Psychological Medicine, 1979, 9, 365-371 Printed in Great Britain
Informing the consultant psychiatrist - the problems of communication I. W. KEMP 1 From the Common Services Agency, Information Services Division, Scottish Health Service, Edinburgh
There is considerable difficulty in providing clinicians with statistics relating to their work which are both relevant in content and suitable in style. As a contribution towards the solution of the problem for psychiatrists, a new type of statistical feedback, the Hospital/National Comparison Tables, has been produced in Scotland. In these tables the work of individual hospitals is compared with the work of all other hospitals of the same type. These are critically examined, together with examples of analyses showing the uses to which the data can be put.
SYNOPSIS
INTRODUCTION Over the years the Information Services Division (ISD) of the Scottish Health Service Common Services Agency has attempted to provide clinicians and administrators with data which are both relevant and easily understood. In order to meet the various service and research needs, the data from each statistical scheme are often produced in several formats, each varying in style, content and detail (Heasman, 1968). There are difficulties in designing routine statistical tabulations which will match the different needs, and nowhere has there been greater difficulty than in providing a suitable 'feedback' to individual clinicians with data concerning their own work (Heasman, 1976; Parkin et al. \916a, b). The earlier work in this field in Scotland was carried out on general hospital statistics but, with the reorganization of the Health Service in 1974, a new attempt was made in respect to the mental hospital in-patient statistics using a somewhat different approach. At that time it was hoped that more psychiatrists would be brought into closer involvement with the management and planning of the service, with the opportunity being facilitated by the formation of clinical divisions, i.e. speciality groups of 'medical staff with like interests' (Scottish Home and Health Department Report, 1 Address for correspondence: Dr I. W. Kemp, Common Services Agency, Information Services Division, Scottish Health Service, Trinity Park House, South Trinity Road, Edinburgh EH5 3SQ.
1971) which were established in many hospitals or on a wider basis in some instances. It was realized from the outset that divisions would require working data relating to individual hospitals and units. In Scotland at this time several series of mental hospital in-patient statistics were being produced, including an 'unpublished series' which provided very detailed tabulations for hospitals, Health Boards and Central Government, and a 'published series' which consisted mainly of data relating to Scotland as a whole and was circulated to Central Government Departments, Health Boards, and academic and research institutions. In addition, a diagnostic case index was sent annually to each hospital. Information systems of this kind are found in several countries, differing in detail. In England, for example, DHSS regularly publish national and regional statistics derived from the Mental Health Enquiry for England. The system differs somewhat from that of Scotland, however, in that there is no national feedback of data at hospital level. Any routine analyses by hospital are left to the discretion of Regional Health Authorities. In Scotland it was concluded that none of the existing routine tabulations were appropriate to meet the needs of the new management and planning advisory system and, to remedy this, a set of tables relating to in-patients was designed - the Hospital/National Comparison tables (the 'blue books') - which referred to individual mental hospitals and psychiatric units attached to general hospitals, with a copy being sent
365 0033-2917/79/2828-3880 $01.00 © 1979 Cambridge University Press 24
PSM 9
366
/. W. Kemp
annually to each consultant relating to his or her own hospital. Mental hospital in-patient statistics in Scotland are derived from data collected on form SMR4 which is completed at the time of admission and discharge of each patient. The fields include basic social, demographic and diagnostic data. The aim of the Hospital/National Comparison Tables was to prepare selected, easy to read, analyses of these data for each hospital which would provide enough detail to be used as a first step in looking at hospital in-patient workload and would also enable some comparison to be made with data on patients cared for in other hospitals. Following consultation with the Scottish Division of the Royal College of Psychiatrists, the tables finally selected gave information on first and repeat admissions, on discharges from hospital, and on residents, by age, sex and diagnosis. Tables were also given on category of admission in terms of the Mental Health (Scotland) Act (1960) and source of admission-for example, referral by general practitioner, from psychiatric out-patient clinic etc. These were followed by tables giving data on duration of stay in hospital of patients discharged during the year under examination, patients still resident in hospital at the end of the year, and finally