In-patient Services

In-patient services should be improved, with sufficient capacity for patients to be admitted locally into an appropriate ward. Improvements in ward conditions and the expansion of child and adolescent and intensive-care beds are key.

The need for a fair deal

Mental health services for adult and young people in the UK do not meet current demands for in-patient beds. Over-occupancy – where a ward has more patients on its admission list than available beds – remains a key problem. It can delay urgent admissions and prevent people being discharged on short-term leave or transferred to a more appropriate ward or hospital. It can hinder patient treatment and well-being, may affect ward atmosphere and patient safety, and place heavy demands on staff time. The College considers that lower occupancy levels for both adult and young peoples’ services of about 85% are necessary for effective and safe care.¹ Aligned with this issue is that of standards of in-patient care and quality of the environment, particularly for detained patients.

What we are calling for

• Bed occupancy levels that are sufficient to enable services to respond to and accommodate emergency admissions and which meet local levels of need.

• The development and adoption of common national standards for effective and efficient in-patient mental health services for adults and young people.

• Robust monitoring by the Care Quality Commission of bed occupancy and conditions for patients detained under the England and Wales Mental Health Act 2007.

• Legislation on delayed transfers of care to local authority housing, extending the scope of the Community Care Act 2003 to include mental health wards, thus removing the disparity between patients with mental and physical conditions.

Examples of what the College will do

• The College will, through its Centre for Quality Improvement, continue to survey, monitor, and develop standards for adult, forensic and child and adolescent mental health services (CAMHS) and learning disability in-patient services.

• We will campaign for more realistic capacity targets (recommended 85%) and better ward conditions for all patients, including those who are detained under mental health legislation.

Capacity: adult in-patients

A high or excessive rate of bed occupancy brings risks to patients and others because services are unable to admit patients in an emergency and may discharge others prematurely in order to create an available bed. It can prevent the opportunity to discharge patients on short-term leave.

The consequent overcrowding can compromise the safety, dignity and privacy of patients and their clinical treatment. Being moved between beds, wards or even hospitals because of over-occupancy clearly disrupts a patient’s care. Staff may find that the demands of bed management divert them from their primary nursing role. The Mental Health Act Commission found that the frustration and stress experienced by staff in over-occupied wards was harmful to staff morale, and that this had an indirect effect on the quality of patients’ experience on the ward.²

Although official statistics indicate bed occupancy levels among adult patients of between 85 and 92% in each of the four UK countries,^3–6 independent surveys have repeatedly found far higher occupancy levels ranging from 100 to 140%.^7,8 Mental health services in England and Wales also report a critical shortage of child and adolescent in-patient beds.⁹

Nick Nalladori, a carer on a College review of wards

'I am no clinician and do not know much about the operational aspects of an acute ward but what I observed was a well-motivated cohesive team working with an inspired leader who appeared quite flexible'. Nalladori observed a ‘culture of friendliness’ and the positive attitude of the staff: ‘they really cared and took pride in the work they did.'

In 2005/2006, more than two-thirds of the NHS budget for clinical mental health services in England was spent on in-patient psychiatric hospital care.¹⁰ However, in England, there are fewer in-patient beds now than at any other time since the introduction of the Mental Health Act in 1983.¹⁰ The Mental Health Act Commission found that between 2005 and 2007, 37% of all wards they visited were running at over 100% bed occupancy.¹⁰ Wards in London frequently had occupancy levels of 100% or more.⁹ Crisis resolution teams are intended to reduce the need for hospitalisation. However, as yet, they do not have sufficient staff to meet this aim.¹¹

In Wales, official statistics indicate that between 2005 and 2007 acute care wards were operating at 92% bed occupancy.⁵ However, the Mental Health Act Commission found that over the same period 40% of acute wards were operating above their bed capacity, with around 10% operating at more than 120% capacity.¹⁰

In Scotland, official statistics indicate an adult in-patient occupancy level for 2005–2006 of around 84%.⁴ However, the Scottish Mental Welfare Commission found average bed occupancy of 92% on in-patient wards, with 42% of wards having occupancy rates of 100% or more.⁸ Finally, in Northern Ireland, official statistics indicate average bed occupancy rates of 91%;⁶ however, published reviews suggest occupancy rates exceed 100%.¹² The Acute Bed Project, a survey conducted every 5 years by the Northern Ireland Division of the College, found in 2004 that:

 ‘bed occupancy in Northern Ireland has increased since 1999, approaching 100% saturation on average. It often exceeds 100% occupancy rates, meaning that two patients are allocated to one bed, and the frequency of this occurring has increased’.¹²

High bed occupancy does not arise only because the numbers of in-patient beds has been reduced but also because of ‘bed blocking’. It occurs usually when there is no local authority placement for a person with complex mental health needs or for a person who is homeless. Patients may remain in hospital for months after their need for hospitalisation has ended while they await transfer to local authority accommodation.

