Use Of Specialist Services Research Articles

Standardized Systematic Description of Provision of Care for Multiple Sclerosis at a Local Level: A Demonstration Study.

This study evaluates and describes the pattern of services provided for people living with multiple sclerosis (MS) in a local area as a starting point for a more global assessment. A health care ecosystem approach has been followed using an internationally standardized service classification instrument-the Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC)-to identify and describe all services providing care to people with MS in the Australian Capital Territory, Australia. Available services were classified according to the target population into those specifically dedicated to people living with MS and those providing general neurologic services, both public and private, and across both social and health sectors. A limited range of services was available. There were no local facilities providing or coordinating multidisciplinary integrated care specific to people with MS. Subspecialty services specific to MS were limited in number (6 of the 28 services), and use of specialist services provided in neighboring states was frequently reported. Overall, very few services were provided outside the core health sector (4%). The provision of care to people living with MS in the Australian Capital Territory is fragmented and relies heavily on generic neurology services in the public and private sectors. More widespread use of the DESDE-LTC as a standardized method of service classification in MS will facilitate comparison with other local areas, allow monitoring of changes over time, and permit comparison with services provided for other health conditions (eg, dementia, mental disorders).

At the junctures of healthcare: a qualitative study of primary and specialist service use by Polish migrants in England

Background:Polish people are the biggest migrant group in the UK and the scholarship shows that they are attentive to their healthcare needs and seek to fulfil them by using various services both within and outside the British public healthcare system. This article explores the role of junctures within healthcare systems in the connections migrants realize between healthcare systems and sectors. The article argues that in a transnational context, migrants enact these junctures by joining different levels of care within the same sector, between sectors and across national borders. In particular, the article explores how Polish migrants’ healthcare seeking practices within and beyond national borders are enacted given the features, availability and relationship between primary and specialist care for how they are articulated between private and public sectors.Methods:This article is based on the second phase of a mixed-methods study on how Polish people in the UK manage their health transnationally. The participants were purposefully sampled from survey respondents (first phase) who identified as having a long-term health condition or caring in a non-professional capacity for someone who is chronically ill. Thirty-two semi-structured audio-call interviews were conducted with Polish migrants living in England between June and August 2020. Transcripts were analysed by applying thematic coding.Results:Key findings include a mix of dissatisfaction and satisfaction with primary care and general satisfaction with specialist care. Coping strategies consisting in reaching specialist private healthcare provided a way to access specialist care at all or additionally, or to partially complement primary care. When Polish private specialists are preferred, this is due to participants’ availability of time and financial resources, and to the specialists’ capacity to fulfil needs unmet within the public healthcare sector in the UK.ConclusionPolish migrants join with their practices systems which are not integrated, and their access is limited by the constraints implied in accessing paid services in Poland. This shapes transnational healthcare practices as relating mostly to routine and ad-hoc access to healthcare. These practices impact not only the wellbeing of migrants and the development of the private market but also the public health provision of services.

Outpatient mental health service use following contact with primary health care among migrants in Norway: A national register study

Majority of mental health problems are treated in primary care, while a minority require specialised treatment. This study aims to identify factors that predict contact with outpatient mental healthcare services (OPMH) among individuals who have been diagnosed with a mental health problem in primary healthcare services (PHC), with a special focus on migrants. Using linked national Norwegian registry data, we followed 1,002,456 individuals who had been diagnosed with a mental health problem in PHC for a period of two years. Using Cox regression, we applied Andersen's Model of Healthcare Utilisation to assess differences in risk of OPMH use between the majority population and eight migrant groups. We also conducted interaction analyses to see if the relationship between OPMH use and predisposing factors (gender, age, migrant status, civil status, education) differed across migrant groups. Migrants from Nordic countries, Western Europe and the Middle-East/North Africa had a higher risk of using OPMH services compared to the majority, while migrants from EU Eastern Europe, Sub-Saharan Africa and South Asia had a lower risk after controlling for all factors. Hazard ratios for non-EU Eastern Europeans and East/South East Asian's did not differ. Men had a higher risk than women. Additionally, the relationship between predisposing factors and OPMH use differed for some migrant groups. Education was not related to OPMH contact among five migrant groups. While lack of help-seeking at the primary care level may explain some of the lower rates of specialist service use observed for migrants compared to non-migrants in previous studies, there appear to be barriers for some migrant groups at the secondary level too. This warrants further investigation. Future research should look at differences between referrals and actual uptake of services among different migrant groups.