deaths, analysed by age, sex and diagnosis. A full list of tables is given in the Appendix to this paper. Comparison with the work of other hospitals took the form of showing, as the first table on each page, the work carried out by the individual hospitals and matching this below with a table for all psychiatric hospitals. Initially each psychiatric unit attached to a general hospital was shown in comparison with all units of this type. However, this relatively small group in Scotland includes children's and psycho-geriatric units and it was decided to show each psychiatric unit in relation to all mental hospitals and units combined. Data relating to hospitals for the mentally handicapped are analysed separately. Percentage distributions are used to facilitate comparison. The aim of this method of presentation is to provide the clinician with a yardstick, against which local data can be placed in perspective. It was hoped that differences revealed in this way would lead to further examination at local levels. Economic production is made possible by copying direct from computer print-out. Par-
ticular care was paid to the design of table formats to ensure clear presentation and elimination of unnecessary detail. The breakdown of each field analysed is kept to a minimum: age groups are limited to 5 categories, diagnostic groups to 10, category of admission to 2, and duration of stay in hospital to 8. Within these limits, a considerable amount of information is given, but if more detailed information is required, this can be provided at reasonably short notice by ad hoc analysis. In every aspect of the work strict rules are observed with regard to confidentiality of the data. Since reorganization of the NHS administration in Scotland, all health statistics are under the control of the NHS. Identifiable patient data are under the direct control of named doctors. All Information Services Division staff are required to sign a confidentiality undertaking. The release of identifiable patient data is only permitted for bona fide research. In general, no names are released, thus ensuring that the consultant in charge of each patient must sign his consent before any further details can be obtained. If names are required for any specific research project, this request must first be vetted by an external ethical committee. General policy on confidentiality is contained in a Scottish Home and Health Department Memorandum, NHS Circular No. 1978(GEN)23. THE DATA IN USE Examples of data provided in the tables are now examined. In comparing local and national data account has to be taken of local factors, and the need for this is demonstrated in the first example which shows the percentage of patients admitted under parts iv and v of the Mental Health Act to 4 large mental hospitals and to all mental hospitals in Scotland for the period 1973-5. The hospitals selected admit annually about one fifth of all the patients admitted to Scottish mental hospitals. Data in Table 1 apparently demonstrated that hospitals A, C and D consistently make freer use of the formal order to effect admission than the average hospital. However, the picture alters when local differences in the organization of the hospital service are considered. It is now common practice for a hospital to work in close association with one or more
Informing the consultant psychiatrist
367
Table 1. Percentage patients 'formally' admitted to selected mental hospitals and all mental hospitals, Scotland, 1973-5 Male Hospital Hospital A % Formal admissions (Total admissions) Hospital B % Formal admissions fTotal admissions) Hospital C % Formal admissions (Total admissions) Hospital D % Formal admissions (Total admissions) All mental hospitals % Formal admissions (Total admissions)
Female 1975
1973
1974
1975
(386)
16 (398)
15 (386)
15 (396)
9 (409)
5 (524)
6 (497)
7 (503)
5 (557)
7 (596)
7 (568)
17 (949)
17
(1026)
17 (969)
16 (1068)
16 (1103)
16 (1133)
(623)
24 (504)
23 (524)
25 (655)
23 (526)
22 (524)
11 (10460)
(10525)
10 (11752)
10 (12229)
10 (11930)
9 (13991)
1973
1974
16 (353)
19
22
11
Table 2. Sources of referral of patients admitted to selected mental hospitals and to all mental hospitals for the first time, Scotland, 1973-5 Hospital A (%) Source of referral General practitioner Domiciliary visit Psychiatric clinic General hospital (ward/clinic) Self, relative, friend* Prison Other Total Number of patients
Hospital B (%)
Hospital C (%)
Hospital D (%)
All mental hospitals (%)
1973
1974
1975
1973
1974
1975
1973
1974
1975
1973
1974
1975
1973
1974
1975
50
46 4 21
44 4
67
66
60 6
17
16
13
16
61 8 6 16
26 29
18
12 6 11
60 6 6 17
23
28 29 9 24
30 31 6 23
45 11 16 18
44 12 16 18
45
11 6
66 8
3 6 3 100 339
4 11 3
1 1 1
1 1 4
1 1 3
10 __ 1
10 1 —
7 —
— 8
1
1
6
5
3 3
3 3
3 2
2
4
3
4
4
4
4
100 324
100 444
100 445
100 468
100 839
100 854
100 976
100 495
100 406
4 13 17
11 3 100 290
4
5 18
10
13 16
17
100 100 100 100 377 9217 9125 9266
* Patients who are 'self referred' or 'referred by relative or friend' are unlikely to have been admitted for the first time although a positive check was carried out on the data at Hospital C. Attention has recently been drawn to the problem of collecting data of this kind by Eastwood et al. (1978).