This has a lasting effect upon their own quality of life, prevents shorter-term patients from admission, and is expensive for mental health providers.¹³ In 2003, the government introduced the Community Care (Delayed Discharges, etc.) Act to address the problem of bed blocking in England and Wales. The Act introduced financial penalties for local authorities who failed to provide services to enable a patient to be discharged. However, this only applies to people with physical illness and does not cover people who are cared for in psychiatric hospitals.

Acutely ill patients may require short-term treatment in a secure psychiatric intensive care unit when their level of disturbance is such that they are unmanageable on open wards. A 2005 survey of psychiatric intensive care units in London found average bed occupancy rates of 90%, and on some wards rates of up to 140%.¹⁴

Colin Gell, Chair of Service User Recovery Forum (SURF)

‘The atmosphere on most wards is, at best, tense and at worst, dangerous. Walk onto any ward and you immediately feel this. We need to create a calmness and interest on wards that is beneficial. People exhibiting the more extreme behaviour are seen as a nuisance and there is a double stigma. These people are already stigmatised by being on the ward but are seen as the "nutter" by other people on the ward. They then find their behaviour very embarrassing when they are better.'

Capacity: child and adolescent in-patients

There are insufficient mental health beds available to meet the current needs of children and adolescents in the UK. Between 2000 and 2005, 34% of child and adolescent mental health units were unable to admit emergency patients,¹⁵ 44% were unable to admit out of hours, and in 2005 consultants estimated they turned away 72% of referrals for emergency admission.¹⁶

Of further concern are reports of children and adolescents being admitted and treated on adult mental health wards because of a lack of in-patient beds. A third of admissions of mentally ill young people are inappropriate admissions to adult psychiatric or paediatric wards.¹⁷

Between 1999 and 2006 the number of in-patient units has increased in England and Wales. However, the majority (69%) of this increase is attributed to the private sector whose market share rose from 25% in 1999 to 36% in 2006 often involving placements a long way from home.¹⁶ There is also considerable geographical variability in the number of beds available across England and Wales. The Royal College of Psychiatrists recommend a minimum of 20 CAMHS beds per million population.⁹ In 2006, however, four regions within England were still well below this minimum.¹⁶

Conditions in in-patient wards

Conditions in wards have been criticised in recent reports.^7,10,18,19 Incongruities between official environmental audits and anecdotal evidence suggest there are many challenges to improving the quality of care in wards. A 2004 survey by Mind found that almost a quarter of recent in-patients in England and Wales had been accommodated in mixed-gender wards, and 27% of respondents said they rarely felt safe while in hospital.¹⁹

In 2008, the Mental Health Act Commission reported that the busy acute wards ‘appear to be tougher and scarier places than we saw a decade ago’.¹⁰ Despite concern about the adequacy of staffing levels in mental health services, there are no universally agreed standards.

The Mental Health Act Commission and nursing staff themselves considered some staffing levels to be unsafe. Patients complained that staff shortages reduce opportunities for escorted leave from the ward and that it was very difficult to develop a rapport with a constantly changing nursing staff.¹⁰

As the Commission points out, patients who are detained under Mental Health Act powers are placed in a quite different situation from many other NHS in-patients. They have not agreed to come into hospital and in some cases do not accept the need for admission, and may not discharge themselves from a ward that they find intolerable.

The new Care Quality Commission will take over the functions of the Mental Health Act Commission to monitor the care and treatment of detained patients in England and Wales. It will be important to ensure that their work is of a similar rigorous standard as that of the Mental Health Act Commission.

Case study

Mental Health Act Commission Findings 2006–2007

We have found wards that are unventilated and hot in summer but cold in winter; wards where there is little natural light; noisy and smoky wards; broken, worn and stained furniture, sticky floor and bad smells; vermin and cockroach infestation; peeling paint and graffiti; non-existent or broken lockable storage for patients’ belongings. We have had cause to comment on broken and dirty toilet facilities and on inadequate numbers of toilet and bathroom facilities.

