Use of acute psychiatric beds: a point prevalence survey in North and South Thames regions

Expert Arguments for Trends of Psychiatric Bed Numbers: A Systematic Review of Qualitative Data

Introduction: Mental health policies have encouraged removals of psychiatric beds in many countries. It is under debate whether to continue those trends. We conducted a systematic review of expert arguments for trends of psychiatric bed numbers. Methods: We searched seven electronic databases and screened 15,479 papers to identify expert opinions, arguments and recommendations for trends of psychiatric bed numbers, published until December 2020. Data were synthesized using thematic analysis and classified into arguments to maintain or increase numbers and to reduce numbers. Results: One hundred six publications from 25 countries were included. The most common themes arguing for reductions of psychiatric bed numbers were inadequate use of inpatient care, better integration of care and better use of community care. Arguments to maintain or increase bed numbers included high demand of psychiatric beds, high occupancy rates, increasing admission rates, criminalization of mentally ill, lack of community care and inadequately short length of stay. Cost effectiveness and quality of care were used as arguments for increase or decrease. Conclusions: The expert arguments presented here may guide and focus future debate on the required psychiatric bed numbers. The recommendations may help policymakers to define targets for psychiatric bed numbers. Arguments need careful local evaluation, especially when supporting opposite directions of trends in different contexts.

Acute mental health admissions in inner London: changes in patient characteristics and clinical admission thresholds between 1988 and 1998

Aims and Method

We undertook a retrospective case-note review of three cohorts of mental health admissions to determine the extent to which patient and service characteristics changed between 1988 and 1998. Changes in clinical admission thresholds were investigated by a psychiatrists' review of handwritten medical admission assessments.

Results

Patients admitted in 1998 were demographically less stable and clinically more complex than those admitted 10 years earlier. Clinical admission thresholds remained consistent.

Clinical Implications

Our findings suggest that the perceived increase in pressure on psychiatric services over this period was a response to a change in population need. This study highlights important questions about the clinical decision-making process leading to use of alternatives to admission and the appropriateness of acute admissions.

Full metal jacket or the emperor's new clothes?

Launched with little more than a whimper during the Labour Party Conference the much vaunted National Service Framework for Mental Health (NSF–MH) outlines the Government's ‘ambitious agenda’ for mental health services (Department of Health, 1999a). The official driving force has been the desire to deliver a quality service throughout the whole NHS via clinical governance and underpinned by professional self-regulation. Developed following widespread consultation and with the advice of the External Reference Group (although some of this advice was clearly disregarded), the NSF–MH provides a series of seven core standards with examples of good practice. Although developed with general psychiatry and severe mental illness in mind, the NSF is not quite the ‘National Schizophrenia Framework’ that some envisaged, since it also acknowledges the needs of young people and the influence of developmental factors on adult mental health. The NSF–MH sets standards in five areas: mental health promotion, primary care and access to services, services for the severely mentally ill, caring about carers and preventing suicide. It is only the second to be published (the other being for coronary care) which is hopefully a reflection of the ‘priority’ once more being given to mental health. However, the near-simultaneous appointment of a cancer ‘tsar’ suggests that ‘priority’ is a readily used and easily diluted term.

Associations of homelessness and residential mobility with length of stay after acute psychiatric admission

BACKGROUND

A small number of patient-level variables have replicated associations with the length of stay (LOS) of psychiatric inpatients. Although need for housing has often been identified as a cause of delayed discharge, there has been little research into the associations between LOS and homelessness and residential mobility (moving to a new home), or the magnitude of these associations compared to other exposures.

METHODS

Cross-sectional study of 4885 acute psychiatric admissions to a mental health NHS Trust serving four South London boroughs. Data were taken from a comprehensive repository of anonymised electronic patient records. Analysis was performed using log-linear regression.

RESULTS

Residential mobility was associated with a 99% increase in LOS and homelessness with a 45% increase. Schizophrenia, other psychosis, the longest recent admission, residential mobility, and some items on the Health of the Nation Outcome Scales (HoNOS), especially ADL impairment, were also associated with increased LOS. Informal admission, drug and alcohol or other non-psychotic diagnosis and a high HoNOS self-harm score reduced LOS. Including residential mobility in the regression model produced the same increase in the variance explained as including diagnosis; only legal status was a stronger predictor.

CONCLUSIONS

Homelessness and, especially, residential mobility account for a significant part of variation in LOS despite affecting a minority of psychiatric inpatients; for these people, the effect on LOS is marked. Appropriate policy responses may include attempts to avert the loss of housing in association with admission, efforts to increase housing supply and the speed at which it is made available, and reforms of payment systems to encourage this.

Residential mobility among patients admitted to acute psychiatric wards

Residential mobility among those with mental disorders is consistently associated with hospital admission. We studied 4485 psychiatric admissions in South London, aiming to describe the prevalence, timing and associations of residential moves occurring in association with admission. Moves tended to cluster around discharge; 15% of inpatients moved during admission or up to 28 days after discharge. The strongest associations were with younger age (especially 16-25 years) and homelessness. Unadjusted effects of gender, marital status and previous service use were mediated by homelessness. Possible mechanisms for the associations with homelessness and younger age are discussed.

The bed requirement inventory: a simple measure to estimate the need for a psychiatric bed

OBJECTIVE

To develop an assessment of bed need that was as little affected by personal bias as possible.

METHOD

The Bed Requirement Inventory (BRI) is an eight-point scale designed to identify the appropriate use of an acute psychiatric bed. This is completed by a member of the ward staff, usually a nurse, and takes 5 minutes to fill in. The reliability, validity and feasibility of using the scale in normal practice were tested in a one-year study, and variations in inappropriate bed use described.

