tag:blogger.com,1999:blog-8285737581949527996.post6861824996678075319..comments2023-10-11T09:14:08.345+01:00Comments on Pyjamas in Bananas: Care clusters: A race to the bottom?pjhttp://www.blogger.com/profile/06832177812057826894noreply@blogger.comBlogger3125tag:blogger.com,1999:blog-8285737581949527996.post-58539158547896042152011-01-24T15:34:51.714+00:002011-01-24T15:34:51.714+00:00I was reading this presentation from a consultant ...I was reading <a href="http://www.londondevelopmentcentre.org/cms/site/docs/PbR%20&%20Clustering%20%E2%80%93%20a%20clinician%E2%80%99s%20perspective%20VERSION%20FOR%20WEB.ppt" rel="nofollow">this presentation</a> from a consultant psychiatrist. He seems pretty upbeat but I noticed a few worrying things such as there was only 60% agreement between the clustering tool and clinician assessment and clinicians only got about 50% of the prototype vignettes into the 'right' cluster.<br /><br />This tallies with my experience where the cluster tool doesn't even seem to get close to the cluster I'm thinking of when I've input some practice data (in one patient example which I designed to illustrate chronic severe psychosis it suggested dementia was most appropriate).<br /><br />The examples of appropriate levels of care given in that presentation are pie in the sky stuff, which the author seems to acknowledge, but that is actively unhelpful to clinicians working on the front lines - being told by your own Trust that you should provide care X when they simultaneously prevent you from doing so.pjhttps://www.blogger.com/profile/06832177812057826894noreply@blogger.comtag:blogger.com,1999:blog-8285737581949527996.post-4336648009156265162011-01-23T12:54:14.622+00:002011-01-23T12:54:14.622+00:00It is similar for ICD-10 (which I presume is the u...It is similar for ICD-10 (which I presume is the underlying basis) but what do you expect if you have a bureaucratic definition of mental illness?<br /><br />I'm sure you're familiar with the way community mental health services work in the UK. Most patients are not seen by a psychiatrist but rather by a community psychiatric nurse who, in theory, isn't supposed to be diagnosing people with specific illnesses but rather addressing care 'needs'. This is just a further development of that, providing a semi-automated pseudo-diagnostic structure that circumvents the need for medical input to diagnosis.<br /><br />Clusters 1-3 go from:<br /><i>"Disorder unlikely to cause disruption to wider functioning."</i><br />to:<br /><i>"Disorder unlikely to cause disruption to wider function but some people will experience moderate problems."</i><br /><br />So a question worth asking is why people with no dysfunction to functioning need to be so minutely subdivided when they're not really suitable for secondary care mental health services in the first place? Perhaps because payment is by cluster so there is money to be made wasting clinician time dealing with patients the GPs should be dealing with?<br /><br />Maybe they're using the whole NICE/APA criteria for depression where all the labels are shifted so mild=none, moderate=mild, etc.pjhttps://www.blogger.com/profile/06832177812057826894noreply@blogger.comtag:blogger.com,1999:blog-8285737581949527996.post-16541920634845373722011-01-23T11:34:17.622+00:002011-01-23T11:34:17.622+00:00Hang on. "Some may experience significant dis...Hang on. "Some may experience significant disruption in everyday functioning."<br /><br />Under DSM-IV criteria you <i>must</i> experience clinically significant impairment to get a diagnosis.<br /><br />Yet for Cluster 4, it's optional. Don't tell me Clusters 1,2, and 3 are for people who experience no impairment in day-to-day functioning?<br /><br />If so, what are they doing getting diagnosed at all?Neuroskeptichttps://www.blogger.com/profile/06647064768789308157noreply@blogger.com