Project 20: Midwives’ insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how

IntroductionContinuity of care models are known to improve clinical outcomes for women and their babies, but it is not understood how. A realist synthesis of how women with social risk factors experience UK maternity care reported mechanisms thought to improve clinical outcomes and experiences. As part of a broader programme of work to test those theories and fill gaps in the literature base we conducted focus groups with midwives working within continuity of care models of care for women with social factors that put them at a higher chance of having poor birth outcomes. These risk factors can include poverty and social isolation, asylum or refugee status, domestic abuse, mental illness, learning difficulties, and substance abuse problems. ObjectiveTo explore the insights of midwives working in continuity models of care for women with social risk factors in order to understand the resources they provide, and how the model of care can improve women’s outcomes. DesignRealist methodology was used to gain a deeper understanding of how women react to specific resources that the models of care offer and how these resources are thought to lead to particular outcomes for women. Twelve midwives participated, six from a continuity of care model implemented in a community setting serving an area of deprivation in London, and six from a continuity of care model for women with social risk factors, based within a large teaching hospital in London. FindingsThree main themes were identified: ‘Perceptions of the model of care, ‘Tailoring the service to meet women’s needs’, ‘Going above and beyond’. Each theme is broken down into three subthemes to reveal specific resources or mechanisms which midwives felt might have an impact on women’s outcomes, and how women with different social risk factors respond to these mechanisms. Conclusions/implications for practiceOverall the midwives in both models of care felt the service was beneficial to women and had a positive impact on their outcomes. It was thought the trusting relationships they had built with women enabled midwives to guide women through a fragmented, unfamiliar system and respond to their individual physical, emotional, and social needs, whilst ensuring follow-up of appointments and test results. Midwives felt that for these women the impact of a trusting relationship affected how much information women disclosed, allowing for enhanced, needs led, holistic care. Interesting mechanisms were identified when discussing women who had social care involvement with midwives revealing techniques they used to advocate for women and help them to regain trust in the system and demonstrate their parenting abilities. Differences in how each team provided care and its impact on women’s outcomes were considered with the midwives in the community-based model reporting how their location enabled them to help women integrate into their local community and make use of specialist services. The study demonstrates the complexity of these models of care, with midwives using innovative and compassionate ways of working to meet the multifaceted needs of this population.

Specialist health care services use in a European cohort of infants born very preterm.

Children born very preterm require additional specialist care because of the health and developmental risks associated with preterm birth, but information on their health service use is sparse. We sought to describe the use of specialist services by children born very preterm in Europe. We analysed data from the multi-regional, population-based Effective Perinatal Intensive Care in Europe (EPICE) cohort of births before 32 weeks' gestation in 11 European countries. Perinatal data were abstracted from medical records and parents completed a questionnaire at 2 years corrected age (4322 children; 2026 females, 2296 males; median gestational age 29wks, interquartile range [IQR] 27-31wks; median birthweight 1230g, IQR 970-1511g). We compared parent-reported use of specialist services by country, perinatal risk (based on gestational age, small for gestational age, and neonatal morbidities), maternal education, and birthplace. Seventy-six per cent of the children had consulted at least one specialist, ranging across countries from 53.7% to 100%. Ophthalmologists (53.4%) and physiotherapists (48.0%) were most frequently consulted, but individual specialists varied greatly by country. Perinatal risk was associated with specialist use, but the gradient differed across countries. Children with more educated mothers had higher proportions of specialist use in three countries. Large variations in the use of specialist services across Europe were not explained by perinatal risk and raise questions about the strengths and limits of existing models of care. Use of specialist services by children born very preterm varied across Europe. This variation was observed for types and number of specialists consulted. Perinatal risk was associated with specialist care, but did not explain country-level differences. In some countries, mothers' educational level affected use of specialist services.

Health care utilization and cost after discharge from a mental health hospital; an RCT comparing community residential aftercare and treatment as usual

