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Objective To explore the applicability of a patient complaint taxonomy to data on serious complaint cases. Design Qualitative descriptive study. Setting Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010. Participants All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period. Main Outcome Measure A thematic analysis of the complaints was conducted to identify particular complaint issues and the Reader et al. (Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014;23:678–89.) patient complaint taxonomy was then used to classify these issues into categories and sub-categories. Results The 138 investigated cases revealed 223 complaint issues. Complaint issues were distributed into the three domains of the patient complaint taxonomy: clinical, management and relationships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care. Conclusions The types of complaints from patients about their healthcare investigated by the NSW Commission were similar to those received by other patient complaint entities in Australia and worldwide. The application of a standard taxonomy to large numbers of complaints cases from different sources would enable the creation of aggregated data. Such data would have better statistical capacity to identify common safety and quality healthcare problems and so point to important areas for improvement. Some conceptual challenges in devising and using a taxonomy must be addressed, such as inherent problems in ensuring coding consistency, and giving greater weight to patient concerns about their treatment.

Purpose There is evidence that social isolation is a risk factor for suicide, and that social connections are protective. Only a limited number of studies have attempted to correlate the number of social connections a person has in their life and suicidal behaviour. Method Two population-based case–control studies of young adults (18–34 years) were conducted in New South Wales, Australia. Cases included both suicides (n=84) and attempts (n=101). Living controls selected from the general population were matched to cases by age-group and sex. Social connections was the main exposure variable (representing the number of connections a person had in their life). Suicide and attempts as outcomes were modelled separately and in combination using conditional logistic regression modelling. The analysis was adjusted for marital status, socio-economic status, and diagnosis of an affective or anxiety disorder. Results Following adjustment for other variables, those who had 3–4 social connections had 74% lower odds of suicide deaths or attempts (OR=0.26, 95% CI 0.08, 0.84, p=0.025), and those with 5–6 connections had 89% lower odds of suicide deaths or attempts (OR=0.11 95% CI 0.03, 0.35, p, Highlights • Suicide among young people comprise a serious public health burden. • There has been limited research into the factors that may protect against suicide. • This study examines social connections and suicide death or attempt. • Fewer social connections are associated with greater odds of suicide. • Increasing social connections could be important for suicide prevention.

To explore the applicability of a patient complaint taxonomy to data on serious complaint cases.Qualitative descriptive study.Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010.All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period.A thematic analysis of the complaints was conducted to identify particular complaint issues and the Reader et al. (Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014;23:678-89.) patient complaint taxonomy was then used to classify these issues into categories and sub-categories.The 138 investigated cases revealed 223 complaint issues. Complaint issues were distributed into the three domains of the patient complaint taxonomy: clinical, management and relationships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care.The types of complaints from patients about their healthcare investigated by the NSW Commission were similar to those received by other patient complaint entities in Australia and worldwide. The application of a standard taxonomy to large numbers of complaints cases from different sources would enable the creation of aggregated data. Such data would have better statistical capacity to identify common safety and quality healthcare problems and so point to important areas for improvement. Some conceptual challenges in devising and using a taxonomy must be addressed, such as inherent problems in ensuring coding consistency, and giving greater weight to patient concerns about their treatment.

Objective: Forty-seven patients with long-term mental illness were transferred to the community following the closure of a psychiatric hospital in Sydney. This 6-year evaluation is an extension of a detailed clinical, ethnographic and economic study of the initial 2-years of community transition. Method: Quantitative evaluation was conducted using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Assessments were completed prior to discharge and at two- and 6-year intervals following community transfer. Repeated measures analysis was utilized to determine changes in outcome variables over time. The residents' perception of 6-years of community living was explored in qualitative semistructured interviews. Details of accommodation, level of care, readmissions, incidents and medication were also documented. Results: During the 6 years following community relocation a total of seven residents returned to hospital for long-term care, three residents died from medical causes and one resident required detention in a corrective services facility. The 36 residents who remained in the community at the 6-year follow-up no longer required intensive 24-h supervision. Living semi-independently, 23 residents resided in two to three person accommodation with either daily or weekly case manager visits. Clinically, community residents remained stable over the 6 years without significant changes in psychiatric symptoms, depression, living skills or social behaviour problems. Clinical stability was achieved with significant reduction in medication levels over the 6 years. Community-based residents continued to experience improved quality of life and reported their marked preference for living in the community. Conclusion: The residents maintained community tenure with significant improvement in quality of life and a reduction in medication, supported by a mental health system with adequate community resources. Issues regarding continuing rehabilitation and social integration need to be addressed. Further deinstitutionalization will require 24-h supervision for most initially and for some on a continuing basis. An ageing population will require specific age related medical and psychiatric services.

