Personal continuity versus specialisation of care approaches in mental healthcare: experiences of patients and clinicians—results of the qualitative study in five European countries

Abstract

Background
The current debate on organisation of the mental health care raises a question whether to prioritise specialisation of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding specialisation (SC) and personal continuity (PCC) of care in five European countries.

Methods
Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders (F20–49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and analysed through a thematic analysis method.

Results
Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic relationship and the smooth transition between hospital and community care. Many positive experiences of patients and clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treatment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for coercion, restraint, forced medication or involuntary admission within PCC.

Conclusions
Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). Therefore, future reforms of mental health services should offer a free choice of either approach, considering that there is no evidence of differences in patient outcomes between PCC and SC approaches.

Full text

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Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
https://doi.org/10.1007/s00127-019-01757-z
ORIGINAL PAPER
Personal continuity versusspecialisation ofcare approaches
inmental healthcare: experiences ofpatients andclinicians—results
ofthequalitative study inve European countries
JustynaKlingemann1 · MartaWelbel1· StefanPriebe2· DomenicoGiacco2· AleksandraMatanov2·
VincentLorant3· DelphineBourmorck3· BettinaSoltmann4· StePfeier4· ElisabettaMiglietta5· MirellaRuggeri5·
JacekMoskalewicz1
Received: 27 February 2019 / Accepted: 20 August 2019 / Published online: 6 September 2019
© The Author(s) 2019
Abstract
Background The current debate onorganisation of the mental health care raises a question whether to prioritise specialisa-
tion of clinical teams or personal continuity of care. The article explores the experiences of patients and clinicians regarding
specialisation (SC) and personal continuity (PCC) of care in five European countries.
Methods Data were obtained via in-depth, semi-structured interviews with patients (N = 188) suffering from mental disorders
(F20–49) and with clinicians (N = 63). A maximum variation sampling was applied to assume representation of patients
and of clinicians with different characteristics. The qualitative data from each country were transcribed verbatim, coded and
analysed through a thematic analysis method.
Results Many positive experiences of patients and clinicians with the PCC approach relate to the high quality of therapeutic
relationship and the smooth transition between hospital and community care. Many positive experiences of patients and
clinicians with the SC approach relate to concepts of autonomy and choice and the higher adequacy of diagnosis and treat-
ment. Clinicians stressed system aspects of providing mental health care: more effective management structure and higher
professionalization of care within SC approach and the lower risk of disengagement from treatment and reduced need for
coercion, restraint, forced medication or involuntary admission within PCC.
Conclusions Neither the PCC, nor the SC approach meets the needs and expectations of all patients (and clinicians). There-
fore, future reforms of mental health services should offer a free choice of either approach, considering that there is no
evidence of differences in patient outcomes between PCC and SC approaches.
Keywords Mental health care organisation· Functional system· Integrated system
All authors declare that the submitted work has not been published
before (neither in English nor in any other language) and that the
work is not under consideration for publication elsewhere.
Electronic supplementary material The online version of this
article (https ://doi.org/10.1007/s0012 7-019-01757 -z) contains
supplementary material, which is available to authorized users.
* Justyna Klingemann
jklingemann@ipin.edu.pl
Extended author information available on the last page of the article
Introduction
Across Europe, health systems have become fragmented
because of medical specialisation, high levels of decentrali-
sation, increased professionalization, novel financing schemes
and diversity in the alternatives for service provision [1]. The
current debate on the organisation of the mental health care
system raises a question whether to prioritise specialisation of
clinical teams by separation of inpatient and outpatient care or
personal continuity of care approach where the same primary
clinician is responsible for an individual patient within hospi-
tal and community services [2–6]. Both approaches have their
own stakeholders and both prevail in different countries as a
result of mental health care reforms having significant con-
sequences in each country in terms of allocation of resources
and service organisation [5, 7–9].
The literature shows that the specialisation of care
approach (SC) is expected to simplify the practical organi-
zation of services, support quick clinical decision-making,
enable clinical teams and clinicians to focus on only one
setting, and foster an expertise in setting specific aspects
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206 Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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of treatment [2, 4, 10]. On the one hand, proponents of this
approach claim that the increasing specialisation of psychi-
atric services represents a progress in our understanding of
mental health problems [9]. On the other hand, the personal
continuity of care approach (PCC) is expected to facilitate
smooth transition of patients from one setting to another, to
support long-lasting therapeutic relationships, and to sim-
plify clinical communication as patients and clinicians are
familiar with each other across the care settings [2, 5, 6, 8].
The mental health reforms in different countries were not
evidence based as the available research has brought inconclu-
sive results and suffered from serious methodological short-
comings (small sample size, local settings, limited range of
outcomes, comparison of newly implemented approaches with
traditional ones) [2, 11]. Moreover, a qualitative exploration
of those issues is lacking. Mental health care approaches are
complex; as much as it is important to assess their clinical out-
comes and costs, focusing exclusively on such aspects, would
overlook the personal experiences and preferences of patients
and clinicians, which are so far under-researched.
