Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The folly of the Harm Reduction Strategy
- Peter O'Loughlin, Beckenham BR3 3AT (12 October 2008)
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GP involvement
- Vasudevan E Krishnan (12 October 2008)
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Is Deinstitutionalization and early intervention working?
- Sahoo Saddichha (14 October 2008)
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The Need for Caution and Context
- Hugh W Griffiths (28 October 2008)
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A confused analysis
- Gyles R. Glover, Rebecca Lee (29 October 2008)
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Availability of inpatient beds for psychiatric admissions in the NHS
- Trevor H Turner (3 November 2008)
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Reply to responses
- Patrick J Keown, Gavin Mercer and Jan Scott (14 November 2008)
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Peter O'Loughlin, Principal The Eden Lodge Practice, Beckenham BR3 3AT
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One wonders how many of the admissions for alocohol and drug abuse, could have been avoided, if the treatment protocols had been abstinence focused recovery, rather than the substitute addictive drug treatment protocols favoured by by the National Treatment Agency, under the guise of 'Harm Reduction' Competing interests: Alcohol and other Drug addiction recovery. |
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Vasudevan E Krishnan, Foundation Year 2 Doctor Claremont Bank Surgery,Shrewsbury,SY1 1RL
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I believe GPs have also played a very good role in managing many cases at the Primary Care level thus reducing admissions.Greater power given to GPs to prescribe medications has also helped ,eg:NICE guidelines in 2004 initially stating that only Specialists or GPs with special interest in psychiatry could prescribe Venlafaxine for Depression or GAD ,which has changed since 2006 except for doses above 300mg. Competing interests: None declared |
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Sahoo Saddichha, Partner, Division of Clinical Research, Emergency Management and Research Institute (EMRI)
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Keown and colleagues [1] have described the falling voluntary admissions and rising involuntary admissions in their recent paper. This now raises an interesting question on the practice of deinstitutionalization that is increasingly the norm in most countries [2] - whether it actually works or not? Are involuntary admissions compensating for voluntary ones? Since voluntary admissions have been falling, it would be also interesting to know the actual effectiveness of early intervention programs. Or is it due to the increasing numbers of patients being dual-diagnosis, that is, with history of substance misuse too? The most significant finding of this study has been the pointer that patients are moving towards private facilities than NHS supported ones. Again the reasons are unknown, but may be due to stigma attached to mental illness which still forces psychiatric patients to keep their illness a secret. However, as mental health professionals, one needs to also ultimately ask the question- what has been the cost of deinstitutionalization, for both the patient and his family [3]? References: 1) Keown P, Mercer G, Scott G. Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006. BMJ 2008;337:a1837. 2)World Health Organization, WHO (2005). Resource Book on Mental Health: Human rights and legislation- ISBN 924156282 (PDF). 3)Saddichha S.Deinstitutionalization of mental illness: At what cost?(E-letter) Br J Psychiatry 12 July 2007. Available at http://bjp.rcpsych.org/cgi/eletters/190/1/81-a#5052 Competing interests: None declared |
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Hugh W Griffiths, Deputy National Director for Mental Health Department of Health, Richmond House, Whitehall, London
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Although this article is a welcome contribution to the analysis and debate about patterns of change in the provision of in-patient mental health care, closer scrutiny of the figures seems to contradict any notion that they provide evidence of “reinstitutionalisation”. (Reference: BMJ Press Release 10th October 2008) The authors report a 20% increase in detentions under the Mental Health Act (1983) in the decade from 1996. But that cannot be taken as proof of a rising trend in compulsory in-patient treatment. As it happens, there was a dip in the total number of detentions in the baseline year 1996/97 And a significant part of the 20% increase is down to greater use of hospitals as places of safety under section 136 of the Act - which does not necessarily involve admission to a bed. In fact, taking section 136 out of the picture, total detentions peaked in 1998/99 and have remained fairly stable since. Repeating the calculation using 1998/99 as the baseline year, there is a small reduction (of about 1%) up to 2005/6. (Reference: Information Centre, In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislation, NHS Trusts, Care Trusts, Primary Care Trusts and Independent Hospitals, England; 1996-97 to 2006-07, Government Statistical Service, 2007). But even disregarding the baseline issue, their figures show a total increase of detentions overall (civil, forensic and place of safety) of 8,517. The increase in place of safety detentions alone is given as 3840. Although they do not separate out s135 from s136, the increase in s136 alone over that period was 3662 which is equivalent to 43% of the total increase in detentions they report. Nevertheless, the changing casemix and increasing proportion of detained patients the authors highlight are important issues for service planning and provision. But there is clearly a need for caution and context in interpreting such data. Competing interests: None declared |
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Gyles R. Glover, Professor of Public Mental Health North East Public Health Observatory, University of Durham Queens Campus, TS17 6BH., Rebecca Lee