BackgroundCommunity residential aftercare (step-down) services can ease the transition after a mental health hospital stay for patients with severe mental illness (SMI).AimsTo investigate use of community and specialised mental health care services and costs in patients with SMI the first 12 months after discharge from a mental health hospital (MHH), comparing community residential aftercare (CRA) and treatment as usual.MethodsAn open parallel group randomised controlled trial with 41 participants. Data on use of specialist services (hospital, ambulant treatment and outpatient treatment) and community services (residential stays, home help, home care nursing, mental health consultation) were collected from specialist and community registers and health records.ResultsFor the primary outcome, utilisation of community mental health services, the intervention group used, on average, 29% fewer hours (mean differences − 21.6 h, 95% CI -93.1 to 44.9, p = .096) with a cost saving of 29% (mean differences − 1845 EUR, 95% CI -8267 to 4171, p = .102), but the estimates were imprecise. For the secondary outcome, the study groups had the same total number of inpatient days (66 days), but the intervention group had on average of 13.4 fewer inpatient days in the mental health hospital (95% CI -29.9 to 0.9. p = .008). The number of inpatient admissions (mean difference − 0.9 admissions, 95% CI -3.5 to 1.5, p = .224) and readmissions (− 0.8, 95% CI -2.5 to 0.9. p = .440) was lower in the intervention group. The intervention group had on average a total cost saving of 38.5% (mean differences − 23,071 EUR, 95% CI -45,450 to 3027. p = .057). A post hoc multivariable regression analysis controlling for baseline characteristics gave a reduction in total cost in favour of the intervention group of − 19,781 EUR (95% CI -44,072 to 4509, p=,107).ConclusionIn this study, it was not possible to draw a definite conclusion about the effect, due to the small sample and imprecision of the estimates. The direction of the results and size of the point estimate, in addition to findings in other studies, indicates that transferring patients ready for discharge from mental hospital to community residential aftercare can have the potential to reduce total consumption of health services and costs without increased hospital admissions.Trial registrationRegistered in clinicaltrials.gov (NCT01719354)

Rates of treated mental disorders in migrants using data from the Parisian sectorized psychiatric hospitals.

Background Increased incidence and prevalence of severe mental disorders (especially psychosis) are reported among migrants in Europe (Jongsma et al., 2017). However, there is evidence that pathways to care and service use are not similar between these groups (Bhui et al., 2003). Paris has about 2 million inhabitants including 20% of migrants. A previous study showed increased admissions for first episode of psychosis among migrants in one district (Tortelli et al., 2014); there is need to extend data regarding the use of all kinds of mental health care facilities. We aimed to estimate the proportion and socio-economic characteristics of migrants treated for mental disorders in mental health facilities in comparison to natives. Methods We calculated day-point estimations of treated population rates in natives and migrants using the number of patients seen on January 31, 2017 in the public psychiatric facilities and Paris population data. We compared socio-economic situations, diagnosis and rates of compulsory admission, using odds-ratios (OR). Results A total of 4,005 patients were included in the study. The treated population rates were 2.15/1 000 inh. among natives and 2.4./1 000 among migrants (p Conclusion We found increased rates of treated mental disorders among migrants than natives, suggesting higher rates of mental disorders compared to the general population. We observed, to some extent, a fair access to public mental health facilities, despite differences in pathways to care and use of specialist services.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany

ObjectivesA considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general...

A systematic review of the use of health services by immigrants and native populations.

BackgroundChanges in migration patterns that have occurred in recent decades, both quantitative, with an increase in the number of immigrants, and qualitative, due to different causes of migration (work, family reunification, asylum seekers and refugees) require constant u pdating of the analysis of how immigrants access health services. Understanding of the existence of changes in use patterns is necessary to adapt health services to the new socio-demographic reality. The aim of this study is to describe the scientific evidence that assess the differences in the use of health services between immigrant and native populations.MethodsA systematic review of the electronic database MEDLINE (PubMed) was conducted with a search of studies published between June 2013 and February 2016 that addressed the use of health services and compared immigrants with native populations. MeSH terms and key words comprised Health Services Needs and Demands/Accessibility/Disparities/Emigrants and Immigrants/Native/Ethnic Groups. The electronic search was supplemented by a manual search of grey literature. The following information was extracted from each publication: context of the study (place and year), characteristics of the included population (definition of immigrants and their sub-groups), methodological domains (design of the study, source of information, statistical analysis, variables of health care use assessed, measures of need, socio-economic indicators) and main results.ResultsThirty-six publications were included, 28 from Europe and 8 from other countries. Twenty-four papers analysed the use of primary care, 17 the use of specialist services (including hospitalizations or emergency care), 18 considered several levels of care and 11 assessed mental health services. The characteristics of immigrants included country of origin, legal status, reasons for migration, length of stay, different generations and socio-demographic variables and need. In general, use of health services by the immigrants was less than or equal to the native population, although some differences between immigrants were also identified.ConclusionsThis review has identified that immigrants show a general tendency towards a lower use of health services than native populations and that there are significant differences within immigrant sub-groups in terms of their patterns of utilization. Further studies should include information categorizing and evaluating the diversity within the immigrant population.

