Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Misleading English
- John B Peniket (18 August 2002)
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The virtual asylum: a destructive editorial.
- Philip A Sugarman, Lorna Duggan and Geoff Dickens (21 August 2002)
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No Lessons Learned
- Leila B Cooke, Dr Peter Carpenter (23 August 2002)
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Re: Editorial 17 August 2002 “The NHS, the Private Sector, and the Virtual Asylum”
- John C Hughes (30 August 2002)
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Commercial oversensitivity
- Rob Poole, Tony Ryan, Service Development Manager and Research Fellow, North West Development Centre, Alison Pearsall, Lecturer in Mental Health, University of Salford. (2 October 2002)
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John B Peniket, Secretary Gloucestershire LMC Gloucester GL1 2RU
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Sir, It is disappointing that you have allowed the editorial “Physical activity for preventing strokes” (BMJ 325, 17.8.02 p. 350) to have been spoiled by poor English. Surely the theme of the editorial is that “Clear evidence links physical INactivity to the incidence of strokes.”? John B Peniket |
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Philip A Sugarman, Medical Director St Andrew's hospital NN1 5DG, Lorna Duggan and Geoff Dickens
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Sir We are surprised to read an editorial of this tone in BMJ, with such stigmatising language and strong opinions, but without cited evidence. Of course the piece does set out many undisputed facts such as the decline of the county asylums and the current inadequate provision of NHS mental health beds. No evidence, however, is cited to support the description of difficult to manage patients in the independent sector, poorly staffed small units, or the lack of activity or rehabilitation for patients. What evidence there is does not support any of these claims 1, 2. Paradoxically, the acknowledgement that larger independent facilities may give a higher quality of care than the NHS is also left unsupported. Further criticisms are made of NHS services and planning, again without evidence. No mention is made at all of the rapid regionalisation of independent sector facilities, a key development in meeting patients needs more locally. Quite how the authors perceive a lack of any policy framework or regulation to protect patients is unclear. The Care Standards Act3 has introduced the National Minimum Care Standards, as part of a stringent framework of policy, clinical standards and inspection, in addition to that provided for patients by the Mental Health Act Commission. Under the aegis of the Independent Healthcare Association, both private and voluntary sector members are also subject to external quality control, such as the King’s Fund Health Quality Service. Interestingly, the Care Standards Act does not apply to the NHS. Offering phrases such as “private madhouse”, “acculturation to institutional life” and “virtual asylum”, the authors raise the possibility of the “private sector" being discredited in a "destructive moral panic". No evidence is given as to why this has become in any way likely, except perhaps as an effect of such palpable hostility. In our view their piece is an example of the conflicted thinking on “public- private partnership” still prevalent in the state sector. It is exactly this which blights NHS planning for constructive partnership, and needs to be addressed in the interests of patients. Dr Lorna Duggan, Consultant Forensic Psychiatrist in Developmental Disabilities Dr Philip Sugarman, Medical Director Mr Geoff Dickens, Chair of Research St Andrew's Hospital, Billing Road, Northampton NN1 5DG Conflict of interest: We are employees of the St Andrew's Group of Hospitals, a registered charity providing specialist psychiatric care in Northamptonshire, Essex and Middlesex. References 1. Moss, K. (2000) A comparative study of admissions to two Regional Secure Units and one independent medium secure hospital. Medicine, Science and the Law, 40, 216–23 2. Lelliott, P., Audini, B. and Duffett, R. (2001) Survey of patients from an Inner-London health authority in medium secure psychiatric care. The British Journal of Psychiatry, 178, 62-6. 3. Department of Health (2000) Care Standards Act, Stationery Office. London. |
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Leila B Cooke, Consultant Psychiatrist in Learning Disabilities New Friends Hall, Heath House Lane, Stapleton, Bristol, BS16 1EQ, Dr Peter Carpenter
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Editor The recent editorial on "The NHS, the private sector and the virtual asylum" must have struck a chord with many psychiatrists.(1) The move from "institutional" to "community" care has occurred later in learning disability services but the same mistakes are being repeated. Around Bristol we have closed the large hospitals for people with learning disability. There are now only 12 admission beds for a population of 1 million and 40 rehabilitation beds which are earmarked for closure over the next year. The loss of over 1200 NHS beds has been replaced with over 1200 private residential care or nursing home beds. For over ten years Social Services have been seen as the main commissioners of care for people with learning disability and with the new partnership boards are to commission residential health care. We still see no evidence of them having the knowledge, strategic vision, will nor manpower to ensure that the private sector overall provides a comprehensive local service, able to deal with a wide range of challenges and needs in an individual manner. There has been no provision planned for the longer term care of detained patients, forensic patients, or those who require rehabilitation by skilled staff. The private sector is subject to market forces and therefore can be responsive to service needs, but it needs good leadership to develop high quality entrepreneurial services. The new private system is open to an external inspection that has teeth to maintain good basic care and a healthy environment, but in learning disability, as in mental health, there is little good supervision of the quality of clinical care provided for the individual. The local disaggregation into five Primary Care Trusts and their partnership boards has now apparently made it impossible to plan jointly the provision of new expensive tertiary or quaternary services. Now the commissioning costs are divided, each is faced with funding expensive emergency placements, without the resources to plan a less expensive service proactively. These emergency placements have cost as much as £750,000 per annum. When longer term skilled placements are needed, people still go out of area, where they are less supervised by the local team and there is little incentive for the provider to rehabilitate them. Until we can obtain good commissioning and good placement supervision along with an effective mechanism to plan together, then patients and their families will continue to suffer and money will be wasted. Yours sincerely Dr Leila B Cooke