We are addressing this research gap by presenting qualita-
tive data drawing upon the experiences of patients and clini-
cians in five European countries (Belgium, Germany, Italy,
Poland and UK) who have received or provided care within
at least one of the two care approaches—SC and PCC. The
positive and negative experiences of frontline providers and
recipients of care are important contributions regarding pol-
icy decision-making, they may also shed light on the mecha-
nisms by which each of the system can be clinically effective
or more responsive to the specific expectations and needs.
Methods
Data collection
The qualitative data set presented here is a part of the recent
COFI study (Full title: Comparing policy, framework, struc-
ture, effectiveness and cost-effectiveness of functional and
integrated systems of mental health care) comparing spe-
cialisation and personal continuity care in five European
countries (Belgium, Germany, Italy, Poland and the UK),
where those approaches are the standard way of providing
mental health care [2]. The COFI project was a prospective,
multi-country natural experiment conducted in 57 hospitals
involving over seven thousands of patients using specialisa-
tion and personal continuity of care. Its quantitative results
showed no difference between specialisation and personal
continuity care approaches in rehospitalisation rates, number
of inpatient bed days, untoward events and social function-
ing in the total sample [12]. Therefore, a complementary
qualitative approach was crucial to increase our general
understanding of both approaches in mental health care.
Data were obtained via in-depth, semi-structured inter-
views with patients and clinicians regarding personal expe-
riences of providing or receiving care within SC and PCC
approaches. Trained interviewers were following the uni-
fied study protocol and interviews’ guidelines developed in a
process involving all partners and including several revision
rounds and pilot interviews in each country ([2]—a detailed
protocol of the COFI study).
To assure diversity of the sample (maximum variation
sampling), researchers recruited similar numbers of patients
treated with SC versus PCC approaches, who had varying
personal characteristics (gender, age, treatment history) and
clinical diagnosis (ICD-10) of psychotic disorders (F20–29),
affective disorders (F30–39) or anxiety/somatisation disor-
ders (F40–49). Accordingly, the sample of clinicians had
different characteristics regarding gender, age, the care
approach adopted by the service they work within (PCC
or SC) and their profession: psychiatrists, psychologists,
nurses, social workers. Clinicians were recruited from the
hospitals or community mental health services participating
in the project. All participants were offered vouchers (25 €)
to compensate for their time and commitment.
Data analysis
Data from semi-structured interviews with patients and cli-
nicians were audiotaped and transcribed verbatim, ensur-
ing the removal of any identifying information to maintain
anonymity and confidentiality. Study centres in each country
generated a list of initial codes based on a line-by-line analy-
sis of translated pilot interviews using CAQDA (computer-
assisted qualitative data analysis). The meaning of each
initial code was discussed between all coders. As a result,
the initial codes were grouped and summarised into uni-
fied coding books for patients (266 codes) and for clinicians
(245 codes). Additionally, the consistency of coding across
all centres was assessed and discrepancies were discussed
till the consistency had reached a satisfactory level and the
coders from each study centre coded the selected part of the
transcript applying a core set of identical codes.
In the next step, all partner countries coded a priori
all transcripts (CAQDA) applying the separate codebooks
for patients and clinicians and using line-by-line analysis
(Atlas.ti) [13, 14]. Equal attention was given to each data
item and extracts of data were coded inclusively not to lose
the context. If new codes emerged, they were adopted if
approved by all partners.
Each partner country produced the coding report trans-
lated into English which comprised of basic informa-
tion about the national sample, list of all codes with data
extracts, which captured the essence of the particular code
without unnecessary complexity, and research memos
regarding the coding procedure and data analysis.
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207Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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In the next step, coding reports from each country were
analysed through a thematic analysis method—some codes
were combined to form an overarching theme, others were
refined, separated, or discarded [14, 15]. To obtain mean-
ingful themes in relation to the comparison of both care
approaches, positive and negative personal experiences of
patients and clinicians were organised and grouped using
a realist, semantic approach. To progress from description
to data interpretation, and to theorise about meaning and
implications of the data collected, patient and clinician
experiences were compared and interpreted as advantages
and disadvantages of PCC and SC approaches.
Sample description
Patient sample
We interviewed a total of 188 patients, 60% female and
40% male. Thirty-nine percent of the patients had experi-
ence of receiving personal continuity of care, 53% spe-
cialisation of care, while 8% experienced both approaches
during 1-year follow-up. Full details of sample character-
istics are shown in Table1.
Clinician sample
In all countries, psychiatrists are the main clinicians and
decision-makers regarding patients’ treatment; therefore,
making up 60% of the sample. Remaining interviews were
conducted with other staff members including psychologists,
psychiatric nurses and social workers. Detailed sample char-
acteristics are presented in Table2.
Results
Homogeneity ofexperiences
An initial assumption was that socio-cultural and histori-
cal differences between the five countries participating in
the COFI study would be reflected by the qualitative data.
However, we have found that the opposite is true—the
analysis shows a high level of homogeneity in the data col-
lected across partner countries. Patients and clinicians in
all five participating countries shared very similar experi-
ences and the understanding of features characteristic to both
approaches. Therefore, the data from all five countries are
presented together.