Impact of preterm birth on maternal well-being and women's perceptions of their baby: a population-based survey

BackgroundApproximately 15 million babies were born preterm worldwide in 2010 and in England in 2014 there were 52 249 preterm births. Preterm babies are at increased risk of poor outcomes...

Examining the relationship between health-related need and the receipt of care by participants experiencing homelessness and mental illness.

BackgroundPeople experiencing homelessness and mental illness face multiple barriers to care. The goal of this study was to examine the association between health service use and indicators of need among individuals experiencing homelessness and mental illness in Vancouver, Canada. We hypothesized that those with more severe mental illness would access greater levels of primary and specialist health services than those with less severe mental illness.MethodsParticipants met criteria for homelessness and current mental disorder using standardized criteria (n = 497). Interviews assessed current health status and involvement with a variety of health services including specialist, general practice, and emergency services. The 80th percentile was used to differentiate ‘low health service use’ and ‘high health service use’. Using multivariate logistic regression analysis, we analyzed associations between predisposing, enabling and need-related factors with levels of primary and specialist health service use.ResultsTwenty-one percent of participants had high primary care use, and 12% had high use of specialist services. Factors significantly (p ≤ 0.05) associated with high primary care use were: multiple physical illnesses [AOR 2.74 (1.12, 6.70]; poor general health [AOR 1.68 (1.01, 2.81)]; having a regular family physician [AOR 2.27 (1.27, 4.07)]; and negative social relationships [AOR 1.74 (1.01, 2.99)]. Conversely, having a more severe mental disorder (e.g. psychotic disorder) was significantly associated with lower odds of high service use [AOR 0.59 (0.35, 0.97)]. For specialist care, recent history of psychiatric hospitalization [AOR 2.53 (1.35, 4.75)] and major depressive episode [AOR 1.98 (1.11, 3.56)] were associated with high use, while having a blood borne infectious disease (i.e., HIV, HCV, HBV) was associated with lower odds of high service use.ConclusionsContrary to our hypotheses, we found that individuals with greater assessed need, including more severe mental disorders, and blood-borne infectious diseases had significantly lower odds of being high health service users than those with lower assessed needs. Our findings reveal an important gap between levels of need and service involvement for individuals who are both homeless and mentally ill and have implications for health service reform in relation to the unmet and complex needs of a marginalized sub-population. (Trial registration: ISRCTN57595077 and ISRCTN66721740).

Predictors of and barriers to service use for children at risk of ADHD: longitudinal study.

Many children with, or at risk of, ADHD do not receive healthcare services for their difficulties. This longitudinal study investigates barriers to and predictors of specialist health service use. This is a 5-year follow-up study of children who participated in a cluster randomised controlled trial, which investigated school-level interventions (provision of books with evidence-based information and/or feedback of names of children) for children at risk of ADHD. 162 children who had high levels of ADHD symptoms at age 5 (baseline) were followed up at age 10 years. Using baseline data and follow-up information collected from parents and teachers, children who had and had not used specialist health services over the follow-up period were compared and predictors (symptom severity, comorbid problems, parental perception of burden, parental mental health, and socio-demographic factors) of specialist service use investigated. The most common parent-reported barrier reflected lack of information about who could help. Amongst children using specialist health services who met criteria for ADHD at follow-up, 36% had been prescribed stimulant medication. Specialist health service use was associated with each one-point increase in teacher-rated symptoms at baseline [inattention symptoms (adjusted OR = 1.40; 95% CI 1.12-1.76) and hyperactivity/impulsivity symptoms (adjusted OR = 1.23; 95% CI 1.05-1.44)]. Parental mental health problems were also independently associated with service use (for each one-point increase in symptoms, adjusted OR = 1.41; 95% CI 1.04-1.91). Severity of teacher-rated ADHD symptoms in early school years is a determinant of subsequent service use. Clinicians and teachers should be aware that parental mental health problems are independently associated with service use for children at risk of ADHD.

Diabetic kidney disease in Australia: current burden and future projections.