Objective This paper explores how hospital complaints managers react to recommendations for systemic quality reforms by health complaints commissions in response to complaints by patients in Queensland and New South Wales. Methods Semi-structured qualitative interviews were conducted with complaints managers in 17 hospitals. Interview transcripts were then thematically analysed and data on responses to health complaint commissions was organised in relation to Valerie Braithwaite’s typology of motivational postures. Results Respondents supported involvement by an independent authority where patients had serious complaints about the services they received in hospital, but wanted more negotiation with commissions on service improvement recommendations. Conclusions Hospital complaints managers mostly responded as virtuous or rational actors to the symbolic power of complaints commissions. This may be context dependent because Australian health commissions operate within a pro-reform context as a result of recent publicity around health system failures. What is known about the topic? Little is known about regulatory relationships between complaints commissions and hospitals. There has been no Australian research considering how complaints managers respond to commission recommendations for quality improvements and reforms to hospital services. What does the paper add? The paper uses a novel theoretical framework based on regulatory theory to understand and describe the reactions of complaints managers to commission recommendations. What are the implications for practitioners? Commissions should seek commentary from complaints managers through open dialogue before making final recommendations. This will ease the progress of reforms and make recommendations more acceptable and ‘genuine’ in the specific context of the hospital.

Since the 1950s deinstitutionalization has taken place for people with mental illnesses in the Western world. The growth of community care and residential facilities, as well as planning and implementation of policies, has varied in timing and orientation. An appreciation of the process of change affecting people discharged to the community highlights their strength, resilience, and vulnerabilities. This paper outlines a two and a half year ethnographic qualitative study undertaken in Australia, where 47 long-stay psychiatric inpatients were discharged to the community. The process accompanied the amalgamation of two major psychiatric hospitals, resulting in the closure of one. Findings demonstrated slow but positive change for residents as they reintegrated into the community. A separate quantitative and economic study was undertaken alongside the qualitative study (for results see Hobbs, et al., 2000; Newton, et al, 2000; Lapsley, et al., 2000).

Objective: To examine the reasons for cannabis use among individuals with psychotic disorders.Method: Forty-nine people with psychotic disorders in treatment with community health centres in Northern Sydney were interviewed to collect information about their experience of antipsychotic side-effects and their influence on cannabis use. Other information collected on cannabis use included: amount and frequency, effects of use and other general reasons given for use.Results: It was found that boredom, social motives, improving sleep, anxiety and agitation and symptoms associated with negative psychotic symptoms or depression were the most important motivators of cannabis use. Positive symptoms of psychosis and antipsychotic side-effects that were not associated with anxiety, were not important motivators of cannabis use.Conclusions: As cannabis use may precipitate relapse in this population, it is important to reduce these motivators of use. Clinician's must assess and treat these problems, thus reducing the need for patients to self-medicate with cannabis, and therefore reducing the risk of relapse.

"SNAP" is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Objective: The closure of a long-stay psychiatric hospital in Sydney caused the transfer of an initial 40 very long-term patients to four community residences, each with 10 beds, for a continuing process of deinstitutionalisation. Community psychiatric service support and 24-h supervision were provided. This paper describes the residents' clinical progress which was assessed over a 2-year period. Method: This study employed a quasi-experimental longitudinal design. Evaluation commenced prior to discharge and continued for 2 years following community relocation using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Readmission, demographic, case history and medication data were also collected. Results: Of the 40 patients initially transferred to the community, seven required long-term readmission to hospital (either prior to or after amalgamation) and one patient died of medical causes. Additional patients transferred from the hospital to the community following the readmissions. Three of these additional patients had achieved a 2-year community tenure during the study period and were included in the clinical evaluation. The 35 residents in total who remained in the community for 2 years, demonstrated a significant improvement in psychotic symptoms, without significant change in the level of neuroleptic medication. Importantly, the 2 years of community living resulted in a significant increase in the residents' life satisfaction. There were no statistically significant changes in residents' living skills, depressive symptoms or social behaviour problems over the 2 years, indicative of the need for supervision and community service support following deinstitutionalisation. Over the 2-year period, some 37% of the residents required temporary readmission. Conclusion: This study demonstrates the clinical effectiveness of deinstitutionalisation, when planned within a mental health system with adequate community resources.

