Acute hospital care: ineffective, inefficient and poorly organised

Despite all the emphasis on community develop ments during the last decades, especially since the introduction of Caringfor People (Department of Health, 1989) and somewhat ambiguously reinforced by the present government in Modern ising Mental Health Services (Department of Health 1998a), figures show that the hub of mental health care is still the hospital. Take cost: In 1997/98 national expenditure by health authorities on in-patient care was 65% of the overall mental health budget (Health Select Committee. 1998). A comparable picture Is shown for staff. The large majority of nurses are still working on the wards, probably as many as 75% (Department of Health, 1998b), although these figures are not wholly reliable due to classification problems. These figures might be seen as surprising if contrasted with the decline in bed numbers. Overall numbers of NHS beds for people with mental illness were down to 38 780 in 1996/97 from 50 280 in 1991/93 (Department of Health, 1998c). Most of this reduction is due to transfer of long-stay beds from the NHS to private nursing homes and residential places. Intriguingly, the highest proportional increase is for beds in secure units, whereas adult acute beds have shown an 11% reduction to 14 500 places. Hardly numbers that one would have thought capable of consum ing such a large proportion of resources. This apparent contradiction is explained by clinical activity. Rates of admission per 1000 population has increased slightly from 4.2 to 4.4 between 1991/92 and 1995/96, but from 3.7 to 4.6 (more than 20%), for the key group aged 2024 years old. In England and Wales, 89% of admissions are unplanned emergencies and about 30% of people are admitted under a Section of the Mental Health Act 1983 (Ford et al 1998), but this figure rises to 57% of patients in inner London (Ward et al 1998). Unsurpris ingly, duration of stay has dropped and occu pancy rates have gone through the roof. Reports of occupancy rates of over 100% are frequent, with rates especially high in inner cities (Shep herd et al, 1997; Ford et al 1998). This intense pressure on beds has changed the profile of patients on psychiatric wards. Inpatient units are filled with highly disturbed people, 75% with a diagnosis of schizophrenia (Shepherd et al, 1997), and growing proportions have complex problems, whether social, psycho logical or physical. The main concern now must be whether patients with the most severe mental illnesses have the opportunity to recover suf ficiently to cope with the demands of community living again on discharge, and whether our hospital wards offer acceptable conditions to do so. Considering the attention given to the quanti tative aspects of hospital care, it is surprising how little is known about what is actually happening on our wards. Very little research has taken place during the last decade studying conditions on in-patient wards or the styles of inpatient care most therapeutic for a changing population. A few publications allow us a glimpse and impressions are not reassuring. A nationwide spot visit of acute adult wards by the Mental Health Act Commission (Ford et al 1998) reported that on a quarter of wards no nursing staff were interacting with patients at the time of the visit. The high staff vacancy rate, the 30% of staff working on a casual basis, and especially the large number of staff pre-occupied with safety procedures such as 'specialling' or 'doorduty' may explain much. In inner London just over 50% of night-staff are agency or bank staff or are working overtime (Ward et al, 1998). A recent study of acute wards by the Sainsbury Centre (Sainsbury Centre for Mental Health, 1998) adds some detail. Most striking is the lack of rehabilitative activity: 40% of patients did not take part in any social or recreational activity during their stay, 30% not even in therapeutic activities. Five per cent received psychological therapies. Interestingly, doctors were seen rela tively frequently 11 contacts during an average 38-day stay. Another study found that patients spend 4% of time with staff and 28% doing nothing or watching television (NuffieldInstitute for Health, 1996). All this suggests an atherapeutic environment, a care vacuum, rather than a place offering the most intensive therapeutic interventions to the most vulnerable and unwell