Diabetes mellitus is now the most common cause of new cases of end-stage kidney disease treated with kidney replacement therapy in Australia. In addition to the approximately 5000 Australians receiving maintenance dialysis or living with a kidney transplant as a consequence of diabetes, many die from untreated end-stage kidney disease due to diabetes (DM-ESKD) each year. For every Australian receiving renal replacement therapy due to diabetes, at least 50 others have earlier stages of diabetic kidney disease (DKD). Based on projected increases in type 2 diabetes prevalence, the size of this underlying population with DKD will potentially exceed half a million by 2025. In addition to the risk of developing DM-ESKD, this population is at increased risk of premature cardiovascular morbidity and all-cause mortality. Higher rates of hospitalization, use of specialist services and prescription drugs mean that those with DKD also incur significantly greater health care costs compared with those with diabetes or chronic kidney disease alone. However, in contrast to the increasing prevalence of diabetes and early stages of DKD, recent trends in the incidence of DM-ESKD suggest that better management in the earlier stages of DKD has been successful in slowing rates of disease progression. Simultaneous improvements in use of renin-angiotensin inhibitors and improved glycaemic and blood pressure control are likely to be largely responsible for this trend. Primary prevention, maximizing early detection of DKD and optimal management of diabetes and kidney disease hold great potential to attenuate the future health burden attributable to DKD in Australia.

Developing a ‘pleural team’ to run a reactive pleural service

Pleural disease is increasingly recognised as an important subspecialty within respiratory medicine, especially as cases of pleural disease continue to rise internationally. Recent advances have seen an expansion in the options available for managing patients with pleural disease, with access to local-anaesthetic thoracoscopy, indwelling pleural catheters and thoracic ultrasound all becoming commonplace. Pleural teams usually consist of a range of practitioners who can optimise the use of specialist services to ensure that patients with all types of pleural disease - who have traditionally needed extended admissions - are managed efficiently, often entirely as outpatients. A pleural service can also provide improved opportunities for enhancing procedural skills, engaging in clinical research, and reducing the costs of care. This article explores the justification for dedicated pleural services and teams, as well as highlighting the various roles of hospital personnel who might be most useful in ensuring their success.

Alcohol consumption, smoking and overweight as a burden for health care services utilization: a cross-sectional study in Estonia.

BackgroundAlcohol consumption, smoking and weight problems are common risk factors for different health problems. We examine how these risk factors are associated with the use of health care services.MethodsData for 6500 individuals in the 25–64 age group came from three cross-sectional postal surveys conducted in 2004, 2006, and 2008 in Estonia. The effect of alcohol consumption, smoking and weight problems on the use of primary and specialist care services, hospitalizations and ambulance calls was analysed separately for men and women by using binary logistic regression.ResultsOverweight and/or obesity were strongly related to the use of primary care and out-patient specialist services for both genders, and to hospitalizations and ambulance calls for women. Current smoking was related to ambulance calls for both genders, whereas smoking in the past was related to the use of primary care and specialist services among men and to hospitalizations among women. Beer drinking was negatively associated with all types of health care services and similar association was found between wine drinking and hospitalizations. Wine drinking was positively related to specialist visits. The frequent drinking of strong alcohol led to an increased risk for ambulance calls. Drinking light alcoholic drinks was positively associated with all types of health care services (except ambulance calls) among men and with the use of specialist services among women.ConclusionsOverweight and smoking had the largest impact on health care utilization in Estonia. Considering the high prevalence of these behavioural risk factors, health policies should prioritize preventive programs that promote healthy lifestyles in order to decrease the disease burden and to reduce health care costs.

Use of specialist services for obsessive–compulsive and body dysmorphic disorders across England

Aims and methodIn April 2007, the National Specialist Commissioning Team of the Department of Health commissioned a group of services to provide treatment to patients with the most severe and profound obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). We decided to examine the usage of these services across England 4–5 years after the start of the new funding arrangements. This survey used data about patients treated in the financial year 2011–2012.ResultsDespite the services offering intensive home-based as well as residential and in-patient services, there was a greater proportion of referrals from London, the South East of England and counties closer to London.Clinical implicationsIt is important that all patients, regardless of where they live, have access to highly specialist services for OCD and BDD. We discuss potential ways of improving this access but we hope this paper will act as a discussion forum whereby we can receive feedback from others.

An audit of the management of heart murmurs on the postnatal wards

Investigation and management of neonatal heart murmurs varies widely and is dependent on local resources. In order to standardise the management of heart murmurs in our hospital a guideline (based on clinical examination with selective cardiology review) was introduced. To establish adherence to and safety of the guideline; to review workload implications and to define the causes of neonatal heart murmurs in our population. Patients were prospectively identified over a 2-year period (August 2006 to July 2008). Case notes were reviewed and examination findings, investigations, follow up and diagnosis recorded. 89 babies were identified. The guideline was generally well adhered to. In total 51 (57%) of babies were referred for cardiology assessment. In 40 babies this assessment included an echocardiogram. 30 babies (34%) had an underlying cardiac malformation: 25 were identified before discharge home. 15/30 (50%) of the babies with a cardiac malformation remain under cardiology follow up at the age of 1 year. No baby discharged from follow up without cardiology review subsequently presented with a cardiac problem. A significant minority of babies with a heart murmur have an underlying cardiac malformation. Our guideline appears to ensure the timely identification of these babies and rationalises our use of specialist services.