Moreover, clinicians and patients showed high level of
consistency when describing their positive and negative
experiences with both personal continuity and specialisa-
tion of care. To illustrate the homogeneity of the data, we
are presenting quotations from clinicians (C) and patients
(P) in the tables. Clinician quotations in the text are marked
by country (BE, IT, GE, PL, UK), type of care (PCC/SC),
and profession (differentiated by id number) and patients’
quotations in the text are marked by country (BE, IT, GE,
PL, UK), type of care (PCC/SC), gender (F/M), age, and
type of disorder.
Positive experiences withPCC
Patients
We have identified a number of positive experiences related
to different features of personal continuity of care, which are
perceived by patients as advantages. Some of them relate
Table 1 Patient sample characteristics
Belgium (BE), Germany (GE), Italy (IT), Poland (PL) and the United Kingdom
BE GE IT PL UK Tot al
No. of interviews 40 39 28 40 41 188
Time of the interview Average (in min.) 66 37 30 48 48 46
Gender Male, n (%) 18 (45%) 14 (36%) 8 (29%) 17 (42%) 19 (46%) 76 (40%)
Age (in years) Average 43 41 44 43 48 44
Minimum 21 21 20 23 22 20
Maximum 66 63 64 63 64 66
Approach in care (no. of cases) PCC 21 8 12 12 21 74
SC 19 27 16 18 19 99
BT (both) 0 4 0 10 1 15
ICD-10 diagnosis (no. of cases) F20–29 12 8 8 10 14 52
F30–39 19 23 10 17 21 90
F40–49 9 8 10 13 6 46
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208 Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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to the quality of the clinician–patient relationship: patients
felt their problems were addressed in a more holistic way,
there was less confusion, stress and frustration during the
consultation, and in general the therapeutic alliance has been
stronger—built over longer period of time and character-
ised by trust and sense of security, even in a crisis situation.
Moreover, patients believed that the PCC approach leads to
shorter hospital stays and smoother transitions between hos-
pital and community care. Examples of patients’ argumenta-
tions are presented in Table3, next to the similar clinicians’
argumentations.
Clinicians
Patients’ accounts have been confirmed by clinicians who
shared their opinions of the quality of the therapeutic alli-
ance in PCC, holistic approach to patients’ problems and
sense of security in crisis situation. Clinicians also believe
that PCC allows to avoid confusion about treatment rec-
ommendations and frustration of repeating personal story
(Table3). They have also discussed additional organisa-
tional advantages of PCC, besides shorter hospital stays and
smooth transitions between the settings. Those advantages
of PCC are listed below with quotations which illustrate the
arguments raised by clinicians:
• higher adherence to treatment;
C: It promotes the adherence to treatment, promotes
the understanding from the patients about what we are
doing for them, promotes the compliance… also from
the family… the compliance to the care project (IT-
PCC: psychiatrist).
• reduced need for coercion, restraint, forced medication
or involuntary admission;
C: The patient was very unwell, he had bipolar, he was
very manic and very vulnerable—needed to come to
hospital—but because he had a really good relation-
ship with the consultant he agreed to come to hospital
voluntarily. If that had been a different consultant who
did not know that patient, the patient would have had
to been sectioned (UK-PCC: nurse).
• lower risk for disengagement from treatment;
C: Further treatment by the familiar person, familiar
personnel means significantly fewer disengagements
and also not so much information is lost (GE-BT: psy-
chologist/psychiatrist).
• more satisfaction for clinician—seeing patient’s condi-
tion improved after discharge;
C: It’s nice to see people over a long period of time.
(…) You’ve got that knowledge, what works and what
does not work, and you’ve seen them ill and well. Just
to see ill people all the time, and as soon as someone
gets well they disappear, and another ill person comes
in… in my experience people burn out, especially
inpatient consultants (UK-PC: psychiatrist).
• better communication between different clinicians/ser-
vices.
C: (…) relationships between staff are just as impor-
tant. They know you so you can talk (UK-PC: psy-
chiatrist).
Table 2 Clinician sample characteristics
Belgium, Germany, Italy, Poland and the United Kingdom
BE GE IT PL UK Tot al
No. of interviews 13 10 12 13 15 63
Time of the interview Average (in min.) 67 36 31 41 50 45
Gender Male, n (%) 6 (46%) 5 (50%) 6 (50%) 5 (38%) 11 (73%) 33 (52%)
Approach in care (no. of cases) PCC 0 0 5 5 8 18
SC 0 6 7 6 6 25
BT (both) 13 4 0 2 1 20
profession (no. of cases) Psychiatrist 6 5 8 8 11 38
Psychologist 1 3 0 3 1 8
Social worker 5 2 0 2 1 10
Nurse 1 0 2 0 2 5
Trainee (psychiatrist) 0 0 2 0 0 2
Years of experience Average 15 10 18 19 19 16
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209Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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Table 3 Positive experiences of patients and clinicians with personal continuity care approach
Results from Belgium, Germany, Italy, Poland and the United Kingdom
Positive experiences with PCC
Clinicians Patients
Stronger therapeutic alliance
C: The relation with the patient is very profound… you really have
the feeling that you are taking a piece of the road together with the
patient (IT-PCC: psychiatrist)
P: Patients like me feel better with a clinician who they know and who
knows them. The relationship doesn’t have to be built during every
new session. Then it’s easier to talk because the matters covered are
rather sensitive and some walls have to be broken down (…). For me
it’s better for both patient and clinician. It is possible to focus on cur-
rent issues (PL-PCC: F58/affective disorder)
More holistic approach to patients’ problems
C: With a more holistic approach, the clinician sees the whole picture.
