For discussion
on 8.2.99


Purpose

This paper sets out the responses of the Administration to the points raised in the paper prepared by Hon Michael Ho. (1) Outpatient Services
1.1 First Attendance

The updated figures on number of first attendance in HA's psychiatric specialist outpatient clinics (SOPC) and average waiting time for first attendance from October to December 1998 are as follows -


(For 95-96, total on waiting list was 2,002 and the percentage increase in 96-97 was 5%)

- The recent increase in the number of first attendance could have arisen due to various reasons. One main reason could be that with improved mental health education which heightens public awareness, there are more and earlier referral of patients to psychiatrists. Since mental disorders are typically multi-factorial in causation, it is difficult to postulate how many of the new referrals to HA's SOPC are due to any specific reasons.

HA's psychiatrists are planning to conduct a longitudinal prospective study to look at the types and frequency of psychiatric illnesses presenting at the outpatient clinics, hoping to find out the causes of the recent increase in attendance.

- HA has adopted various cost-effective measures to fully utilize the limited resources to meet the increasing demand. HA will continue to monitor the public demand for psychiatric services and to review the need to allocate or redeploy resources as appropriate to maintain service quality.

1.2 Weekend Depot Service

- Patients who have difficulty in attending psychiatric clinic for injection during week days will be referred by doctors at the specialist outpatient clinics to receiving the weekend depot service, which will help diminish patients' chance of relapse.

United Christian Hospital (UCH) has offered Sunday depot injection for over 10 years and has therefore accumulated a larger number of patients. For the Kwai Chung Hospital (KCH) and the Pamela Youde Nethersole Eastern Hospital (PYNEH), the service only started at the end of 1997. From experience, a gradual accumulation of patients for depot injection at KCH and PYNEH is expected.

- HA is also piloting psychiatric evening clinic services at Yau Ma Tei Psychiatric Centre and Queen Mary Hospital. The service is targeted at the working psychiatric patients who have difficulty in taking leave for attending psychiatric outpatient clinics during normal working hours. Patients also have to be referred by doctors at SOPCs.

- HA considers that the current provision of services is able to meet the demand of those patients who have genuine needs. HA will continue to monitor public demand for such services and evaluate its efficacy in improving patient care to ensure that the aim of the services can be achieved. HA will also review the cost benefits and cost effectiveness of the Sunday Depot and Evening Clinic services, with a view to achieving optimal use of available resources.

(2) Inpatient Services

- Every year, resources are allocated to HA for opening of new beds based on unit bed cost, including that for psychiatric beds. The unit bed cost formula has already taken into account the expenditures of inpatient services, A&E services, specialist outpatient services and community services.

- Referring to the particular cases in PYNEH and KCH, as mentioned in Hon Michael Ho's paper, the following should be noted -

PYNEH
- To offer a wide variety of daytime rehabilitative activities for needy psychiatric patients, the hospital has converted one of the psychiatric wards into a day activity area. Although the conversion had resulted in an increased number of beds in the remaining psychiatric ward, the provision of the day activity area has been well received by patients and their families.

With the commissioning of a new ward in June 1998, the occupancy rate of the ward in question has declined. In the week of 19 to 25 January 1999, the ward accommodated between 62 and 67 patients, compared to about 100 before. The average number of qualified nurses per daytime shift is 4 to 5 per ward, with each ward accommodates fewer patients than before. In other words, the number of patient per nurse has decreased.

KCH
- The reduction in the number of wards is a temporary measure because of the refurbishment works for KCH wards. The average number of patients is 54 per ward during the refurbishment period. KCH may reopen the wards upon completion of the refurbishment project, subject to the service requirements at the time.

The number of nursing staff at KCH has been increased -

	1995	1998
Qualified nurses	502	522
Student nurses	104	194

- HA, with the necessary expertise and experience, is given the flexibility in service planning of the hospitals. HWB will closely liaise with HA through regular channels and meetings to discuss various issues relating to the provision of hospital services.

- HA is currently reviewing the application of manpower indicators in the process of manpower planning. Since the extent of care required by different types of patients in different setting varies, such indicators should allow adequate flexibility in the manpower planning to suit the different needs.

(3) Community and Outreach Services

3.1 Community Psychiatric Nursing (CPN) Services

- At the time of discharge, depending on a patient's condition at discharge, the patient will be assessed on whether CPN service is needed, and if so, the first home visit will then be scheduled. The interval between visits will be decided by health care professionals and social workers, depending on the individual needs of a patient. In 95-96, 96-97 and 97-98, the total number of discharges and deaths should be 8,697, 9,407 and 11,013 respectively.