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Keown and his colleagues have ventured into a complex statistical area in which they seem out of their depth. The figures they have chosen, include elements of in- patient general psychiatric services, secure psychiatric care, learning disability services, and the care of mental illnesses in general hospital specialties. Their commentary suggests an analysis concerned primarily with the first two. Their analysis of hospital admission statistics appears to have many technical flaws. The most serious is their choice of scope: admissions to NHS hospitals for ICD10 F chapter diagnoses. We have been unable to reproduce their figures exactly from the description given, but our analysis of NHS admissions with a primary diagnosis in this group shows that psychiatric services account for only about 70% of them in most years - 60% in 2005/6. In the three most recent years covered (2003/4-5/6), the largest single diagnostic sub-group (20% of the admissions) was F10 – disorders due to the use of alcohol. 40% of these were under a medical and 20% a surgical speciality. Only 30% were to psychiatric beds. On the other hand, between 25% and 30% of admissions which did occur under psychiatric specialties would have been omitted from the analysis presented because the primary diagnosis was outside the F chapter or missing. The authors appear to conflate numbers of admissions and of people admitted. Our analysis of Hospital Episode Statistics from 1996/7 to 2005/6 indicates that for the psychiatric specialties, (all ages combined, excluding learning disabilities), admissions numbers rose to a peak at 190k in 1999/00 and thereafter fell to 143k in 2005/6. However the best estimate of the number of people admitted, suggests this fell throughout the period (from 134k in 1996/7 to 100k in 2005/6). Keown et al’s analysis of patterns of bed availability and compulsion is muddied by their decision to use annual totals for the number of NHS beds rather than looking more closely at the 12 sub-categories in which these are reported. The overall 29% fall in bed numbers they report conceals a 78% rise in NHS secure units – an additional 1232 beds, in which it is to be expected that all patients will be under compulsion. If the occupants of these beds are deducted from the annual numbers of involuntary patients in NHS beds reported, the remainder, presumably mainly on acute psychiatric wards, went from 9,225 in 1996 up to a peak of 10,198 in 2000 and thereafter fell back to 9,325 (roughly the 1996 figure) by 2005. Since the overall number of beds on short stay wards for working age and older adults fell (by about 10% or 2100 beds), this does not alter the authors observation that a higher proportion of patients in these would have been involuntary at the end of the decade than at its start. However the explanation for this would seem to lie in the reduction in admissions of people for whom it was inappropriate or avoidable, through better assessment and alternative provision outside hospital. While this may add to the challenge of providing a satisfactory ward environment it is hard to see that it could be considered regrettable. The increase in the number of secure beds is no surprise. This has been explicit government policy since 1998, in part it was intended to accommodate people otherwise inappropriately placed in prison. This would be expected to show an increase in numbers of involuntary patients. Reference: Department of Health 1998, Modernising mental health services: safe, sound and supportive. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publicati ons/PublicationsPolicyAndGuidance/DH_4003105 (accessed 28/10/08) Competing interests: None declared |
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Trevor H Turner, Consultant Psychiatrist City & Hackney Centre for Mental Health E9 6SR
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The debate about acute psychiatric inpatient beds always seems to focus on numbers rather than quality. As outlined in your editorial (BMJ 2008 337: a1561), numbers vary enormously across Europe, and the USA situation is one of utter despair. These figures may reflect what has been termed ‘Penrose’s Law’, namely that there is an inverse relationship between psychiatric beds and prison numbers in a given (developed economy) population. The UK’s record prison numbers (80,000+) and of course the USA’s nearly 2,000,000 prisoners, illustrate this nicely. Working in the NHS, in the inner city (Hackney) I and my colleagues have seen an increasingly psychotic inpatient population, and rising rates of detention under the Mental Health Act, very much reflecting the findings of Keown and colleagues (BMJ 2008, 337:1837). This is despite the enhanced community support of crisis intervention / home treatment teams, assertive outreach and early intervention. This is not surprising, in urban populations at least, since many patients do not have a home and the nature of their illness prevents them seeking or complying with treatment. However, negative views about acute inpatient wards are often somewhat selective. Quarterly assessments by our local Patients Council indicate that compliments outweigh complaints by between 2 and 3 to 1, and have done so consistently over the last 5 years. Patients mostly complain about being on medication (since they do not think they need it, thus their detention under the Mental Health Act) and the formalities and paperwork (and embarrassments?) of the Care Programme Approach (CPA) process. With regard to their environment, the nursing staff, the psychiatrists and even the food they are often very positive! The Royal College of Psychiatrists has also instituted an Accreditation Programme, for Acute Inpatient Mental Health Services (AIMS), in collaboration with psychologists, occupational therapists and nurses, focused on identifying the quality of services and supporting patients and staff in those services. Over 130 acute wards are now signed up, there is enthusiastic collaboration between staff on these wards (as well as carers’ and patients’ representatives) and marked improvements have been noted thanks to the pressure this puts on Trusts to take the acute wards seriously. Analysis of UK trends in terms of declining bed numbers and rising rates of detention under the Mental Health Act (before then both were nicely coming down together, true ‘deinstitutionalisation’), shows a distinct separation starting around 1980. Community care can cope with many patients and their illnesses, but not all. Our prisons are full to overflowing, the medium secure units are full and have waiting lists, and the intensity and turnover of our acute wards, particularly in urban areas, indicate that we have gone beyond what can be seen as a safe and healthy limit. And the people seeking the sanctuary of our (often very welcoming) acute wards are the patients and carers themselves, no matter what official service user documents may say. Dr Trevor Turner, Consultant Psychiatrist & Chairman of AIMS Accreditation Advisory Committee of the Royal College of Psychiatrists Competing interests: None declared |
