What do we know about life on acute psychiatric wards in the UK? a review of the research evidence
Introduction
Mental health services in the UK are moving into the third stage of a progressive shift between ‘care paradigms’, as defined by the locus of patient care (Lelliott, Audini, Johnson, & Guite, 1997). The first stage was the decision, arising in 1962 from Enoch Powell's ‘Hospital Plan for England’, to reduce National Health Service (NHS) bed numbers and close large psychiatric hospitals. The second, which reached its peak in the 1970s and 1980s, was the development of small psychiatric units, often on district general hospital sites, with a limited range of community services to meet the needs of those who no longer required hospital accommodation. The third stage, heralded by the white paper Caring for People: Community Care in the Next Decade and Beyond (Department of Health, 1989), is intended to divert people from community-based residential services into their own homes. This transition from hospital to community care has parallels in mental health services across the developed world. However, the pace of change and extent to which it has progressed, as gauged for example by the rate at which beds numbers have been reduced, varies considerably between and within countries.1 For example, the timing and pace of de-institutionalisation in the United States followed closely those in the United Kingdom; in Germany this process happened later and was slower. In Italy the change was greatly accelerated by legislation, ‘Law 180’, which made it illegal to admit patients for the first time to large mental hospitals from 1978, and to admit any patients after 1980. From this time onwards, Italian mental health services were expected to rely solely on psychiatric units, with limited numbers of beds, in general hospitals for in-patient care.
Numerous arguments have been advanced to account for the general trend towards the policy of care in the community (for reviews, see Prior, 1991; Nettleton, 1995; Ham, 1999; Carpenter, 2000). First, it has largely been attributed to pharmacological advances, especially the development of neuroleptic drugs, which have made it feasible and safe for people with serious mental illness to live in the community. Second, de-institutionalisation is seen to have been driven by fiscal crises and the need to reduce costs (community care being proposed as a cheaper option). And third, it has been argued that the asylum was ‘destroyed from within’ (Prior, 1991) due to the transformation of psychiatric knowledge — from mental illness to the domain of mental health, and from the diseased body as the object of its focus to the whole person — and its inextricable link to psychiatric practice. In short, this reconceptualisation of the medical model has meant that the rationale for confining psychiatry within the grounds of a hospital no longer exists (discussed further below).
Whatever the relative merits of these ‘technological’, ‘economic’ and ‘discursive’ explanations (reviewed in Carpenter, 2000), and regardless of the undoubted proliferation of sites for the practice of psychiatry (Health Select Committee (1986), Rose (1986)), the hospital in the UK remains the hub of mental health services. One indication of this is that expenditure on in-patient care still accounts for 65% of UK health authorities’ overall mental health budget (Health Select Committee, 1998). The decline in the number of NHS hospital beds for mentally ill people (Lelliott, 1996; Sainsbury Centre for Mental Health, 1998; Audini, Duffet, & Lelliott, 1999) has not been matched by the increase in the numbers of residential places in other settings (Lelliott, 1996). This reduction in overall provision of residential places for people with a mental illness has occurred during a period when the homeless population, a high proportion of which has mental health problems, has grown. The fact that ‘no fixed abode’ admissions have not increased over the past 30 years has led some to argue that psychiatric services are failing this group (Commander & Odell, 1998). Another area of probable unmet need for residential care is the many remand and sentenced prisoners who are mentally ill ([43]NACRO, 1993, 1995, NACRO, 1993, 1995).
Studies indicate that rates of admission have increased, particularly of young people (and especially of young men) (Lelliott, 1996; Lelliott, Audini, Johnson, & Guite, 1997; Muijen, 1999). Admissions are now largely unplanned emergencies often made compulsorily under the Mental Health Act (Fulop, Koffman, & Carson, 1994; MILMIS, 1995; Ford, Durcan, & Warner, 1998; Ward, Gournay, & Thornicroft, 1998; Audini et al., 1999). Bed occupancy rates on acute wards2 have increased (MILMIS, 1995; Shepherd, Beardsmore, & Moore, 1997; Ford et al., 1998; Audini et al., 1999) to levels as high as 153% in some areas (Higgins, Hurst, & Wistow, 1999). Pressure on beds is particularly intense in inner-London (Audini et al., 1999; Fulop et al., 1994; Lelliott, 1997). Various strategies are employed when a person requires admission to a local psychiatric ward which is already full. All are unsatisfactory. Referrals of patients to distant hospitals, because all local beds are allocated, are on the increase (Lelliott, 1996). Patients awaiting urgent admission or transfer to inner-London acute wards can be found in a variety of settings, such as other psychiatric or general medical wards, community settings or in prison or police cells (Audini et al., 1999). Finally, people already in hospital may be sent on short-term leave, permaturely and often at short notice, to free up a bed for a new admission.