For example, we have a patient who (…) lost his home (…) his
mother had also suffered from schizophrenia and had committed
suicide. (…) the father abused alcohol and there was a lot of violence
at home. (…) We went through it together and it brought us together.
Had he come to us from the best clinician with some laconic report
and he’d have to describe it all over again, he would not have han-
dled it (PL-PCC: psychiatrist)
P: When my wife had cancer, I was visiting her [my clinician] all the
time and she simply lead me through and helped me out with medica-
tions so I did not fall apart. She guided me after my wife’s death as
well. (…) Having a good trusted clinician who has empathy and does
not treat me like a number or a patient only, but like a person (PL-
PCC: M56/anxiety disorder)
Less confusion about medications and treatment recommendations
C: I think it was better for patients to have a consistent relationship
with a psychiatrist. (…) personal continuity did avoid some of the
problems of patients coming across consultants with completely dif-
ferent views… [which we have now] (UK-SC: psychiatrist)
P: The clinician who conducted my treatment in hospital and following
my discharge is able to compare. I think he got to know me over those
two weeks at the hospital when he took care of me and can relate that
to various levels of my mood and emotional state (PL-BT: F25/anxi-
ety disorder)
No stress and frustration of having to repeat personal story
C: There is less anxiety and the patient doesn’t have to get stressed
about coming in and telling the clinician the whole story (PL-PCC:
social worker)
P: If I had to get a new psychiatrist now and explain everything (…). It
would take me 4 sessions, and we could only start work at the end of 4
sessions, which is actually 4months later, so I would not get better for
4months. By the time everything settles down again I’ve lost a whole
year (BE-PCC: M66/psychotic disorder)
Greater sense of security in crisis situation
C: It can be calming for the patient to know that someone knows him
well, knows his story and remains present. I would say it’s reassuring
for the patient (…) to have continuity (BE-BT: psychiatrist)
P: There’s the familiarity and the sense of safety from seeing the same
face. There’s feeling like they know you when you’re well so they’ll
possibly be more inclined to involve you in any decisions they make
while you’re acutely unwell, for as much as they can anyway. [Sigh]
(UK-PCC: F35/psychotic disorder)
Shorter hospital stays
C: We can intercept crises. I think we can see when our patients are
usually a little unstable. We can mitigate it or even shorten the stays
in the hospital (GE-BT: psychologist)
P: You’re dealing with a fresh doctor every time, they’ve got to reopen
your case and go through your history and so they started keeping
me in this ward, but there’s no continuity there, they don’t know what
medications you take, they don’t know your coping strategies, noth-
ing… (UK-PCC: M58/psychotic disorder)
Smooth transition between settings
C: Personal continuity is easier—if there is a link, patients do not feel
the discontinuity in the transition through settings (IT-SC: psychia-
trist)
P: The clinician controls the whole process from the ward to the centre.
He arranged all the paperwork, prepared everything and in 1 day
I was discharged and no hassle. I got a definite date for a visit and
information as to where I was to go. Everything was clear and did
not require any additional effort or searching. And because I was
very pleased with the clinician, and I also knew I was going to see the
same psychologist, I had no doubts at all… (PL-PCC: F58/affective
disorder)
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210 Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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Positive experiences withSC
Patients
Some patients treat the fact of being treated by two dif-
ferent clinicians in two different settings as natural: they
have never questioned it, as they feel that they have a good
rapport with both clinicians, especially if the collaboration
between inpatient and outpatient services is well estab-
lished. Analysis of patients’ positive experiences led to the
identification of features related to specialisation of care,
which can be interpreted as advantages of this approach.
Patients believe they experienced more autonomy and
more choice and could separate a crisis period from regu-
lar life, which was important to them. Moreover, they felt
that the staff at the hospital wards was more available for
them and believed that they had higher chances receiving
a more accurate diagnosis and treatment. Their reasoning
is presented in Table4.
Clinicians
The experiences of clinicians with specialisation of
care which are perceived as a relative advantage of that
approach over personal continuity of care are very similar
to the patients’ views as Table4 shows. However, clini-
cians also addressed two additional features related to the
organisation of care. They believe that SC approach offers
a higher professionalization of care,
C: Clearly the fact that there is a team dedicated to
the ward allows a specialisation of care and the best
management of acute phases (IT-SC: psychiatrist).
and a more effective management structure.
C: I feel specialisation of care may make it a bit
easier for the system to accommodate the different
treatment options, availability of staff, just to manage
that a bit better (UK-PC: nurse).