neighbouring hospitals. Thus, hospital A provides in-patient cover for a northern rural area of Scotland in conjunction with 4 other hospitals and the majority of the formal admissions from the area are made to only 2 of these, 1 being hospital A. Although the percentage of formal admissions to this hospital is therefore high, for the group as a whole it is close to the national average. A similar situation occurs with regard to hospital D where the local policy is to divert the majority of formal admissions from a neighbouring hospital to hospital D. In contrast, hospital C is the only hospital serving a widely distributed catchment population. There have been difficulties over the years
in maintaining adequate staffing levels. Moreover, the community psychiatry services are not as well developed as in other areas. In this case, the higher percentage of formal admissions is likely to be a sign of pressure on the hospital. Hospital B is in a quite different position. Although it is the only hospital serving a large area, it is backed by a good community psychiatric service and has no problem in obtaining staff. The lower than average percentage of patients formally admitted can be reasonably interpreted as a reflection of these characteristics. In the second example, the source of patients admitted for the first time to the 4 hospitals is compared with the source of admission to all 24-2
/. W. Kemp
368
Table 3. First admissions to mental hospital E and all mental hospitals by diagnostic group, males, Scotland, 1973-5 1973 (%) Diagnostic group Schizophrenias Depressions (incl. depressive neuroses) Psychoses (incl. mania but excl. senile and presenile) Senile and presenile psychoses Psychoneuroses (excl. depressive neuroses) Alcoholism/alcoholic psychoses Behaviour disorders Remainder Total Number of patients
1974 (%)
1975 (%)
All mental All mental All mental Hospital E hospitals Hospital E hospitals Hospital E hospitals 7 11 2 12 4 47 12 5 100 331
Scottish hospitals (Table 2). Again, consistency in practice is demonstrated within each hospital over the period. Interest lies in hospital D where just under one third of first time admissions were preceded by a domiciliary consultation. The data were discussed with the chairman of the psychiatric division to which the consultants of hospital D belong. He had been unaware of the high percentage of domiciliary consultations and concluded that this was evidence of the pressure on beds, particularly in relation to psycho-geriatrics where the service had recently been described by one consultant as 'near to collapse'. This interpretation was confirmed from other data supplied in the 'blue book' for the hospital which showed that 30 % of patients admitted for the first time following domiciliary consultation suffered from senile or presenile psychosis compared with a national figure of only 12 %. Hospital in-patient statistics have been one of the main sources of evidence used in demonstrating a high prevalence of alcoholism in Scotland. In Table 3 the diagnostic breakdown is examined of patients admitted to hospital E which is situated in an area customarily regarded as having a very high prevalence of alcoholism. It will be noted that, while the percentage of first admissions to hospital E is some 17% higher for alcoholism and alcoholic psychosis, the percentage with depression is consistently lower during the 3 years studied. While it is likely that the prevalence of alcoholism is high in the area, presentation of the data in this form draws attention to the need for careful investigation to exclude the effect on admission of
8 17 9 10 4 30 11 11 100 4282
6 13 4 11 3 51 8 4 100 358
7 17 8 11 4 33 10 10 100 4236
7 12 5 10 4 41 15 6 100 311
6 18 9 8 5 34 9 11 100 4988
differences in diagnostic practice as well as other factors, such as criteria for admission and availability of beds. The data contained in the tables can be useful in other directions, for example in assessing the duration of stay in hospital. Thus, observation can be kept on the change in the number and proportion of patients remaining in hospital for particular periods of time, and the local and national figures can be compared. The data can also be used to monitor the number and proportion of patients admitted to hospital each year with a diagnosis such as 'drug dependence', or to identify unusually high or low numbers of patients with a particular diagnosis admitted to hospital. So far hypothetical examples of how the data can be used have been given. In the course of an investigation additional information is often requested and from requests received by ISD for such information, the actual use to which data of this type are being put can be observed. The following are some examples of requests received during 1977. (a) Number of admissions to Hospital X by diagnosis, age and sex for selected areas of residence. (Data required for a local working party set up - ' To determine what differences the establishment of a community psychiatry service has made to patterns of admission from these areas'.) (b) Place to which patients are discharged who suffered from alcoholism and alcoholic hallucinosis in hospitals in Health Board X. (Data required for planning purposes.) (c) Patients admitted to Hospital W with a
Informing the consultant psychiatrist
primary or secondary diagnosis of alcoholism. (Data required to assist the local investigation of provision of hostel accommodation in conjunction with Alcoholics Anonymous.) (d) Current and projected numbers of residents with mental handicap by age and hospital of treatment resident within Health Board A. (Data required for planning.) (
Informing the consultant psychiatrist - the problems of communication I. W. KEMP 1 From the Common Services Agency, Information Services Division, Scottish Health Service, Edinburgh
There is considerable difficulty in providing clinicians with statistics relating to their work which are both relevant in content and suitable in style. As a contribution towards the solution of the problem for psychiatrists, a new type of statistical feedback, the Hospital/National Comparison Tables, has been produced in Scotland. In these tables the work of individual hospitals is compared with the work of all other hospitals of the same type. These are critically examined, together with examples of analyses showing the uses to which the data can be put.
