The need to improve access to psychological therapies
• The need for better information for carers and more access to support for them in their caring role
• The need for better systems so that information can be shared appropriately between different professionals involved in a person’s care

Mark Winstanley, Chief Executive of Rethink Mental Illness said:

This is a vital barometer of care for people with schizophrenia in England and Wales, and for the first time this year it provides a detailed localised picture. This must now be adopted by commissioners and providers to identify the priorities for improving their local mental health services.

Summary

This new audit and the supporting documents make for sobering reading for anyone involved in the management, care or treatment of people with schizophrenia.

The 2012 audit was a wake-up call to everyone from senior managers in the Department of Health to mental health professionals working at the coalface. This new audit published nearly two years later shows that progress has been slow or non-existent. There is huge variation in how NHS Trusts are performing and many service users and carers continue to receive sub-standard care.

Clearly, the audit results are not all negative, but this report is undoubtedly a rallying cry for us all; especially coming as it does on World Mental Health Day 2014 where Living With Schizophrenia is the theme. I personally have been heartened to see the response to #SchizophreniaAwarenessWeek on social media this week, as well as some of the positive coverage that the topic has received in some areas of the media.

However, the reality for many service users and carers is that day-to-day life with schizophrenia remains an enormous struggle. This important report underlines the size of the problem and recommends what we can all do to bring about meaningful change.

Links

National Audit of Schizophrenia website. Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI), Healthcare Quality Improvement Partnership, Rethink Mental Illness. 9th Oct 2014.

National Audit of Schizophrenia: Full second round national report 2014 (England and Wales) (PDF). Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI), Healthcare Quality Improvement Partnership, Rethink Mental Illness. 9th Oct 2014.

National Audit of Schizophrenia: Second round executive summary 2014 (England and Wales) (PDF). Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI), Healthcare Quality Improvement Partnership, Rethink Mental Illness. 9th Oct 2014.

Second National Audit of Schizophrenia – what you need to know – findings from the audit in plain English, which has been compiled by Rethink Mental Illness and NAS (PDF). Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI), Healthcare Quality Improvement Partnership, Rethink Mental Illness. 9th Oct 2014.

Tomlin A. National Schizophrenia Audit calls for improved monitoring of physical health in people with schizophrenia. The Mental Elf, 14 Dec 2012.