Enquiry analysis and user opinion of the Drugs in Breastmilk Helpline: a prospective study.

BackgroundSince breastfeeding is universally recognised as the ideal way to feed infants, it is understandable, and at times inevitable, that breastfeeding mothers will want, or be required, to take medication. To meet the information demands of breastfeeding mothers and healthcare professionals, a UK charity, The Breastfeeding Network, established a free telephone helpline to answer queries on medicines in breastmilk. This study reports on the enquiries received by the Drugs in Breastmilk Helpline and user opinion of the service.MethodsAll enquirers to the Helpline between December 2010 and January 2011 were asked if they could be contacted in 2 to 4 weeks to provide more information on their experience of using the service. A combination of telephone semi-structured interviews and email surveys were used depending on whether the enquiry originated via telephone or email.ResultsInformation was gained from 101 participants; 77 women and 24 healthcare professionals. Women reported high levels of service satisfaction (94%, n = 72/77) and healthcare professionals found the information provided useful (92%, n = 22/24). Women used the service for reassurance or because they had received conflicting information or distrusted healthcare professional advice. Healthcare professionals often could not answer questions or took a cautious approach to recommendation (i.e. advised avoidance of medicines whilst breastfeeding); this was often at odds to advice given by staff from the Helpline. Healthcare professionals did not routinely access resources to answer questions, but when they did, showed a lack of confidence in data interpretation.ConclusionsThe Breastfeeding Networks’ Drugs in Breastmilk Helpline provides an important service to breastfeeding women and healthcare staff to make informed decisions on medicine taking whilst breastfeeding. Healthcare professional uncertainty and incorrect advice given to breastfeeding women suggests that healthcare professional education needs improving and that greater use of specialist services should be encouraged.

Re-conceptualising Approaches to Meeting the Health Needs of Homeless People

AbstractThe experience of homelessness not only affects physical health, but can also constrain access to required health care. In a number of European countries, national strategies to tackle homelessness have sought to deliver integrated solutions across housing, health and other social policy areas. This article examines approaches to meeting the health care needs of homeless people in relation to such strategies, drawing upon recent research in Norway and Scotland. The article presents a comparative analysis of approaches to service provision in relation to welfare models and the concepts of universal and specialist provision. The analysis suggests a cross-national shift in the conceptualisation of appropriate responses to the health care needs of those who experience homelessness. The provision of some specialist health services, while reflecting a selective model of welfare, need not be solely interpreted as conflicting with a more universal model of ensuring access to mainstream services. Rather, the challenge is to recognise the need for a process approach which supports an effective transition from the (sometimes necessary) use of specialist services for this group, towards (the ideal of) full integration into mainstream health care.

Trends in Recognition of and Service Use for Attention-Deficit Hyperactivity Disorder in Britain, 1999–2004

National data suggest that attention-deficit hyperactivity disorder (ADHD) is underdiagnosed in Britain and that parental factors determine service use. This situation may have changed in recent years following policy and research recommendations. This study investigated changes in rates and correlates of service use for ADHD in Britain between 1999 and 2004. Use of various services by children aged five to 16 with ADHD (N=176) who were identified in the cross-sectional, nationally representative 2004 British Child and Adolescent Mental Health Survey was examined. The 2004 sample was compared with a community sample identified in a similar survey conducted in 1999. Most parents (90%) of children with ADHD recognized the presence of a problem, and 55% thought that their child had hyperactivity. Past-year contacts with education-based professionals exceeded those with professionals in specialist health services (74% versus 51%). One-third of children with ADHD were taking medication. Child factors, including severity of ADHD and a comorbid emotional or behavioral disorder, were the main determinants of service use. Parental burden was also associated with specialist service use. Specialist service use increased over five years after adjustment for severity and parental perceptions and burden (odds ratio=1.76, 95% confidence interval=1.13-2.75, p=.013). Barriers to care for ADHD in Britain appear to have been reduced in recent years. Medication for ADHD appears to be used cautiously, and the study found little empirical evidence of overuse. There is a need for health services to provide training and support for education-based professionals to help them recognize and manage children with ADHD.