Negative experiences withPCC
Patients
We have also identified some features related to patients’
experiences with personal continuity of care which con-
stitute a relative disadvantage of the approach over spe-
cialisation of care (Table5). Patients talked about limited
possibilities to confirm the diagnosis as well as treatment
Table 4 Positive experiences of patients and clinicians with specialised care approach
Results from Belgium, Germany, Italy, Poland and the United Kingdom
Positive experiences with SC
Clinicians Patients
Better supports patients’ autonomy
C: It’s a patient who is active… (…) It’s also a patient for whom we
have built an outpatient structure adapted to the situation at the
appropriate moment. It’s a patient who cuts off, when they stop their
hospitalisation (BE-BT: psychiatrist)
P: I saw that they trusted me [because they gave me the opportunity to
go outside the ward]…They understood that I wasn’t there to make
trouble but rather to follow my pathway and leave as soon as pos-
sible… (IT-SC: M23/affective disorder)
Different clinicians provide new, additional information or more adequate diagnosis and treatment
C: Sometimes it is really quite good, if someone different has a look at
the situation, this results in more opinions. Finally, it may even result
in different treatment approaches (GE-SC: psychiatrist)
P: More than one opinion is better and if they coincide then it is even
better. That is why I see it positively, that I was treated by more than
one doctor (GE-SC: M34/psychotic disorder)
Patients have more choice regarding the change of the clinician
C: (…) Some patients are happy to not see me and to have another
clinician, this depends on the diagnosis and on the personal rela-
tionship that they have with you (IT-SC: psychiatrist)
P: I have a chance to compare people, clinicians and their professional-
ism. And whether they are not doing any harm with their medications.
That is very important (PL-SC: F63/psychotic disorder)
Different clinicians across settings help to separate a crisis period from regular life
C: There are patients that for some time prefer to be away from every-
thing, including the outpatient staff (IT-SC: psychiatrist)
P: It is better that the person who takes care of the severe phases sees
people only in the worse [periods], and the clinician who refers to the
hospital and takes on outpatient care actually has a chance to see the
person in the reality of daily life (PL-SC: F32/psychotic disorder)
Higher availability of staff in a hospital ward
C: I’m not splitting my time between here and the wards and some-
times here and sometimes there (UK-SC: psychiatrist)
P: If you have the same doctor, they’d be very busy and that it’d be a lot
to take on, but as long as both doctors inside and outside the hospital
know exactly what’s going on, then two doctors is fine (UK-SC: M24/
psychotic disorder)
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211Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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recommendations, and a somewhat lower availability of staff
in hospital wards. Moreover, they felt that PCC approach
results in having more difficulties in separating and isolating
a crisis period from a regular life:
P: I think there should be an inpatient psychiatrist and
an outpatient psychiatrist because the inpatient psy-
chiatrist sees you when you’re unwell… I’ve got a new
consultant psychiatrist at the moment and I like the
fact that she has met me when I’m well in the com-
munity because then she doesn’t have that previous
picture or judgement of me (UK-PCC: F30/affective
disorder).
Clinicians
Similar features related to clinicians’ experiences with the
personal continuity model of care, constituting a relative
disadvantage of this approach over specialisation of care,
were identified (Table5). Moreover, clinicians see the per-
sonal continuity of care approach also related to the higher
workload and management difficulties.
C: That works very well, but psychiatrist have got
massive caseloads. How much they know each person
in detail, I’m not sure, because they’ve got so much
they’ve got to deal with (UK-PCC: psychologist).
C: It takes time and commitment and often it is not
possible to reconcile hospital work with community
work. Sometimes it’s hard to treat the same patient
for years. It’s sometimes so stressful to work with the
same family all the time, especially when working at
the hospital as well (PL-PCC: psychiatrist).
Negative experiences withSC
Patients
We have also identified a number of features related to
patients’ experiences with specialisation of care which con-
stitute a relative disadvantage of that form of care in com-
parison with personal continuity care. Those features again
relate to the quality of a therapeutic relationship [(1) low
trust in unfamiliar clinicians, (2) a less holistic approach
to patients’ problems, (3) frustration or stress of patients
having to repeat their personal story], accuracy of diagno-
sis and treatment (receiving confusing recommendations
from different clinicians) and organisation of care [(1) lack
of smooth transition between hospital and community care,
(2) longer inpatient stays, (3) higher uncertainty of clinician
at discharge]. As those features correspond to—as oppo-
sites—the advantages of personal continuity care approach
described above (Table3), Table6 illustrates only selected
themes.
