Beds – there is a problem but the main solutions lie outside hospital
No controversy rages more fiercely in healthcare, and in particular mental health care, than that of whether there are enough beds. Although it is 20 years since the closure of the last long stay mental health hospital, the number of beds still holds significant sway as the working currency of psychiatric care. The debate is a philosophical one as well as a practical one. One side of the debate sees beds as the epitome of oppressive medically dominated care, in some cases arguing that with the right community resources there may be no need for beds at all, or at least not for what we currently define as psychiatric inpatient beds. Others see the gradual erosion of inpatient beds as a big mistake and cites the undoubted pressure on resources in some parts of the country as proof of the urgent need for new capacity to be opened.
Pressure there undoubtedly is some parts of the country. The routine use of out of area placements for non-specialist cases and the deplorable increase of the use of police stations as a place of safety are clear evidence of a system which is not working properly. The Royal College of Psychiatrists has established an independent Commission under the chairmanship of Lord Nigel Crisp, former Chief Executive of the NHS, to look into the issues around the pressures on inpatient beds.
My own view rests in the middle of this debate. I think there is clear evidence of an intolerable pressure in the system in some parts of the country, in part due to increased demand and in part reflecting cuts in services (not just in bed numbers). I also think that it is unacceptable that patients in acute mental distress should have travel a long distance from home to access a routine inpatient beds. However I do not believe that the answer is necessarily to open more beds although I would accept that in some places this may be necessary, at least in the short term.
So what are the answers?
First there is a question of the political and another commitment to ensure this issue is addressed. This has to be a major a test for the principle of parity of esteem. It is been interesting to see the effort which has been put in over the last couple of months to respond to concerns about performance against the 4 hour wait target for A&E. Why should there not be a similar level of interest to ensure that everyone in mental health crisis and who needs a bed or appropriate alternative gets one without having to travel out of area or ending up first in a police station? The Crisis Concordat has been positive and helpful first step but why is the response to a broken leg transparently still more important than the response to a broken mind?
There is a big place for effective alternatives to admission. Just as we are beginning to do in respect of physical health care we need to look clinically at the kind of intervention which is required in the community to keep people well supported and safe in the community. While mental health has spawned a number of excellent specialist services such as Home Treatment teams , the unevenness across the country in the level of provision and, at times, a lack of integration with other community based provision whether in the form of primary care or community mental health teams can reduce their effectiveness.
Part of the response for me would to invest in short term community based residential alternatives such as the Recovery Houses which, as I know from my time at Rethink Mental Illness, voluntary sector providers are well placed to provide, working alongside Home Treatment Teams. Such provision has the ability to provide an effective alternative to admission for many of the patients who would, historically, have been admitted as voluntary patients.
The third strand of action is around how we manage the existing inpatient provision. The heart of this is to ensure that there is a clear therapeutic purpose for the admissions we make and the necessary provision to ensure the necessary resources exist to support recovery. Benchmarking data demonstrates that inpatient units with greater capacity to provide psychological support for patients experience shorter lengths of stay. Inpatient care cannot only be defined as place of last resort for patients who cannot be safely managed in the community. We also need to focus on the support and welfare of staff and recognise that inpatient wards are amongst the hardest places we ask mental health professionals to work.
My final point relates to commissioning. There is challenge here for local commissioners who have not always taken as full a sense of responsibility as they might for commissioning the right level of inpatient provision nor pushed providers as far as they could to ensure the provision available is of the best standard. There is much good practice available in this area and accreditation schemes such as the Royal College of Psychiatrists AIM scheme or improvement initiatives such as Star Wards should be the norm for any commissioning worth its salt.
My other commissioning issue relates to secure care. My answer to the beds conundrum is probably that we do need more local inpatient provision but, at the same time, fewer medium secure beds. As I said at the time of Rethink Mental Illness’ Schizophrenia Commission report it is a scandal that we spend around 20% of the whole adult mental health budget on secure provision. Much of the problem is a commissioning one and it is of no help that there is now a fault line between locally commissioned inpatient provision and nationally commissioned secure beds.
So in conclusion the pressure on acute mental health beds is indeed a major source of concern and a testament to how far we need to go to secure parity of esteem. At the same time, as in physical care the major solutions to the problem lie outside the hospital and the success or otherwise with which we can join up the system of care which can intervene before people reach crisis point and intervene quickly and sympathetically if they do.