Dr Peter Carpenter
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John C Hughes, Chief Executive Bowden House Clinic HA5 4DH
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Dear Sirs: Your 17th August editorial “The NHS, the Private Sector, and the Virtual Asylum” naively understates and misrepresents the contribution of us independent psychiatric providers. The DOH figures cited (www.doh.gov.uk/HPSSS/TBL B23) helpfully give us more information than your authors report. This table shows the NHS with 34,210 (55%) inpatient psychiatric beds and the independent sector with 28,780 (45%), both of which exclude residential care units. The authors complain that independent operators are “…disbursed, invisible and not properly regulated…”. Count me among those who are delighted that these 28,780 beds are disbursed; they are mostly small establishments which respond fast to the call to provide community care on a 24 hour, 365 day basis. They are not invisible: they are shiny, clean, proud, quasi-public institutions which devote huge effort to visibility in order to attract inpatient and outpatient customers. They are heavily regulated by the National Care Standards Commission, Kings Fund Health Quality Service, the Mental Health Act Commission, private medical insurers, malpractice insurers, and other regulatory bodies in varied ways which NHS hospitals are not. Our strictest regulation comes from NHS GPs and specialist teams who refer to us. Each receives a confidential weekly status report, each is invited to periodic care programme planning meetings (CPAs), and each receives a discharge summary by fax or email on the date of discharge. Our consultants do ward rounds at least three times per week as a condition of their contracts. If professional referrers are dissatisfied with the service their patients receive they have freedom of choice to select another independent unit from among twenty or more organisations who compete on the basis of quality, immediacy of response, and price. This market discipline has in fact ruthlessly closed more than ten independent units in the last decade via withholding referrals – and we are all better off because of it. The cited DOH statistics also show 231,000 completed consultant episodes in NHS psychiatry in 1998. That means our small, 400-bed organisation’s 3,600 acute admissions this year makes a contribution to public health roughly equal to 1.7% of the NHS’ total provision. A census of 60 competing private establishments and 200 consultant psychiatrists in full time private practice would run this tally up to perhaps 25% of total provision in all acute care and high dependency areas of psychiatry. Half of this work is NHS funded and half self -funded in cash or via private medical insurance schemes which the authors don’t mention. Everyone wants the debate to continue so that all psychiatric providers – public, voluntary sector and independent can best serve patients. But you need to inform your readers with hard facts on all sectors. Please avoid perpetuating naïve misconceptions. Sincerely yours, John C. Hughes
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Rob Poole, Consultant Psychiatrist Mersey Care NHS Trust, Windsor House, Liverpool, L8 7LF, Tony Ryan, Service Development Manager and Research Fellow, North West Development Centre, Alison Pearsall, Lecturer in Mental Health, University of Salford.
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Dear Sir We are disappointed, although not entirely surprised, that our editorial has provoked a defensive and tendentious response from St. Andrew’s and their business partners Cygnet Inc (1,2). Our editorial is not an attack on the private sector, and it contains no criticisms of Cygnet or St Andrew’s. It explicitly concerns the system of care for long stay in-patients. John Hughes seems to have used the opportunity to advertise the full range of his company’s services, much as he did in a recent Sunday Times article (3). Contentious though his assertions are, they are a distraction from the point at hand. The problems we have described are widely recognized in mental health, and evidently also in the field of learning disabilities (4). They cause concern to responsible private sector providers. The regulatory bodies are aware of the limitations of focusing on institutional processes, but they have no mechanism to monitor individual care. The St Andrew’s correspondents (1) correctly identify a lack of information in the public arena. Research is very much needed to develop an informed understanding of the needs of this group of patients, the long-term process of care outside of the NHS and the barriers that impede their return to district of origin services (where appropriate). However, to date there seems to have been limited academic or clinical interest in exploring the needs and wishes of these often highly excluded patients and their families. Sadly we cannot have great confidence in the openness of institutions to investigate sensitive concerns when they feel so easily stigmatized by the neutral use of accepted historical terminology (private “madhouses”) and observable processes (acculturation to institutional existence). We are not opposed to the involvement of the private sector in long- term inpatient care; indeed it is fortunate that the private sector has been so swift in providing extra bed capacity for these patients who have been failed by the NHS. It may be the case that some private sector facilities offer a better quality of care than NHS provision. However, that does not negate the problems of an absence of effective care co ordination, regulation and monitoring. We would like to see the development of a whole systems approach and a true partnership between the public and private sector that best serves the interests of patients and their families. If commercial over sensitivity prevents a realistic appraisal of difficulties then it is hard to see how vulnerable patients can ever be protected. Yours, Rob Poole, Consultant Psychiatrist, Mersey Care NHS Trust. Tony Ryan, Service Development Manager and Research Fellow, North West Mental Health Development Centre. Alison Pearsall, Lecturer in Mental Health, University of Salford. References 1. Duggan, D., Sugarman, P. and Dickens, G. (2002) The virtual asylum: a destructive editorial. British Medical Journal Rapid Response. 21 August. 2. Hughes, J.C. (2002) Re: Editorial 17 August 2002 “The NHS, the Private Sector, and the Virtual Asylum” British Medical Journal Rapid Response. 30 August. 3. The Sunday Times (2002) Private sector can help NHS care better for mentally ill: The Enterprise Network. Business Section. 14 July 2002. 4. Cooke, L.B. and Carpenter, P. (2002) No lessons learned. British Medical Journal Rapid Response. 23 August. No competing interests |
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