Table 5 Negative experiences of patients and clinicians with personal continuity care approach
Results from Belgium, Germany, Italy, Poland and the United Kingdom
Negative experiences with PCC
Clinicians Patients
Limited possibility to confirm diagnosis and treatment with other clinicians
C: I don’t see it as the ideal solution… because it is likely that having only a clinician freezes
the vision of the patient which instead needs different points of view (IT-PCC: psychiatrist)
P: …and at one point we were all sitting there,
the four of us, that were all same psychia-
trist’s patients in the hospital (…) and real-
ised that we were all taking quetiapine with
four completely different diagnoses. (…) So it
would be good to be able to have a different
opinion… I thought that might not be the best
about having just seen same psychiatrist all
the time (UK-PCC: F23/affective disorder)
Lower availability of staff in a hospital ward
C: You are more thinly spread between, so you cannot be on both sides at one time, so you
have to give part of your time to inpatient and part of your time for the outpatient (UK-PCC:
psychiatrist)
P: They didn’t have the time. It works better
through external visits since there are certain
windows to receive us for a half hour, forty-
five minutes of discussion. But in the hospital
setting, we realize that it gets botched, some
people don’t stop calling so we’re talking
about the bare minimum, about the medica-
tion, did you sleep well, how are you doing
with everything, that’s all (BE-PCC: F32/
affective disorder)
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212 Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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Clinicians
Clinicians had the similar perception of disadvantageous
features of specialisation of care and have mentioned all fea-
tures described in patient accounts (Table6). However, they
have also discussed some other important features related
to clinicians’ experiences with specialisation of care which
constitute a relative disadvantage of that form of care in
comparison with personal continuity care:
• higher risk of disengagement from treatment;
• communication problems between different clinicians
and services;
• conflicts between different clinicians and services;
• less satisfaction for clinician—not seeing patient’s condi-
tion improved.
The arguments of the clinicians can be illustrated by the
following quotation:
C: So, the main difference is, that it’s more frus-
trating. Because if you’ve got an idea you can not
follow it through because you have to delegate and
ask someone else to do it for you, and they need to
be convinced, which is difficult if you have a dedi-
cated and knowledgeable person who has got their
own ideas, then to convince them that well, your idea
is a good idea—it takes a lot of time, especially if
it’s controversial… I think that’s the main problem;
that’s frustrating and it’s setting people up to get
more and more fights with each other; because you
have to bridge all these interfaces, then they have
to live with the frustration that the team that you
are asking to follow-up your ideas may be not want-
ing to follow that up and saying look but we do not
see it this way, we see it totally different. (…) mis-
understandings are the norm. The more interfaces
you create, the more misunderstandings we will get,
and the more people that drop out in-between. (…)
Table 6 Negative experiences of patients and clinicians with specialised care approach
Results from Belgium, Germany, Italy, Poland and the United Kingdom
Negative experiences with SC
Clinicians Patients
Low trust in unfamiliar clinicians and frustration or stress of having to repeat personal story
C: It would definitely be good for patients if the reference person would
stay the same. And I think it would be a huge advantage for the doc-
tors if trust is established (GE-SC: social worker)
C: It’s true that patients say, “are you going to send my file, are you
going to explain to the people you send me to see?”, because the
feeling often is “I do not want to tell this whole story again” (BE-BT:
psychiatrist)
P: It is often very strenuous, if one has to keep on starting from the
beginning and has the feeling ‘I’ve just told someone else every-
thing’. When I change, they naturally have no idea of what I told
the other person and ask the same questions again, which I know
by heart. I fell into a kind of monotony and simply answer like a
gramophone record, which keeps on repeating the same thing, but
omits some details, leaves out this and that to speed up the process
(GE-SC: F29/affective disorder)
Receiving confusing recommendations from different clinicians
C: I think it can be really confusing—we can disagree on medication,
on diagnosis, and that means that you’re disagreeing on the message
you give to people about the nature of their problems and how they
should address them (UK-SC: psychiatrist)
P:…but they’ve all got their own opinions, and obviously I’ve got my
own opinion as well (…). Especially when it comes to medication…
Right now, my doctor in hospital reckons I should be on the injection
and my doctor in the community is not sure. So it’s been down to me
to decide (UK-SC: M31/affective disorder)
Lack of smooth transition between hospital and community care
C: I have such a concrete case in mind that I ca not get out of my head.
It was a woman patient whom I had transferred to the outpatient
appointment and further treatment. (…) The patient did not keep her
psychiatric appointment and again slipped into the psychosis. (…) My
hands are tied, because I am no longer treating the patient (GE-SC:
psychologist)
P: There is a smooth transition missing, so in general there is a lack of
connection between ward and outpatient clinic, where in the begin-
ning someone is helping to manage daily issues, (…) someone who
supports you, so one doesn´t feel lost. (…) As soon as control from
hospital was gone and I was responsible myself, nothing worked out
(GE-SC:F29/affective disorder)
Longer inpatient stays and higher uncertainty of clinician at discharge
C: There is no sense of ownership of the patient. The community staff
(…) do not have really motivation to facilitate the discharge because
patient is risky in the community, so for them it’s actually “he needs a
little bit longer” etc. (…) Patients with personality disorders say “my
community consultant said something completely different, he told
me that I have a bipolar disorder…” and this can of course affect the
treatment and length of stay, so there’s difficulty with transferring the
patients… (UK-BT: psychiatrist)
P: The problem is that a different clinician is in contact with me every
time I stay at the hospital. It’s a bit silly, because, no matter how
much the clinician would like to get to know the patient, they won’t
be able. The patient would have to stay at the hospital half a year for
that to happen (PL-SC: F56/affective disorder)
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213Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
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If you create all these interfaces you will obviously
have more likely disengagement of the patients, …
there has been good research in many places and…
the most single most powerful predictor if a patient
will attend is if they’ve seen you before. …all the
other bits you can record, you can input telephone
messages, letters—and all of this we do—but the sin-
gle most powerful is this; that the patient has seen
you before and has discussed the follow-up with you.