SYNOPSIS
INTRODUCTION Over the years the Information Services Division (ISD) of the Scottish Health Service Common Services Agency has attempted to provide clinicians and administrators with data which are both relevant and easily understood. In order to meet the various service and research needs, the data from each statistical scheme are often produced in several formats, each varying in style, content and detail (Heasman, 1968). There are difficulties in designing routine statistical tabulations which will match the different needs, and nowhere has there been greater difficulty than in providing a suitable 'feedback' to individual clinicians with data concerning their own work (Heasman, 1976; Parkin et al. \916a, b). The earlier work in this field in Scotland was carried out on general hospital statistics but, with the reorganization of the Health Service in 1974, a new attempt was made in respect to the mental hospital in-patient statistics using a somewhat different approach. At that time it was hoped that more psychiatrists would be brought into closer involvement with the management and planning of the service, with the opportunity being facilitated by the formation of clinical divisions, i.e. speciality groups of 'medical staff with like interests' (Scottish Home and Health Department Report, 1 Address for correspondence: Dr I. W. Kemp, Common Services Agency, Information Services Division, Scottish Health Service, Trinity Park House, South Trinity Road, Edinburgh EH5 3SQ.
1971) which were established in many hospitals or on a wider basis in some instances. It was realized from the outset that divisions would require working data relating to individual hospitals and units. In Scotland at this time several series of mental hospital in-patient statistics were being produced, including an 'unpublished series' which provided very detailed tabulations for hospitals, Health Boards and Central Government, and a 'published series' which consisted mainly of data relating to Scotland as a whole and was circulated to Central Government Departments, Health Boards, and academic and research institutions. In addition, a diagnostic case index was sent annually to each hospital. Information systems of this kind are found in several countries, differing in detail. In England, for example, DHSS regularly publish national and regional statistics derived from the Mental Health Enquiry for England. The system differs somewhat from that of Scotland, however, in that there is no national feedback of data at hospital level. Any routine analyses by hospital are left to the discretion of Regional Health Authorities. In Scotland it was concluded that none of the existing routine tabulations were appropriate to meet the needs of the new management and planning advisory system and, to remedy this, a set of tables relating to in-patients was designed - the Hospital/National Comparison tables (the 'blue books') - which referred to individual mental hospitals and psychiatric units attached to general hospitals, with a copy being sent
365 0033-2917/79/2828-3880 $01.00 © 1979 Cambridge University Press 24
PSM 9
366
/. W. Kemp
annually to each consultant relating to his or her own hospital. Mental hospital in-patient statistics in Scotland are derived from data collected on form SMR4 which is completed at the time of admission and discharge of each patient. The fields include basic social, demographic and diagnostic data. The aim of the Hospital/National Comparison Tables was to prepare selected, easy to read, analyses of these data for each hospital which would provide enough detail to be used as a first step in looking at hospital in-patient workload and would also enable some comparison to be made with data on patients cared for in other hospitals. Following consultation with the Scottish Division of the Royal College of Psychiatrists, the tables finally selected gave information on first and repeat admissions, on discharges from hospital, and on residents, by age, sex and diagnosis. Tables were also given on category of admission in terms of the Mental Health (Scotland) Act (1960) and source of admission-for example, referral by general practitioner, from psychiatric out-patient clinic etc. These were followed by tables giving data on duration of stay in hospital of patients discharged during the year under examination, patients still resident in hospital at the end of the year, and finally deaths, analysed by age, sex and diagnosis. A full list of tables is given in the Appendix to this paper. Comparison with the work of other hospitals took the form of showing, as the first table on each page, the work carried out by the individual hospitals and matching this below with a table for all psychiatric hospitals. Initially each psychiatric unit attached to a general hospital was shown in comparison with all units of this type. However, this relatively small group in Scotland includes children's and psycho-geriatric units and it was decided to show each psychiatric unit in relation to all mental hospitals and units combined. Data relating to hospitals for the mentally handicapped are analysed separately. Percentage distributions are used to facilitate comparison. The aim of this method of presentation is to provide the clinician with a yardstick, against which local data can be placed in perspective. It was hoped that differences revealed in this way would lead to further examination at local levels. Economic production is made possible by copying direct from computer print-out. Par-