Quantitative and survey research indicates problems of violence (Warren & Beardsmore, 1997; Sainsbury Centre for Mental Health, 1998; McGeorge & Lelliott, 2000) and sexual harassment (Lelliott, Audini, & Darroch, 1995; MILMIS, 1995; Barker, 2000) in this setting, with high proportions of patients detained under the Mental Health Act (Sainsbury Centre for Mental Health, 1998). Illicit drug and alcohol use is common in acute ward settings (Barker, 2000; McGeorge & Lelliott, 2000). Acute wards are also characterised by rapid staff turnover, extensive use of bank and agency staff and low morale (Ford et al., 1998).
Overall the duration of stay has declined (Muijen, 1999) while rates of admission have increased. However, there is evidence that acute admission wards, which are intended for short stays, invariably accommodate some people for prolonged periods (Lelliott & Wing, 1994; Lelliott, 1996; Audini et al., 1999) who remain even though the ward manager thinks they no longer require acute care on that ward (Fulop et al., 1994). Such ‘bed blocking’ is occurring despite opposing pressures of an ideological (‘community care’) and practical (very high bed occupancy) kind, and is partly due to lack of suitable community-based residential accommodation (Lelliott & Wing, 1994; Lelliott, 1996). Difficulties in discharging young men with a severe mental illness and histories of violence are most pronounced, as there is evidence that hostels exclude people who pose a risk of violence (Lelliott, 1996).
The pressures described above have effected a change in the profile of patients, with acute wards now tending to house the more ‘difficult’ patients (especially young men with schizophrenia) (Lelliott & Wing, 1994; Lelliott, 1996). Acute wards are, in effect, the only part of the system which cannot refuse to accept a referral. As such they function as a depository for those patients who cannot be managed by community services (Muijen, 1999).
The emergent picture is that:
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the reduction in bed numbers has created a ‘concentrating’ effect whereby the threshold for admission has increased;
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probably because of this, and the loss of ‘economies of scale’, the unit cost of in-patient care (i.e. cost per patient per day) has increased, resulting in little money being saved from bed closures;
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high bed occupancy rates mean that quality of care is compromised. Some people have to be admitted to distant hospitals with subsequent loss of continuity; nurses spend most of their time managing crises rather than giving care;
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because of the concentrating effect, wards are disturbed places where ‘violence breeds violence’. It is also likely that more people have to be detained under the Mental Health Act to ‘persuade’ them to stay;
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unavailability of beds compromises the quality of community care which requires easy access to beds for short-term management of crises or for respite.
These findings point to a bleak experience for people admitted onto acute wards. Indeed, it has raised serious concern that wards currently offer a non-therapeutic environment for those patients who are most vulnerable and unwell, and fail to address patients’ social and psychological needs (Barker, 2000; Muijen, 1999).
Yet there is currently little in-depth evidence for how the changing institutional context of in-patient care has impacted upon patients and their experience of treatment in this setting. Furthermore, some practitioners note that the tensions and problems described above are by no means uniformly felt across UK services and argue that such “blanket criticism” obscures real differences within service provision and thereby prevents important lessons being learnt from the best services (Burns & Priebe, 1999).
The purpose of this paper is to review what is known about psychiatric in-patient care, focusing on the experience of patients on acute admission wards, and to recommend directions for future research.
Section snippets
Previous studies of the nature of psychiatric in-patient care
In order to establish what is known about acute in-patient care for this paper, various bibliographic databases were searched for references. These included ASSIA Plus, MedLine, PsychLIT, Sociological Abstracts and Social Sciences Citation Index as well as those relating to specific institutions, such as the British Library. Of the references and abstracts that were identified, more than 170 papers, books and reports were subsequently gathered and read. Seven psychiatrists and two sociologists
Conclusions and future directions
The UK Government's National Service Framework for Mental Health (NHS, 1999), backed by promises of increased investment in mental health services, aims to lay down models of treatment and care which people will be entitled to expect across the country, and presents national standards for mental health. It is founded upon a few key principles, such as service user involvement in the planning and delivery of care, and the delivery of safe, high-quality treatment and care that is well suited to
Acknowledgements
The authors wish to thank Jim Birley, Katie Buston, John Cox, David Goldberg, Bob Kendall, Tim Kendall, Clive Seale, Mike Shooter and Mark Winston, as well as Mildred Blaxter and one of the anonymous reviewers, for their very helpful comments on an earlier draft of the literature review.
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