And that’s what I used to do… would give a date
follow-up and then people would attend (UK-SC:
psychiatrist).
Discussion
The international exploration of clinicians’ and patients’
positive and negative experiences with specialisation of care
and personal continuity of care approaches has led to a com-
prehensive identification of number of features, which con-
stitute the advantages and disadvantages of these different
approaches. The study used a consistent methodology across
five European countries: Belgium, Germany, Italy, Poland
and the United Kingdom. It found commonalities in attitudes
towards and experiences of patients and clinicians regarding
specialisation and personal continuity of care approaches,
which validates the results across borders. Many positive
experiences of patients and clinicians with the personal
continuity care approach not only relate to the high quality
of therapeutic relationship based on trust and the sense of
security, but also to the smooth transition between hospital
and community care. Many positive experiences of patients
and clinicians with the specialised care approach relate to
concepts of autonomy and choice and to the higher adequacy
of diagnosis and treatment. In addition to the experiences
related to the quality of care discussed by both study groups,
clinicians stressed also system aspects of providing mental
health care: more effective management structure and higher
professionalization of care within specialisation approach
and the lower risk of disengagement from treatment and
reduced need for coercion, restraint, forced medication or
involuntary admission within personal continuity of care.
Strengths andlimitations
This comparative qualitative study examines experiences of
mental health professionals and patients regarding speciali-
sation and personal continuity of care approaches in different
European countries in a comprehensive manner, providing
information with higher transferability than previous quali-
tative studies in this area. The data coding consistency has
been checked across all countries. The research team was
multidisciplinary; therefore, the analysis and data inter-
pretation benefited from different perspectives. Moreover,
participants of that study received or provided care in coun-
tries in which different care approaches were encouraged
by different funding mechanisms and political and clinical
arrangements.
There are also limitations. While the participants were
selected to achieve maximum variation sampling, the selec-
tion of interview participants was purposive. In addition, it
included only those, whose mental and somatic health was
good enough to carry out an in-depth interview. Therefore,
we did not explore the opinions of patients who probably
might have benefited less and have been less satisfied with
the care received.
Results related toprevious ndings
Our results show that, despite the recent increase in spe-
cialised and technologically advanced medical treatments,
neither clinicians nor patients have forgotten the importance
of a more traditional part of medical practice: the relation-
ship between clinicians and patients [16]. Therefore, it is
not surprising that many positive experiences with the per-
sonal continuity care approach relate to the features of that
approach, which increases the quality of the therapeutic
relationship (a better therapeutic alliance; greater sense of
security in crisis; less frustrating and less confusing deliv-
ery of care). For those reasons, many patients from the
specialisation care participating in our study also declared
preferences for having the same clinician—at least within
one setting, but also across different settings. Those findings
are supported by earlier research which suggests that trust
is important to patients and continuity of care is a frequent
theme in building trust. Moreover, trust in clinician–patient
relationship often translates into trust towards the mental
health care system in general [16–18].
Some positive experiences with the specialisation care
relate to concepts of autonomy and choice (i.e. more free-
dom to choose the clinician; separation of a crisis period
from a regular life). However, we argue that specialisation
care offers more autonomy than personal continuity of care
rather from an economic than from a philosophical point of
view. While philosophical and ethical arguments underpin
the idea for more patient choice, the economic arguments
focus on patients having more choice between several cli-
nicians or wards competing to deliver a service for them.
However, it does not necessarily offer greater autonomy for
the patient in their individualised treatment plan, as none
of the clinicians may offer participation in decision-making
[16]. Moreover, studies show that even if patients expect
shared decision-making, they do not necessarily demand a
fully autonomous choice [16, 19–21]. Calsyn etal. [22] sug-
gested that choice may improve outcomes in patients who
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214 Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
1 3
are functioning relatively well, but not in patients with more
pervasive and severe mental illnesses [16].
Our results point out two important advantages of the spe-
cialisation approach: higher adequacy (different clinicians
provide new, additional information and more adequate
diagnosis and treatment) and higher professionalization of
care. It has been argued that increasing specialisation of ser-
vices is inevitable as our evidence base expands, providing
us with a better and deeper understanding of what exactly
works best and for whom [9]. The arguments are forwarded
in favour of a specialisation of care which emphasise the
increase in the overall skills of the consultants carrying out
their respective jobs in more focused manner and having
sufficient time to participate in teaching, management and
other non-clinical work [23].
The specialisation approach has been criticised as empha-
sising the biological aspects of illness over the psychological
and social factors. A holistic view tends to be avoided, as
it is easier to measure reductionist models of human expe-
rience and therefore establish a clear evidence base [16,
24]. At the same time, positive experiences related to the
personal continuity care are more holistic care, a higher
adherence to treatment, lower risk for disengagement from
treatment and smooth transition between hospital and com-
munity care. It is another important argument in preven-
tion of the appearance of the “Bermuda triangle” in mental
health care system where lack of holistic view of patient
needs and poor coordination of different providers’ tasks
leads to the high risk of disengagement from treatment [1,
25]. Lack of personal continuity increases the need of the
patients to look after the continuity of care themselves, and
to see that relevant information is conveyed to different
actors. Therefore, overall quality of care depends not only
on the effectiveness of each agency, but also on the per-
sonal competence of patients [26–28]. Moreover, treatment
of severely marginalised patients may require not only the
personal continuity of care, but collaboration between clini-
cians and other professionals involved in delivery of medical
and social care, covering a wide variety of physical, mental
health, and social care interventions [1, 26–29].
