Has the closure of psychiatric beds gone too far? NoBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7410 (Published 22 November 2011) Cite this as: BMJ 2011;343:d7410
Four ideas, each flawed, underpin views that bed closure has gone too far in the UK. These are that inpatient provision is now meagre, that community care policies result in high levels of antisocial behaviour and failure to sustain community living, that inpatient wards are an environment conducive to dealing with the major problems associated with severe mental illness, and that we have exhausted potential strategies for reducing reliance on beds. I will challenge each of these ideas in turn.
Our bed numbers are not especially low
Bed numbers have fallen steadily since the mid-1950s. However, at 60.6 psychiatric beds per 100 000 population, recent World Health Organization figures place UK provision in the middle of the European range, which extends from 10.6 per 100 000 in Italy to 180.1 in Belgium; Germany, Sweden, Denmark, and Spain are among the countries with fewer beds than the UK.1 Our rates of involuntary admission are fairly high in international context.2 Current levels of bed use in the UK are thus unremarkable.
Community care is not toxic
The second idea, that deinstitutionalisation has unleashed a cohort of mentally ill people who are a threat to others and incapable of sustaining acceptable community functioning, is familiar from the media. It remains rare, however, for mentally ill people to kill someone, and the most recent data suggest a declining rate.3 With an adequate resettlement budget, former long stay patients have not tended to become homeless or perpetrate violence,4 and recent findings suggest homelessness among inpatients is no more prevalent than in past decades.5 Most people with serious mental illnesses live peaceful lives in the community most of the time, many achieving reasonable subjective wellbeing despite considerable adversities.6
High quality long term support in the community is the priority
Thirdly, it is doubtful whether acute wards, whose main function is now containment of immediate risk,7 are good environments for dealing with the most difficult problems that people with severe mental illnesses face. These include very low rates of employment,8 poor physical health leading to early deaths,9 high rates of drug misuse,10 and pervasive experiences of social isolation and stigma.11 Many people with serious disorders might also benefit from earlier intervention and from more acceptable and individually tailored treatments to which they are content to adhere. In most of these areas, sustained improvements in outcomes are more likely to be achieved through long term support and treatment in community settings, where social networks can also be involved when appropriate, than through brief interventions in an institutional environment.12 Admission may even exacerbate long term difficulties—for example, through attrition of coping skills, loss of employment and community tenure, greater exposure to illicit substances, or traumatic experiences in hospital.13 Thus it does not make sense to concentrate resources on wards if we can avoid it, especially given their unpopularity with many patients.7 Nevertheless, in 2008, 45% of the NHS mental health budget was dedicated to inpatient care.7
Potential to reduce bed use
Finally, the evidence suggests that potential strategies for reducing the current pressure on the inpatient mental health system have not been exhausted. The major NHS investment in alternatives to acute admission has been crisis resolution teams, now operating throughout England. These can, when well implemented, reduce admission, shorten hospital stays, and achieve good satisfaction.14 However, the extent to which these outcomes have been realised in practice varies greatly,15 not surprisingly given that the model is inadequately specified and implementation is inconsistent. We need to get this model right nationwide to ensure that the large investment made in it is repaid.
Research on community residential alternatives such as crisis houses suggests that these can substitute for hospital for some patients and allow early discharge for others, with relatively low costs and high levels of satisfaction.16 Their availability remains patchy, however, as does that of acute day hospitals and short stay admission wards, two other models that seem to help avoid or shorten some hospital stays.16 17 A further preventable drain on inpatient resources is delayed discharge because of unresolved social difficulties.
Joint crisis cards, which are advance agreements with patients about the management of future crises, are one of the few interventions that have been shown to reduce compulsory admissions, but they are not yet widely used.18 Further back along the pathway to admission, interventions to reduce relapse that have proved effective in trials but are not extensively implemented include family intervention in schizophrenia19 and a range of structured self management and relapse prevention planning strategies—for example, in bipolar disorder.20 At service level, early intervention teams, which deliver good quality psychosis care with a strong focus on social recovery, have reduced relapse and admissions, but these positive effects dissipate once patients are transferred to standard services21: can we extend these benefits and reduce bed use through longer exposure to this way of working for selected patients?
Thus increasing psychiatric bed provision would, in the current climate of scarcity, be both profligate and pointless. Let us instead dedicate the limited resources we have to improving the quality of existing inpatient services and increasing their acceptability to patients, and to implementing as fully as we can the knowledge that we already have about how reliance on inpatient services may be reduced.
Cite this as: BMJ 2011;343:d7410
I thank Justin Needle and Brynmor Lloyd-Evans for their input.
Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
“Has the closure of psychiatric beds gone too far?” is the subject of a Maudsley debate at the Institute of Psychiatry, King’s College London (www.iop.kcl.ac.uk/events/?id=1209) on 30 November.
Provenance and peer review: Commissioned; not externally peer reviewed.