11 Recommendations

In 2000, the Royal College of Psychiatrists Neurosurgery for Mental Disorder report noted that “it would be unwise to allow neurosurgery for mental disorder to die out.” Eleven years later, this review has found that the Advanced Interventions Service has provided a valuable service for people with highly chronic and severe treatment‐refractory depression and obsessive compulsive disorder from across Scotland and the rest of the UK.

11.1 Continuing fit against National Services Advisory Group criteria

National designation has both helped to sustain this highly specialised service, and to nurture the service’s ongoing surgical and non‐surgical development, bringing clear benefits to a number of people with chronic and severe mental health conditions. The Expert Advisory Group noted that the service clearly continues to meet the National Services Advisory Group criteria, and recommended that the Advanced Interventions Service continues to be nationally designated, in providing both anterior cingulotomy and vagus nerve stimulation. It was also recommended that the national service should receive more formal recognition for its existing non‐surgical assessment and advice service, which are necessary to complement and support the surgical service provided.

11.2 Recommendations for a person‐centred service

Person‐centred service: “Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision‐making."

11.2.1 Assessment process

It is recommended that the Advanced Interventions Service’s current assessment process continues in its positive focus on the service user. This will allow for the continued development of mutually beneficial partnerships and shared decision‐making between service users and the service.

11.2.2 Capturing service user feedback

It is recommended that the service continue to capture feedback from service users, and to actively use this feedback to improve the ongoing quality of the service.

11.2.3 Access for patients from across UK

In acknowledging that the Advanced Interventions Service is available to patients from across the UK, continued dialogue should be facilitated by the Advanced Interventions Service and National Services Division with other services and Commissioners in NHS England and Wales. This will need to be undertaken in a planned and stepped manner to ensure that future demand does not outstrip capacity and that if necessary, the Advanced Interventions Service can develop capacity to meet future levels of demand.

11.3 Recommendations for a safe and effective service

Safe service: “There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times.
Effective service: “The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated."

11.3.1 Communication

The national service needs to proactively communicate and engage with the clinical community in Scotland to ensure that it is appropriately meeting the true Scottish need for the service. It has been suggested that distributing the service’s referral criteria on an annual basis to the wider psychiatric community would support an increase in the referral rate into the service.

The service has indicated the desire to more proactively communicate with the UK Psychiatric Community by placing low‐cost advertisements in the British Journal of Psychiatry and assessing its impact. It is believed that this approach will support an increase in awareness of the service, and an associated increase in referrals to the service. The service should ensure that they are proactively identifying low‐referring services, and developing links with these services. This will support both the referral rate and the conversion rate to surgery.

There is a need to continue to ensure close liaison between the national service and the team retaining responsibility for the ongoing care of the patient to ensure that approved treatment recommendations are followed. This will support the ongoing efficacy of treatments provided by the service.

11.3.2 Benchmarking

Formal links should be nurtured to support the further benchmarking between the Advanced Interventions Service, the English OCD networks; and the two other services providing neurosurgery for mental disorder: the University Hospital of Wales, and Frenchay Hospital, Bristol. Where possible, National Services Division should work in partnership with the service to support this work. The Advanced Interventions Service should continue to report robustly, develop the evidence‐base and use the literature to benchmark internationally.

11.3.3 Non‐surgical service activity

Recognising that the vast majority of the activity within the service focuses on undertaking comprehensive assessments and developing detailed treatment recommendations for patients and referring clinical teams, it is important to ensure that this activity and the fuller patient pathway within the service is recognised within future service reports, and that this element of the service is clearly added to the future service definition. This should encompass assessment, home visits, the development of treatment recommendations, the delivery of the educational programme, and advice provided to other clinical teams.

11.3.4 Deep brain stimulation

If in the future, when the evidence‐base is developed, it becomes apparent that deep brain stimulation is a safe and effective procedure for the conditions covered by the national service, then the service could consider applying in a separate bid for an extension to their existing national designation.

11.4 Future activity levels and finance

It is hoped that the suite of recommendations included within this report will support the national service’s sustainability and promote the development of the service, by increasing referral levels into the service. It is hoped that improved communication and engagement with referrers will bring about an increase in referrals from across Scotland and the UK, resulting in an increased level of surgical and non‐surgical activity within the service. As the service’s degree of success in promoting future referrals and developing activity levels remains unknown, it is recommended that activity levels are continuously reviewed by National Services Division; and that commissioning assumptions and the associated service budget are updated as appropriate once trends in future activity levels are available.

11.5 Provision of tertiary level OCD services in Scotland

The Specialised Services National Definition Set for England and Wales recognises that people with complex and refractory mood affective disorders (ICD‐10 codes: F30.‐ to F39.‐) and anxiety disorders (ICD‐10 codes: F40.‐ to F43.‐) require specialised in‐patient and outpatient services. Such patients pose major therapeutic challenges and centres of expertise concentrate skills and experience to treat the relatively low number of patients. It is recommended that in order to appropriately recognise and develop tertiary OCD services, a mapping of service‐need and existing provision for people with OCD be undertaken by NHS Scotland or the Scottish Government. This will support the further development of a safe and effective referral pathway for Scottish residents.

11.6 Provision of quaternary psychopharmacological and psychiatric services for OCD

If it is thought that there is the expertise to provide quaternary specialised psychopharmacological, psychiatric and other treatments for OCD in Scotland, then NHS Scotland service providers should consider making an application to provide this level of service to the National Services Advisory Group.


Last Updated on Wednesday, 28 August 2013 10:10

National Services Scotland

Advanced Interventions Service
Area 7, Level 6
South Block
Ninewells Hospital and Medical School
Dundee, DD1 9SY. UK.
Tel: +44 (0)1382 496233

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