Mental healthcare faces a problem of bed shortages for inpatient care, but while a large part of the solution might be stronger community support rather than increasing the number of available beds, there is still a need in some places to boost their number. Mat Kinton and Suki Desai explain

Mental healthcare faces a problem of bed shortages for inpatient care, but while a large part of the solution might be stronger community support rather than increasing the number of available beds, there is still a need in some places to boost their number. Mat Kinton and Suki Desai explain

Psychiatric bed numbers have fallen by more than half since the 1983 Mental Health Act came into force, yet the number of civil detentions has doubled in that time. The increasing focus on community care for mentally disordered people appears to have had a general effect of making their hospital admissions shorter, and more of a 'last resort' than in previous decades. This is surely a good thing, as psychiatric hospitalisation under the coercive powers of the Mental Health Act is a massive infringement of a person's liberties. But are there now too few beds to provide patients with safe and secure services at times of acute crisis?

In January this year, the Mental Health Act Commission suggested in its biennial report to Parliament that, notwithstanding developing community services, some local provision of inpatient beds may simply be inadequate to serve the catchment area. This month, as the commission publishes a paper on the incidence and impact of bed occupancy in the acute sector, a psychiatry subcommittee of the British Medical Association has talked of a 'bed shortage', particularly in London and Manchester, leading to dangerous delays in admitting people under the Mental Health Act. In one case reported to the MHAC, a patient was waiting at home for admission for over 28 days. Some social workers are reported to be refusing to undertake assessments under the Act for want of a viable bed, and even refusing to visit patients at home because of fears for their safety.

A decade ago the MHAC observed that the reduction in bed numbers had left acute inpatient services managing increasing numbers of people with more severe mental illness, while the emphasis of policy and managerial support had been on the development of community care. We continue to see some acute inpatient services stretched beyond their capacity, with widespread 'over-occupancy' of beds.

'Over-occupancy' refers to the practice of having more patients 'on the books' of a ward than that ward has beds. Typically this situation is managed by patients being given short-term leave from the ward to go home, or transferred within or between hospitals to a vacant bed, or in some instances accommodated in temporary beds established on the ward for the additional patient numbers.

Detracting from core duties

The practical effects of over-occupancy can be seriously detrimental to inpatient services. Time spent by nursing staff finding or engineering vacant beds takes away from core nursing tasks, so that nurses can feel they are managing the organisational crisis rather than helping patients through their mental distress. Patients may feel less secure with the possibility of short-notice leave or transfers, and may fear being asked to leave a bed before they feel ready to do so, or may even resist taking therapeutically appropriate home-based leave from the ward because they are concerned their bed will not be there when they return. Patients also complained of losing possessions during moves, and of feeling a loss of autonomy through being shifted around the mental health system.

This leads us to conclude that over-occupancy of beds can be harmful to those patients who need to get into hospital, and to those patients who are already there. It has been a great concern of the MHAC and other observers of mental healthcare that the conditions on some acute wards may be damaging to the very people who are taken there for treatment.

The systemic relation between hospital and community elements of mental healthcare makes it difficult to determine whether inpatient overcrowding should be addressed by increasing bed numbers or further concentration on community support. The case for concentrating on community support is strong. Government policy is that services should move out into the community as far as possible. Many community services are still 'in development', so that their full effects in preventing hospital admissions have perhaps yet to be felt. It is also clear in visiting hospitals that there are still some delayed discharges because of a lack of supportive community provision.

If there is still much potential for development in community-based provision, then the long-term needs of the service as a whole may be best addressed through an increased concentration on community aspects of the service. Redirecting resources to increase acute inpatient ward capacity could be counterproductive to the strategic aim of establishing a working spectrum of care with several types of residential care appropriate to different levels of need.

A continuing need for beds

On the other hand, community services cannot take the place of acute inpatient beds completely, as some patients need hospital care at times of acute crisis. An inpatient bed in such circumstances should be 'asylum' in the positive sense of that word: a place of refuge and safety. And if there is a need for such beds, then it must be possible that the need outstrips the supply.

The problem may lie partly with NHS commissioning. We have expressed concern before that primary care trusts do not necessarily have sufficient expertise or enthusiasm in commissioning mental health services. In the scramble to balance NHS books, acute inpatient beds are vulnerable for their expense and relative unpopularity. In our report to Parliament in January we suggested resources had been being taken from existing inpatient budgets, including staffing budgets, to fund developments in community services. Since that time it would seem that these services may have also been raided to fund deficits across the wider NHS.

It is important not to polarise this issue falsely. We have no misplaced nostalgia for the old hospital system, and we accept that as much care as possible should be provided to patients without hospital admission. However, it just isn't good enough to accept uncritically that community care will, sooner or later, resolve these problems of a changing service. For some patients, community care still means abandonment, whether this is at home alone or in the hands of carers who are struggling to cope with them. Where hospital admission under the Mental Health Act is necessary, delays are dangerous and inhumane.

Our report on bed occupancy makes two practical recommendations to address the problems facing some services. First, hospital managers should review their bed-management practice, especially with a view to fostering a culture of patient involvement about bed-management decisions that affect their care and treatment. We would hope managers doing such reviews will be open to the possibility that their bed provision may be inadequate. Second, the NHS should promote a forum for discussion of innovative practice in bed management. However, the only salve for some acute services in crisis may yet be to open more beds.

Mat Kinton is senior policy analyst and Suki Desai is regional director with the Mental Health Act Commission. The MHAC reportWho's been sleeping in my bed? The incidence and impact of bed over-occupancy in the mental health acute sector is available at www.mhac.org.uk