To detect early relapses, institute timely and appropriate treatment and intervention to discharged mental patients, community psychiatric and community psychogeriatric teams pay regular visits to the homes, half-way houses, long stay care homes, sheltered workshops and the workplaces of individual discharged mental patients to monitor their treatment and rehabilitation. The teams also give advice and support to family members and carers of discharged mental patients so as to ensure compliance with treatment.

Patients referred to receiving community and outreach services will also be supported by other available services in the community, for example, they will also concurrently attend SOPC or receive treatments at day hospitals.

- The information on the 12 Community Psychiatric Nursing Offices and their service area and catchment population is at Annex.

- The workload and staffing level of CPNS for the past three years is shown as follows -

Year	No. of centres	No. of nurses	No. of home visits	No. of new cases
95/96	12	50	24,340	1,909
96/97	12	53	27,286	2,402
97/98	12	60	31,731	2,410

- The staffing level and workload of community psychiatric teams (CPTs) and community psychogeriatric teams (CPGTs) for the past three years are as follows -

CPTs

Year	No. of funded teams	No. of outreach-service attendance
95/96	3	1,116
96/97	3	1,383
97/98	3	1,581

CPGTs

Year	No. of teams	No. of outreach-service attendance
95/96	6	9,912
96/97	8	15,199
97/98	8	19,986

- HA monitors closely the increasing demand for CPN service. HA has implemented various measures to improve service efficiency and reduce work pressure of the CPNs. These measures include the development of computer systems to reduce time required for nursing documentation, data collection, collation and reporting. HA has also enhanced the training of CPN, with 30 nurses completing their training in 1999.

- Priority follow-up patients are those who are clinically assessed to be at higher risk of violence or relapse. This group of patients are further divided into two categories - "target" and "sub-target", whereby the ones assessed at the highest risk are called "sub-target". The criteria used to assess whether a patient should be classified as "sub-target" are -

1. whether the patient is a previous offender, and if so, the nature and severity of the offence;
   
   
2. history of violence;
   
   
3. present clinical condition; and
   
   
4. social and home environment.

- The workload for priority follow-up sub-target group takes up about one-third of the total workload of the CPN service.

- The CPN service team and community psychiatric team at the Castle Peak Hospital work as a collaborative team in providing hotline telephone service. With an average of 8 telephone hotline calls per month, the hotline service has not imposed a great demand on the time or workload of community psychiatric nurses.

3.2 Central Registration System

- The Priority Follow-up system has been in use for over a decade. Each psychiatric institution or SOPC keeps a local register of the "priority follow-up" patients in the system and monitors their conditions locally. The practice is different from that in the past when mental health service was centralized, with a central register of the priority follow-up patients kept in the consultant psychiatrist i/c office. With the decentralization of the psychiatric services in recent years, the central register was no longer maintained as the local registers could already have served the purpose.

(4) Long Stay Care Home

- Long Stay Care Home (LSCH) is a facility for chronic mental patients who are in stable or controlled medical and mental conditions, who require no active medical treatment but who need long term residence and some nursing care. Training programmes, such as that on social skills, home care and basic health care knowledge, are organized to help residents progress from a state of being dependent to semi-independent, or eventually to be independent.

- In the context of providing LSCH services, the respective definitions of "dependent", "semi-independent" and "independent" are -

"dependent"	-	the resident requires supervision and assistance of the staff in LSCH in his or her daily living, personal hygiene and participation in social activities. For instance, the resident may need to be reminded to clean up every day.
"semi-independent"	-	the resident still requires some assistance of the staff in certain aspects eg medication and social activities;
"independent"	-	the resident can take care of himself or herself in every aspect.

- To apply for admission to LSCH, the applicant has to be referred by medical social workers to the Central Referral System for Disabled Adults (CRSDA) for registration. For referral to LSCH, the patient should be in stable medical and mental conditions, with no history of violence or alcoholism, but at the same time is unable to live independently in the community. The CRSDA will inform the concerned medical social worker whenever there are places available in LSCHs. Subject to the affirmation of the applicant's need for LSCH services by medical social workers and health care professionals, the selection group of the concerned LSCH will meet the applicant to assess whether the applicant is suitable for admission and whether the patient is willing to stay in LSCH.

In the past year, about 30% of the cases referred to the CRSDA and selected for meeting the selection group of LSCHs had withdrawn their applications. There were about only 18% of the applicants who were considered by the LSCHs as not suitable for admission. To enable more mental patients to receive appropriate services, SWD has been liaising with the LSCHs to formulate a set of assessment criteria to be commonly adopted by all LSCHs.

- As at 1 January 1999, there are 1,258 mental patients awaiting admission to LSCH, and the average waiting time is 32 months. In view of the low turnover rate of LSCH, Government is in active progress of developing other LSCHs, which will provide an additional 800 places by 2002-03.


Health and Welfare Bureau
February 1998