ticular care was paid to the design of table formats to ensure clear presentation and elimination of unnecessary detail. The breakdown of each field analysed is kept to a minimum: age groups are limited to 5 categories, diagnostic groups to 10, category of admission to 2, and duration of stay in hospital to 8. Within these limits, a considerable amount of information is given, but if more detailed information is required, this can be provided at reasonably short notice by ad hoc analysis. In every aspect of the work strict rules are observed with regard to confidentiality of the data. Since reorganization of the NHS administration in Scotland, all health statistics are under the control of the NHS. Identifiable patient data are under the direct control of named doctors. All Information Services Division staff are required to sign a confidentiality undertaking. The release of identifiable patient data is only permitted for bona fide research. In general, no names are released, thus ensuring that the consultant in charge of each patient must sign his consent before any further details can be obtained. If names are required for any specific research project, this request must first be vetted by an external ethical committee. General policy on confidentiality is contained in a Scottish Home and Health Department Memorandum, NHS Circular No. 1978(GEN)23. THE DATA IN USE Examples of data provided in the tables are now examined. In comparing local and national data account has to be taken of local factors, and the need for this is demonstrated in the first example which shows the percentage of patients admitted under parts iv and v of the Mental Health Act to 4 large mental hospitals and to all mental hospitals in Scotland for the period 1973-5. The hospitals selected admit annually about one fifth of all the patients admitted to Scottish mental hospitals. Data in Table 1 apparently demonstrated that hospitals A, C and D consistently make freer use of the formal order to effect admission than the average hospital. However, the picture alters when local differences in the organization of the hospital service are considered. It is now common practice for a hospital to work in close association with one or more
Informing the consultant psychiatrist
367
Table 1. Percentage patients 'formally' admitted to selected mental hospitals and all mental hospitals, Scotland, 1973-5 Male Hospital Hospital A % Formal admissions (Total admissions) Hospital B % Formal admissions fTotal admissions) Hospital C % Formal admissions (Total admissions) Hospital D % Formal admissions (Total admissions) All mental hospitals % Formal admissions (Total admissions)
Female 1975
1973
1974
1975
(386)
16 (398)
15 (386)
15 (396)
9 (409)
5 (524)
6 (497)
7 (503)
5 (557)
7 (596)
7 (568)
17 (949)
17
(1026)
17 (969)
16 (1068)
16 (1103)
16 (1133)
(623)
24 (504)
23 (524)
25 (655)
23 (526)
22 (524)
11 (10460)
(10525)
10 (11752)
10 (12229)
10 (11930)
9 (13991)
1973
1974
16 (353)
19
22
11
Table 2. Sources of referral of patients admitted to selected mental hospitals and to all mental hospitals for the first time, Scotland, 1973-5 Hospital A (%) Source of referral General practitioner Domiciliary visit Psychiatric clinic General hospital (ward/clinic) Self, relative, friend* Prison Other Total Number of patients
Hospital B (%)
Hospital C (%)
Hospital D (%)
All mental hospitals (%)
1973
1974
1975
1973
1974
1975
1973
1974
1975
1973
1974
1975
1973
1974
1975
50
46 4 21
44 4
67
66
60 6
17
16
13
16
61 8 6 16
26 29
18
12 6 11
60 6 6 17
23
28 29 9 24
30 31 6 23
45 11 16 18
44 12 16 18
45
11 6
66 8
3 6 3 100 339
4 11 3
1 1 1
1 1 4
1 1 3
10 __ 1
10 1 —
7 —
— 8
1
1
6
5
3 3
3 3
3 2
2
4
3
4
4
4
4
100 324
100 444
100 445
100 468
100 839
100 854
100 976
100 495
100 406
4 13 17
11 3 100 290
4
5 18
10
13 16
17
100 100 100 100 377 9217 9125 9266
* Patients who are 'self referred' or 'referred by relative or friend' are unlikely to have been admitted for the first time although a positive check was carried out on the data at Hospital C. Attention has recently been drawn to the problem of collecting data of this kind by Eastwood et al. (1978).