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Patrick J Keown, Consultant Psychiatrist and Honorary Senior Lecturer East CMHT, Molineux Centre, Newcastle upon Tyne, NE6 1SG, Gavin Mercer and Jan Scott
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We agree with many points raised by those commenting on our recent publication. For example, Griffiths rightly states that in the last decade involuntary admission rates have stabilized compared to the preceding decade. However we contend that there has continued to be an upward trend in civil detentions. For example two of the most commonly used detentions are formal admission to hospital under sections 2 or 3 of the Mental Health Act (1983). These more than doubled from 8,910 in 1984 to 23,306 in 1998/99. Since then they have continued to rise, albeit more steadily and currently stand at 25,271 (data from 2007/08). So since 1998 it appears that voluntary admissions have been falling but involuntary admissions continue to rise, suggesting that the factors influencing psychiatric admissions are having different effects according to the type of admission (voluntary/involuntary). We agree with Griffiths’ observation that a large proportion of the increase in detentions reported in our paper was due to increasing use of place of safety orders: an issue that certainly merits further analysis. Glover & Lee make a number of important points. We are of course aware that the admission data referred to a variety of inpatient settings, but we aimed to give headline figures. Constraints, such as article length, precluded more detailed discussion of implications for services such as learning disability and old age psychiatry. Their comments about alcohol admissions raise a number of important questions. We knew that some of these admissions were to medical wards. However, given that alcohol related deaths have doubled in England between 1991 and 2004(1), and admissions for alcohol related liver disease have been increasing since 1989(2), why is it that admissions with alcohol or drug use as the primary diagnosis only started to increase in 2003? And why are 20% of alcohol admissions to surgical specialities? We raise these issues as they were unexpected findings, but we would emphasize that a more important take home message from our paper is that whilst psychiatric admissions have fallen, involuntary admissions have increased, and this increase has largely occurred in the private sector. Glover & Lee also comment on the overall number of admissions. Their analysis of the data also shows that admissions are falling as are the number of patients being admitted. We agree that there are many different ways of interrogating the Hospital Episode Statistics and indeed other statistics, each of which can produce different absolute numbers (e.g. Hotopf et al. reported that NHS psychiatric hospital admissions increased from 190,000 in 1984 to 213,000 in 1996(3)). In our paper we acknowledged the limitations of the data and accept there are bound to be differences in interpretation - indeed we avoided extensive statistical analyses or over-detailed analysis at this stage for that very reason. We do not suggest that the reduction of admissions is necessarily regrettable. Clearly effective community based treatments have many benefits, but the issue is of interest to the NHS in general and to mental health providers in particular. In the original article we submitted the WHAT THIS STUDY ADDS box read “The number of NHS psychiatric admissions appears to have peaked in 1998 and is now falling”. In the published article it became “The number of patients admitted to the NHS with mental disorders...is now decreasing”. The former is what our results show and we apologise for any confusion caused. Glover and Lee also refer to the different changes that have occurred in bed provisions among the various psychiatric sub specialities. We agree that the rise in secure beds is no surprise (and indeed was a well publicised plan), but the overall fall in forensic detentions is unexpected and raises the possibility that different processes may be operating: in secure settings there is increased provision but reduced numbers of forensic detentions (? possibly indicating those detained have increasing lengths of stay); whilst in non secure settings there are falling bed numbers but increasing numbers of civil detentions. As might be expected, our paper presented as many questions as it did answers, but its main goal has been achieved - there is a more open debate on a critical aspect of mental health care. We anticipate this is the start and not the end of those discussions. 1. Breakwell C, Baker A, Griffiths C, Jackson G, Fegan G, Marshall D. Trends and geographical variations in alcohol-related deaths in the United Kingdom, 1991-2004. Health statistics quarterly / Office for National Statistics 2007;33:2-24. 2. Thomson SJ, Westlake S, Rahman TM, Cowan ML, Majeed A, Maxwell JD, et al. Chronic Liver Disease--An Increasing Problem: A Study of Hospital Admission and Mortality Rates in England, 1979-2005, with Particular Reference to Alcoholic Liver Disease. Alcohol Alcohol. 2008;43(4):416-422. 3. Wall S, Hotopf M, Wessely S, Churchill R. Trends in the use of the Mental Health Act: England, 1984-96. BMJ 1999;318(7197):1520-1521. Competing interests: None declared |
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