That brings us to the issue of overall care organisation,
as positive experiences with personal continuity care in our
study suggest that this approach leads to shorter hospital
stays as clinicians are able to react quickly to an emerg-
ing crisis and are more confident about treatment decisions.
This approach is also more satisfactory for clinicians (seeing
patient’s condition improved after discharge; fewer disagree-
ments between different clinicians/services). In comparison,
the advantages of specialisation of care suggest higher avail-
ability of staff in the hospital ward and more effective man-
agement structures. This might result in diminished work-
load and more efficient management of specialised hospital
wards.
Conclusions
Our data lend support to both, personal continuity and spe-
cialisation of care—or when expressed differently, show
shortcomings of both care approaches. Advantages as much
as disadvantages of both approaches may balance or coun-
terweight each other resulting in similar primary outcomes
in the quantitative follow-up, as specific aspects of care may
have different relevance in specific contexts and logistic and
organisational considerations may favour one approach over
the other. Therefore, even though there appears to be no
quantitative differences in primary outcomes between per-
sonal continuity and specialisation of care [12], the issue
remains important for many clinicians and patients and influ-
ences their experiences.
In our study, regardless of the form of care, there were
patients who stressed that they received help they needed
and who were very satisfied with medications they were pre-
scribed. Many patients in both approaches to care reported
feeling safe, respected, and confident to negotiate their own
opinion regarding the course of treatment. Consequently,
patients might link the positive experience of care, not to any
specific approach, but to the high quality of care received
within that approach.
Our qualitative study is of unique value by complement-
ing the quantitative exploration where no significant differ-
ences between PCC and SC were found in terms of patient
outcomes over a 1-year period [12]. It identifies and high-
lights substantial differences in terms of perceived advan-
tages and shortcomings of both approaches. Therefore,
along with continuous efforts to improve the quality of care,
offering clinicians and patients a choice between alternative
approaches needs to be considered, whenever possible and
feasible.
Acknowledgements The authors would like to acknowledge the sup-
port of the funders, participants and wider COFI study group.
Funding This study was funded by the European Commission 7th
Framework Programme (Grant agreement number 602645) and co-
financed by Polish Ministry of Science and Higher Education (agree-
ment number 3153/7.PR/2014/2 to conduct a co-financed international
project no. W112/7.PR/2014).
Compliance with ethical standards
Conflict of interest The authors declare that they have no competing
interests.
Ethical approval The authors confirm that the study had been approved
by the appropriate ethics committees in all five countries and have
therefore been performed in accordance with the ethical standards laid
down in the 1964 Declaration of Helsinki and its later amendments.
Ethical standards The authors confirm that the ethical approval was
obtained in all countries:
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215Social Psychiatry and Psychiatric Epidemiology (2020) 55:205–216
1 3
1. Belgium: Comité d’Ethique hospital of acultaire des Clin-
iques St-Luc;
2. England: NRES Committee North East - Newcastle & North
Tyneside;
3. Germany: Ethical Board, Technische Universität Dresden;
4. Italy: Comitati Etici per la sperimentazione clinica (CESC)
delle provincie di Verona, Rovigo, Vicenza, Treviso, Padova;
5. Poland: Komisja Bioetyczna przy Instytucie Psychiatrii i
Neurologii w Warszawie.
Open Access This article is distributed under the terms of the Crea-
tive Commons Attribution 4.0 International License (http://creat iveco
mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
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Aliations
JustynaKlingemann1 · MartaWelbel1· StefanPriebe2· DomenicoGiacco2· AleksandraMatanov2·
VincentLorant3· DelphineBourmorck3· BettinaSoltmann4· StePfeier4· ElisabettaMiglietta5· MirellaRuggeri5·
JacekMoskalewicz1
1 Department ofStudies onAlcohol andDrug Dependence,
Institute ofPsychiatry andNeurology, ul. Sobieskiego 9,
02-957Warsaw, Poland
2 Unit forSocial andCommunity Psychiatry (World Health
Organisation Collaborating Centre forMental Health
Services Development), Queen Mary University ofLondon,
London, UK
3 Institute ofHealth andSociety IRSS, Université
Catholique de Louvain, Ecole de Santé Publique,
Clos Chapelle-aux-champs, 30 bte 30.15 - 1200
Woluwe-Saint-Lambert, Brussels, Belgium
4 Department ofPsychiatry andPsychotherapy, Carl Gustav
Carus University Hospital, Technische Universität Dresden,
Universitätsklinikum Carl Gustav Carus, Klinik und
Poliklinik für Psychiatrie und Psychotherapie, Fetscherstraße
74, 01307Dresden, Germany
5 Section ofPsychiatry, Department ofNeuroscienze,
Biomedicine andMovement, University ofVerona, Verona,
Italy
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4.
5.
6.
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