RESULTS

The inter-rater reliability of the scale was good (intra-class correlation coefficient = 0.63) and a comparison of the need for a psychiatric bed (comparing the BRI score with the judgement of an independent multidisciplinary group of professionals) also showed good agreement (k = 0.69), suggesting reasonable validity (although when the assessment was made by the named nurse agreement was less good). Results from a year-long survey in two West London hospitals showed that 17% of admissions were inappropriate and 32% had delayed discharge, black Caribbean patients had a significantly higher proportion (25%) of inappropriate admission than others (11%) and those referred from housing charities and hostels had a higher proportion (50%) of inappropriate bed use at some time than other groups (33%).

CONCLUSIONS

The Bed Requirement Inventory is a quick and reliable method of determining the appropriate use of a psychiatric bed and could be of use in estimating local bed needs. Delayed discharge remains a serious reason for inappropriate bed use in London.

Psychiatric hospitalization: reasons for admission and alternatives to admission in South Auckland, New Zealand

OBJECTIVE

To describe reasons for admission and alternatives to admission in a government funded acute inpatient unit.

METHOD

Reasons for admission and alternatives to admission were rated for a consecutive sample of 255 admissions to an acute psychiatric unit in Auckland, using interviews with staff and case note review.

RESULT

Most patients had a functional psychosis and were admitted involuntarily. Forty percent came from areas of marked social deprivation. The major reasons for admission were for reinstatement of medication (mainly linked to non-concordance with prescribed medication), intensive observation, risk to self and risk to others. Only 12% of admissions could have been diverted, of whom most would have required daily home treatment. For those still admitted at 5 weeks, 26% could have been discharged, mainly to 24 h nurse-staffed accommodation. If the alternatives had all been available, simulated bed-day savings were 11 bed years per year. Simulated bed day savings were greater through implementing early discharge than by diverting new admissions.

CONCLUSION

Greater availability of assertive community treatment and of interventions to improve medication concordance may have prevented a small number of admissions. For patients admitted longer than 5 weeks, it appeared that greater availability of 24 h nurse-staffed accommodation would have allowed considerable bed-day savings.

Homelessness and the use of acute psychiatric beds: findings from a one-day survey of adult acute and low-level secure psychiatric patients in North and South Thames regions

This paper describes the impact of homelessness on the use of adult acute and low-level secure psychiatric beds in North and South Thames regions. We specifically focus on those homeless patients who no longer required the acute psychiatric facilities in order to determine the complement of accommodation and alternative services necessary to enable them to be discharged. A point prevalence survey of all patients occupying adult acute and low-level secure psychiatric beds in North and South Thames regions was carried out on 15 June 1994. All patients occupying adult acute and low-level secure psychiatric beds in 54 mental health providers and seven private psychiatric units in North and South Thames regions were included in the survey. Demographic, admission, and diagnosis data were collected. Homeless patients were identified as those patients not living in permanent accommodation. Ward managers (nurses) were also asked to identify patients who, in their opinion, no longer required acute care and to identify more appropriate provision for these patients. Of the 3978 adult and low-level secure patients enumerated 20.5% (817) were recorded as homeless. A total of 306 homeless patients were identified by ward staff as inappropriately located, of whom 58.2% of were unsuitable to be discharged into the community but still required some form of alternative health provision, for example staffed-housing in the community and in-patient rehabilitation services based in hospitals. However, 51.8% of patients were suitable to be discharged back into the community and the majority required housing as a key component within their 'package of care'. Homeless psychiatric in-patients have contributed to the increasingly precarious state of mental health services provision and represent a failure to provide a sufficient level of community alternatives for those who can no longer access the long-stay hospital services, and for whom the pool of acute psychiatric beds is ever reducing.

Ethnicity and use of acute psychiatric beds: one-day survey in north and south Thames regions

BACKGROUND

Previous studies have shown higher rates of psychiatric admissions, compulsory admissions, and diagnosed schizophrenia in Black ethnic groups compared with other population groups.

METHOD

In a point-prevalence study, demographic and clinical data were collected for adult acute and low-level secure psychiatric in-patients in all National Health Service and seven private psychiatric units in North and South Thames regions on 15 June 1994.

RESULTS

A total of 3710 adult acute and 268 low-level secure psychiatric patients were surveyed; 75% of the patients were White, 16% were Black, and 4% were Asian. Analysis reveals that a high proportion of the Black population were admitted to a psychiatric unit; that Black patients are more likely to be admitted under Section; to be located in locked wards; have an inpatient diagnosis of schizophrenia; and not be registered with a general practitioner.

CONCLUSIONS

These findings demonstrate the over-representation of Black ethnic groups within current psychiatric provision. The complement of services to all minority ethnic groups should be examined in terms of access, appropriateness and quality of care. Racism awareness and staff training need to be incorporated into mental health service provision as a matter of priority.

The Nottingham Acute Bed Study: alternatives to acute psychiatric care

BACKGROUND

Although modern psychiatric services seek alternatives to hospitalisation wherever appropriate, the national trend toward higher bed occupancies on acute psychiatric wards has refocused attention on community-based alternatives and methods of assessing reed for acute care.

METHOD

We surveyed key decision makers in a community-oriented district service with a low acute psychiatric bed to population ratio, in order to examine alternatives to hospitalisation in a cohort of consecutive admissions over a six-month period.

RESULTS

Alternatives to acute ward hospitalisation were identified for 29% of admissions, and for 42% of those with an admission duration of more than 60 days. Residential options were chosen more often than intensive community support. Simulated bed day savings were considerable.

CONCLUSIONS

In a community-oriented service, key decision-makers could identify further alternatives to acute ward hospitalisation, although relatively few non-residential, community support options were chosen. Although this methodology has limitations, data based upon keyworker judgements probably have greater local 'ownership', and the option appraisal process itself may challenge stereotyped patterns of resource use.