neighbouring hospitals. Thus, hospital A provides in-patient cover for a northern rural area of Scotland in conjunction with 4 other hospitals and the majority of the formal admissions from the area are made to only 2 of these, 1 being hospital A. Although the percentage of formal admissions to this hospital is therefore high, for the group as a whole it is close to the national average. A similar situation occurs with regard to hospital D where the local policy is to divert the majority of formal admissions from a neighbouring hospital to hospital D. In contrast, hospital C is the only hospital serving a widely distributed catchment population. There have been difficulties over the years
in maintaining adequate staffing levels. Moreover, the community psychiatry services are not as well developed as in other areas. In this case, the higher percentage of formal admissions is likely to be a sign of pressure on the hospital. Hospital B is in a quite different position. Although it is the only hospital serving a large area, it is backed by a good community psychiatric service and has no problem in obtaining staff. The lower than average percentage of patients formally admitted can be reasonably interpreted as a reflection of these characteristics. In the second example, the source of patients admitted for the first time to the 4 hospitals is compared with the source of admission to all 24-2
/. W. Kemp
368
Table 3. First admissions to mental hospital E and all mental hospitals by diagnostic group, males, Scotland, 1973-5 1973 (%) Diagnostic group Schizophrenias Depressions (incl. depressive neuroses) Psychoses (incl. mania but excl. senile and presenile) Senile and presenile psychoses Psychoneuroses (excl. depressive neuroses) Alcoholism/alcoholic psychoses Behaviour disorders Remainder Total Number of patients
1974 (%)
1975 (%)
All mental All mental All mental Hospital E hospitals Hospital E hospitals Hospital E hospitals 7 11 2 12 4 47 12 5 100 331
Scottish hospitals (Table 2). Again, consistency in practice is demonstrated within each hospital over the period. Interest lies in hospital D where just under one third of first time admissions were preceded by a domiciliary consultation. The data were discussed with the chairman of the psychiatric division to which the consultants of hospital D belong. He had been unaware of the high percentage of domiciliary consultations and concluded that this was evidence of the pressure on beds, particularly in relation to psycho-geriatrics where the service had recently been described by one consultant as 'near to collapse'. This interpretation was confirmed from other data supplied in the 'blue book' for the hospital which showed that 30 % of patients admitted for the first time following domiciliary consultation suffered from senile or presenile psychosis compared with a national figure of only 12 %. Hospital in-patient statistics have been one of the main sources of evidence used in demonstrating a high prevalence of alcoholism in Scotland. In Table 3 the diagnostic breakdown is examined of patients admitted to hospital E which is situated in an area customarily regarded as having a very high prevalence of alcoholism. It will be noted that, while the percentage of first admissions to hospital E is some 17% higher for alcoholism and alcoholic psychosis, the percentage with depression is consistently lower during the 3 years studied. While it is likely that the prevalence of alcoholism is high in the area, presentation of the data in this form draws attention to the need for careful investigation to exclude the effect on admission of
8 17 9 10 4 30 11 11 100 4282
6 13 4 11 3 51 8 4 100 358
7 17 8 11 4 33 10 10 100 4236
7 12 5 10 4 41 15 6 100 311
6 18 9 8 5 34 9 11 100 4988
differences in diagnostic practice as well as other factors, such as criteria for admission and availability of beds. The data contained in the tables can be useful in other directions, for example in assessing the duration of stay in hospital. Thus, observation can be kept on the change in the number and proportion of patients remaining in hospital for particular periods of time, and the local and national figures can be compared. The data can also be used to monitor the number and proportion of patients admitted to hospital each year with a diagnosis such as 'drug dependence', or to identify unusually high or low numbers of patients with a particular diagnosis admitted to hospital. So far hypothetical examples of how the data can be used have been given. In the course of an investigation additional information is often requested and from requests received by ISD for such information, the actual use to which data of this type are being put can be observed. The following are some examples of requests received during 1977. (a) Number of admissions to Hospital X by diagnosis, age and sex for selected areas of residence. (Data required for a local working party set up - ' To determine what differences the establishment of a community psychiatry service has made to patterns of admission from these areas'.) (b) Place to which patients are discharged who suffered from alcoholism and alcoholic hallucinosis in hospitals in Health Board X. (Data required for planning purposes.) (c) Patients admitted to Hospital W with a
Informing the consultant psychiatrist
primary or secondary diagnosis of alcoholism. (Data required to assist the local investigation of provision of hostel accommodation in conjunction with Alcoholics Anonymous.) (d) Current and projected numbers of residents with mental handicap by age and hospital of treatment resident within Health Board A. (Data required for planning.) (
