UK Inpatient Services - Under Pressure?
It is an unfortunate fact that recent seemingly positive developments in the UK in the community treatment of individuals with severe mental illness – usually people afflicted with schizophrenia, schizoaffective disorder, mania and depression (often complicated or caused by drug use) – has coincided in a de facto deterioration in the lot of inpatients. Why has this come about? Well to understand this you have to understand what has been occurring in the development of community services.
Community mental health teams (“CMHT’s”) have changed from solely being so-called “generic” teams to having additional more specialised and smaller teams. There are generic teams still, but with a different focus – either Assessment and Brief Therapy teams (“ABT” teams) or Continuing Care Teams. The former take people in to CMHT management and look after them for 3 or 4 months, whilst the later take over the management thereafter if the person has a chronic illness and need for care (and most people with severe mental illness do).
What are the new teams? They are of two main types – Home Treatment Teams and Assertive Outreach Teams. The former offer home treatment as an alternative to admission, and early discharge to home treatment for those who are admitted having originally been judged too ill for home treatment. The latter, Assertive Outreach Teams, receive referrals from the other CMHT’s of patients who are liable to be difficult to manage in the community – individuals who are not willing to take medication as prescribed, individuals who have a record of frequent breakdown, individuals who are difficult to access, and so forth.
You might think this sounds all well and good, and so it is in principle. In practice there are a number of problems. The first is that inpatient units tend to become places where there is a concentration of an increasingly ill patient group – a much more challenging environment for fellow patients and staff, typically with more behavioural disturbance – i.e. violence and intimidation. Less ill patients are either treated at home or discharged early.
You might ask, “Well surely this means at least you have fewer patients overall as inpatients?” In practice not – indeed many inpatient wards now routinely run at 110% occupancy and have frequent bed crises. Thus you have more and iller patients.
Well at least you can increase the staffing levels you might think. Unfortunately you can’t – infact by making more though smaller CMHT’s you have to move staff from the inpatient units to the community. Why? Well there is an essentially fixed allocation of medical posts and salaries, especially training posts – the junior grades of senior house officer (SHO) and specialist registrar (SpR, formerly known as a senior registrar). Thus you have fewer medical staff managing a rising population of iller and more disturbed inpatients. Not only this you are having a higher turnover of patients which results in more admission clerkings for the juniors, more patients to work up, more investigations to organise, more relatives to see, and more admission reports to write (also known as admission summaries), and more Mental Health Act hearings to attend (tribunal hearings for detained patients).
What is the effect? Not infrequently low morale, burnout, and a loss of trainees to the speciality of general adult psychiatry. For the patient a more disturbed environment with less individual time from staff members, especially doctors. For patient care – apart from the obvious - little time to really work-up the patient’s existing and past history and complete investigations before home treatment beckons.
Not a good system to be unfolding nationally. What would help? – an increase in the provision of medical staff (some would say moving resource from managerial posts to front line care, and undoubtedly this will need to be done as it seems unlikely that there will be significant new money), targeting and remedying effectively the reasons why some people keep breaking down and being readmitted (the unfortunate phrase “revolving door patients” is used for this group but better would be “patients for whom community care has failed and needs improving”), and appointing someone to effectively manage those inpatients who are well, but cannot be discharged. This group can amount to as much as a third to a half of the ward. At about £300 a day this is a big “loss” of resource. In say a 21-bedded ward this amounts to say 7 x £300 a day (£2100) a day, times 7 for a weekly figure of about £14,000 a week. Is this picked up by Audit studies? Well you know the answer – no. How many wards serve a borough? – about 5. How many boroughs in the UK? Not a comfortable thought.
Having followed this you might well ask why are the number of patients needing an inpatient stay going up, given Assertive Outreach and Home Treatment – two seemingly positive developments. The answer reflects a number of factors – poor control of outflow factors (the patients no longer needing admission but with no accommodation to go to –“bed-blockers”), pressure on forensic psychiatry budgets with more forensic patients going to general services rather than forensic units, rising use of stronger drugs in the population – especially cocaine and “skunk” cannabis, possibly better pathways into CMHT’s through better liaison between GP’s and non-governmental mental health organizations, and other reasons besides. Arguably better CMHT’s “attract” more patients – which is good.
It is a difficult predicament. Not only are the wards often full, but also patients are under pressure to accept less ideal accommodation to clear space for other admissions – a factor behind some early breakdowns and readmissions.
Should you need admission to hospital you can still expect to find kind, highly professional staff who are generally well-motivated. However if you find them busy, stretched, and at times preoccupied with behavioural disturbance you will perhaps understand why. One thing should be clear – it is improbable that you would ever be kept in hospital longer than is necessary, and it is likely you will be offered home treatment as soon as you are well enough to safely receive it.
