Care of people with schizophrenia suffers as too much money is spent on secure units

BMJ 2012; 345 doi: (Published 13 November 2012) Cite this as: BMJ 2012;345:e7712
  1. Zosia Kmietowicz
  1. 1London

Too much of the mental health budget in England is spent on keeping patients inappropriately locked up in secure units and should instead go to better hospital care and support in the community, says an independent inquiry.

The report from the Schizophrenia Commission, which was established in 2011 by the charity Rethink Mental Illness, says that greater investment in hospital services, early intervention services, respite units, and recovery houses to help manage the transition from hospital to the community would better meet the needs of patients.1

The report describes standards of care on some acute mental health wards as “shameful.”

Speaking at the launch of the report, Robin Murray, professor of psychiatric research at the Institute of Psychiatry at King’s College London, called wards “very untherapeutic” environments that can make patients more ill, not better.

The care is often fragmented and poor, with patients having to repeat their story six times as they are shuttled between different members of the team. They spend too long in hospital, where staff are unable to cope with the number of patients; treatment with antipsychotics is often inappropriate; and patients’ general health needs are overlooked.

The report calls for every ward in England to be brought to a standard where people would recommend them to a friend or relative with mental illness.

Murray said that early intervention units, which have been set up in the NHS in the past 10 years, have been very successful at treating people after a first episode of psychosis but are under threat from squeezed budgets.

Also speaking at the briefing, Alison Brabban, a consultant clinical psychologist and the lead on early intervention in psychosis at Tees, Esk, and Wear Valley NHS Foundation Trust, said that many trusts claim to be providing early intervention services but that the components were being diluted.

“Trusts may still have what looks like a team, but it does not follow guidelines. For example, caseloads are no longer capped, and psychological therapies are not so readily available,” she said.

For the report, The Abandoned Illness, the commission heard evidence from 80 experts in schizophrenia and people affected by the illness and received more than 2500 online reports of care.

An economic analysis for the commission by the London School of Economics estimated that schizophrenia cost society £12bn (€15bn; $19bn) in premature death, unemployment, and unpaid care, while public sector costs—for health and social care, institutional costs, and forgone taxes—amounted to £7bn a year.

Currently 19% (£1.2bn) of the metal health budget is spent on secure care. But much of that could be spent more effectively on strengthening community and prevention programmes and providing psychological therapies, which only 10% of patients receive.

Murray said that society had “become over-preoccupied with the idea of schizophrenia as a madman wielding an axe.” He added, “No psychiatrist ever loses their job for locking someone up, but they can if they are thought to be at fault for an incident [involving a patient].”

He said better public education about schizophrenia was needed to reduce the stigma of the illness.

The report also says that patients’ views of their treatment are rarely considered and that antipsychotic polypharmacy is widespread, with between a fifth and half of all patients prescribed more than one antipsychotic at a time, a practice that is not supported by evidence. Clozapine, which the report says has transformed the lives of many people with schizophrenia, is also underused.

David Taylor, director of pharmacy and pathology at the Maudsley Hospital and professor of psychopharmacology at King’s College London, said that before clozapine is prescribed to patients they may have tried five other antipsychotics rather than the two recommended by guidelines.

He added, “If only one thing were to change, I would want it to be the right for people to be consulted about the medicines prescribed to them—for them to make an informed contribution and for them to have the confidence and permission to come back and say, ‘I don’t like this one. What else can I try?’”


Cite this as: BMJ 2012;345:e7712