Objective: Deinstitutionalisation of seriously mentally ill people in the developed world, including Australia, has occurred since the middle of this century. Evaluation of the effects of this change on the lives of individuals is of paramount importance to ensure that policies are acceptable and effective. Increasingly, multifaceted studies are considered essential for comprehensive health research. The qualitative aspect of this study complements the clinical and economic components. Method: An ethnographic approach enabled contextual, qualitative data to be gathered from within the social world of 47 hospital residents as they moved to the community. A social anthropologist acting explicitly as a participant observer undertook fieldwork over two and a half years both pre- and post-discharge. Qualitative data were collected, stored and analysed separately from quantitative and economic data. Results: Ethnographic findings generally supported and, in many cases, mirrored clinical results. Of the total cohort of 47 patients transferred to the community, the 40 who continue to live outside of hospital all reported a preference for community living. The importance of freedom and simple liberties cannot be underestimated as factors that enabled this resilient group of people to work creatively through difficult periods. Conclusion: Properly planned and resourced deinstitutionalisation not only maintains people with a prolonged mental illness outside of hospital, it also enhances their quality of life. Subjective descriptive material focusing on personal experiences adds meaning to quantitative research data allowing health professionals to more fully understand the implications of health policy on the lives of individuals.

Objective: This project studied the cost analysis of psychiatric hospital and then community care for long-stay patients with chronic mental illness discharged during the closure of a psychiatric hospital in Sydney. Method: Expenditure and income data in both settings were collected. Costs were analysed on an occupied bed-day basis. Results: The hospital setting cost more per patient per day compared with the various community costs which were one-third to one-half of the comparable hospital costs. Conclusions: The analysis demonstrated overall that hospital care was nearly twice as expensive as care in the community setting. The factors which may have influenced, although not necessarily altered, the substance of the findings largely related to ‘organisational efficiency’. The mental hospital as an older, more rigid system was likely to be less efficient than the newer community service provision which was under intensive scrutiny both clinically and financially by all interested parties.

The objective of this study is to examine current activities, barriers, and capacity needs for the assessment and management of smoking, nutrition, alcohol and physical activity behavioural risk factors in rural and urban general practices. A cross-sectional survey of 287 general practitioners (GPs) was conducted in a rural and urban Division of General Practice in NSW. A total of 146 GPs responded yielding Divisional response rates of 51% rural and 61% urban. For each of the SNAP risk factors, between 37% and 46% of GPs report using guidelines. Verbal advice is given "very often" for smoking by 68% of GPs, for nutrition and alcohol by 48%, and physical activity by 60%. Guideline use is associated with increased frequency of advising patients. Patient compliance is the most frequently reported barrier to giving advice, especially for smoking and alcohol. GPs report that they "often" or "very often" refer patients due to nutritional risk factors (48%), with lower referral rates reported for physical activity and alcohol risk factors (28% and 27% respectively). Only 10% refer patients "often" or "very often" for smoking management, and referral for smoking management and physical activity increase as a result of training in these areas. There is considerable variability in smoking, nutrition, alcohol and physical activity risk factor intervention and management in the general practice setting. A range of strategies is required to improve the systematic management of risk factors including training, use of guidelines, referral networks, and patient education.

Background Suicide in young adults remains an important public health issue in Australia. The attributable risks associated with broader socioeconomic factors, compared to more proximal psychiatric disorders, have not been considered previously in individual-level studies of young adults. This study compared the relative contributions of psychiatric disorder and socio-economic disadvantage associated with suicide in terms of relative and attributable risk in young adults. Method A population-based case–control study of young adults (18–34 years) compared cases of suicide (n = 84) with randomly selected controls (n = 250) from population catchments in New South Wales (Australia), with exposure information collected from key informant interviews (for both cases and controls). The relative and attributable risk of suicide associated with ICD-10 defined substance use, affective, and anxiety disorder was compared with educational achievement and household income, adjusting for key confounders. Prevalence of exposures from the control group was used to estimate population attributable fractions (PAF). Results Strong associations were evident between mental disorders and suicide for both males and females (ORs 3.1 to 18.7). The strongest association was for anxiety disorders (both males and females), followed by affective disorders and substance use disorders. Associations for socio-economic status were smaller in magnitude than for mental disorders for both males and females (ORs 1.1 to 4.8 for lower compared to high SES groups). The combined PAF% for all mental disorders (48% for males and 52% for females) was similar in magnitude to socio-economic status (46% for males and 58% for females). Conclusion Socio-economic status had a similar magnitude of population attributable risk for suicide as mental disorders. Public health interventions to reduce suicide should incorporate socio-economic disadvantage in addition to mental illness as a potential target for intervention.