Community mental health teams (“CMHT’s”) have changed from solely being so-called “generic” teams to having additional more specialised and smaller teams. There are generic teams still, but with a different focus – either Assessment and Brief Therapy teams (“ABT” teams) or Continuing Care Teams. The former take people in to CMHT management and look after them for 3 or 4 months, whilst the later take over the management thereafter if the person has a chronic illness and need for care (and most people with severe mental illness do).
What are the new teams? They are of two main types – Home Treatment Teams and Assertive Outreach Teams. The former offer home treatment as an alternative to admission, and early discharge to home treatment for those who are admitted having originally been judged too ill for home treatment. The latter, Assertive Outreach Teams, receive referrals from the other CMHT’s of patients who are liable to be difficult to manage in the community – individuals who are not willing to take medication as prescribed, individuals who have a record of frequent breakdown, individuals who are difficult to access, and so forth.
You might think this sounds all well and good, and so it is in principle. In practice there are a number of problems. The first is that inpatient units tend to become places where there is a concentration of an increasingly ill patient group – a much more challenging environment for fellow patients and staff, typically with more behavioural disturbance – i.e. violence and intimidation. Less ill patients are either treated at home or discharged early.
You might ask, “Well surely this means at least you have fewer patients overall as inpatients?” In practice not – indeed many inpatient wards now routinely run at 110% occupancy and have frequent bed crises. Thus you have more and iller patients.
Well at least you can increase the staffing levels you might think. Unfortunately you can’t – infact by making more though smaller CMHT’s you have to move staff from the inpatient units to the community. Why? Well there is an essentially fixed allocation of medical posts and salaries, especially training posts – the junior grades of senior house officer (SHO) and specialist registrar (SpR, formerly known as a senior registrar). Thus you have fewer medical staff managing a rising population of iller and more disturbed inpatients. Not only this you are having a higher turnover of patients which results in more admission clerkings for the juniors, more patients to work up, more investigations to organise, more relatives to see, and more admission reports to write (also known as admission summaries), and more Mental Health Act hearings to attend (tribunal hearings for detained patients).
What is the effect? Not infrequently low morale, burnout, and a loss of trainees to the speciality of general adult psychiatry. For the patient a more disturbed environment with less individual time from staff members, especially doctors. For patient care – apart from the obvious - little time to really work-up the patient’s existing and past history and complete investigations before home treatment beckons.
Not a good system to be unfolding nationally. What would help? – an increase in the provision of medical staff (some would say moving resource from managerial posts to front line care, and undoubtedly this will need to be done as it seems unlikely that there will be significant new money), targeting and remedying effectively the reasons why some people keep breaking down and being readmitted (the unfortunate phrase “revolving door patients” is used for this group but better would be “patients for whom community care has failed and needs improving”), and appointing someone to effectively manage those inpatients who are well, but cannot be discharged. This group can amount to as much as a third to a half of the ward. At about £300 a day this is a big “loss” of resource. In say a 21-bedded ward this amounts to say 7 x £300 a day (£2100) a day, times 7 for a weekly figure of about £14,000 a week. Is this picked up by Audit studies? Well you know the answer – no. How many wards serve a borough? – about 5. How many boroughs in the UK? Not a comfortable thought.
Having followed this you might well ask why are the number of patients needing an inpatient stay going up, given Assertive Outreach and Home Treatment – two seemingly positive developments. The answer reflects a number of factors – poor control of outflow factors (the patients no longer needing admission but with no accommodation to go to –“bed-blockers”), pressure on forensic psychiatry budgets with more forensic patients going to general services rather than forensic units, rising use of stronger drugs in the population – especially cocaine and “skunk” cannabis, possibly better pathways into CMHT’s through better liaison between GP’s and non-governmental mental health organizations, and other reasons besides. Arguably better CMHT’s “attract” more patients – which is good.
It is a difficult predicament. Not only are the wards often full, but also patients are under pressure to accept less ideal accommodation to clear space for other admissions – a factor behind some early breakdowns and readmissions.
Should you need admission to hospital you can still expect to find kind, highly professional staff who are generally well-motivated. However if you find them busy, stretched, and at times preoccupied with behavioural disturbance you will perhaps understand why. One thing should be clear – it is improbable that you would ever be kept in hospital longer than is necessary, and it is likely you will be offered home treatment as soon as you are well enough to safely receive it.
posted by Dr Arthur Bostock at 10:26 AM
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