What the College is doing: College Centre for Quality Improvement

The Centre for Quality Improvement is developing and promoting standards for a range of in-patient settings including:

Acute In-patient Mental Health Services (AIMS) is a ward-based accreditation service which engages clinical staff, service users and carers in recognising and sharing good practice. It accredits wards that demonstrate that they provide a 'timely and purposeful admission in the context of a safe and therapeutic environment': of 129 member wards, 37 have been accredited, 5 with excellence.

Learning Disability Accreditation Programme aims to raise standards in specialist residential services for adults and young people with learning disability. It is a response to a Health Care Commission review of 638 units across 72 NHS trusts and 17 independent providers which concluded that there were unacceptably wide variations in the standards of care.

Adaptations that adult wards must make to accommodate young people who are admitted to adult wards despite the requirement for admission to an age-appropriate environment. This will be helpful in the short-term (and for exceptional circumstances), while hospitals plan in the long term for accommodation for CAMHS patients.

References

1   Royal College of Psychiatrists (1988) Psychiatric Beds and Resources: Factors Influencing Bed Use and Service Planning. Gaskell.

2   Mental Health Act Commission (2006) Who’s Been Sleeping in My Bed? The Incidence and impact of Bed Over Occupancy in the Mental Health Acute Sector. Mental Health Act Commission.

3   Department of Health (2006–7 data). Bed availability and occupancy, England. (http://www.performance.doh.gov.uk/hospitalactivity/data_requests/beds_open_overnight.htm).

4   Information Services Division NHS Scotland. Available beds by specialty and NHS board of treatment, 1997/98 to 2007/08. (http://www.isdscotland.org/isd/information-and-statistics.jsp? pContentID=3426&p_applic=CCC&p_service=Content.show&).

5   Health Service for Wales (2006–7 data). StatsWales. Welsh Assembly Government. http://www.statswales.wales.gov.uk/index.htm

6   Department for Health, Social Services and Public Safety in Northern Ireland (2006–7 data). Hospital Statistics. DHSSPSNI. (http://www.dhsspsni.gov.uk/index/stats_research/stats-activity_stats-2/hospital_statistics.htm#hospital).

7   Garcia, I., Kennett, C., Quraishi, M., et al (2005) Acute Care 2004: A National Survey of Adult Psychiatric Wards in England. Sainsbury Centre for Mental Health.

8   Mental Welfare Commission for Scotland (2006) Unannounced Visit Report 2005. Mental Welfare Commission.

9   Royal College of Psychiatrists (2006) Building and Sustaining Specialist Child and Adolescent Mental Health Services. Council Report CR137. Royal college of Psychiatrists.

10   The Mental Health Act Commission (2008) Risk, Rights and Recovery. Twelfth Biennial Report 2005–2007. TSO (The Stationery Office).

11   National Audit Office (2007) Helping People Through Mental Health Crisis: The Role of Crisis Resolution and Home Treatment Services. TSO (The Stationery Office).

12   Neil, J. & McNeill, O. (2004) The Acute Bed Project. Royal College of Psychiatrists, Northern Ireland Division.

13   Care Services Improvement Partnership (2007) A Positive Outlook: A Good Practice Toolkit to Improve Discharge from Inpatient Mental Health Care. National Institute of Mental Health in England.

14   Pereira, S., Sarsamk, M., Bhui, K., et al (2005) The London Survey of Psychiatric Intensive Care Units: service provision and operational characteristics of National Health Service units. Journal of Psychiatric Intensive Care, 1, 7–15.
doi:10.1017/S1742646405000038

15   Cotgrove, A., McLoughlin, R., O’Herlihy, A., et al (2007) The ability of adolescent psychiatric units to accept emergency admissions: changes in England and Wales between 2000 and 2005. Psychiatric Bulletin, 31, 457–459.
doi:10.1192/pb.bp.106.013979

16   O’ Herlihy, A., Lelliott, P., Bannister, D., et al (2007) Provision of child and adolescent mental health in-patient services in England between 1999 and 2006. Psychiatric Bulletin, 31, 454–456.
doi:10.1192/pb.bp.106.013870

17   O’Herlihy, A., Worrall, A., Lelliott, P., et al (2002) Distribution and characteristics of in-patient child and adolescent mental health services in England and Wales. British Journal of Psychiatry, 183, 547–551.
doi:10.1192/bjp.183.6.547
PMid:14645027

18   Mental Health Act Commission (2006) In Place of Fear? Eleventh Biennial Report 2003–2005. TSO (The Stationery Office).

19   Mind (2004) Ward Watch. Mind.