Deaths among frail, elderly mentally ill patients following their transfer from hospital to the community are not inevitable. Kenneth Bledin and John Riordan explain

The deaths of frail, elderly mentally ill patients soon after their transfer from hospital to smaller community units have attracted considerable media coverage. In a minority of cases, relocations seem to have been conducted without adequately preparing residents and staff. But deaths following relocation are not inevitable. In 1996, as part of the final closure programme of Claybury Hospital, we transferred 14 residents, aged 70 to 96, into a community nursing home without a single death in the six months following the move.

In July 1983, North East Thames regional health authority decided to close Claybury, one of six large psychiatric hospitals in the region. Opened in 1893, Claybury housed more than 2,000 residents in the early part of this century, but by 1983 the number had fallen to 900. The first long-stay (non-dementia) patients began leaving in September 1985, but the closure programme progressed slowly: 350 residents were still there in 1993. Then, following the closure of Friern Hospital, the largest psychiatric hospital in the region, Redbridge and Waltham Forest health authority turned its attention once again to the Claybury closure programme.

An assessment team was established for the reprovision programme, comprising two assistant psychologists, two occupational therapists and two seconded nurses. This team completed assessments of all the remaining continuing care patients in Claybury who had come from Redbridge or Waltham Forest. They included 15 patients under 65, and 24 patients over 65. The older group, whose resettlement we describe here, comprised people with dementias as well as functional psychiatric illnesses and disabilities.

The two of us, a consultant clinical psychologist with previous experience of reprovision planning, and the head of the psychology services, who specialises in working with elderly people, managed the team and provided clinical supervision.

The assessments took account of the views and wishes of patients and the patients' relatives, friends and nursing staff. When they were completed in September 1993, the HA invited bids from providers of reprovision facilities. The contract was awarded to an independent organisation to provide 14 beds in one unit for physically mobile older people with dementia and, separately, elderly people with functional psychiatric illnesses.

Forest Healthcare trust, which had administered Claybury and provided care for its residents, was contracted to provide eight beds in one unit for the group of frail, elderly mentally ill people. The remaining two patients were to be housed near their families outside the district.

In 1995, Redbridge and Waltham Forest HA provided further funding for a transition team to facilitate patients' moves to the community. Once again, we were responsible for managing this team, and providing clinical supervision.

Our intention was to recruit a team incorporating varied professional, theoretical and practical knowledge and experience. We had no difficulty in recruiting an assistant psychologist and a support worker who was also a psychology graduate.

A social worker with considerable previous experience as team leader of a local authority generic team added depth and breadth of experience.

The response from the hospital's nursing staff to advertisements for an F-grade nurse was disappointing, and the nurse who was appointed chose to leave soon after the team's inception and was not replaced. We were unable to recruit an occupational therapist, but later arranged for occupational therapy assessments on a contractual basis.We also had invaluable secretarial support. A student social worker and an additional assistant psychologist also provided some short-term input to the team.

The team's brief was based on a survey of relevant literature and previous experience of working with an earlier cohort of Claybury reprovision patients and their relatives, carers and professional care staff.1,2,3 It was to work with patients, principal carers, relatives and advocates or significant others to identify the strengths and needs of each individual patient, and then to develop and carry out appropriate plans and programmes to facilitate the transition process. Team members would establish links with staff of the new community units, arrange for patients to visit their new homes, and for staff in the community units to visit the patients in Claybury. Contact and liaison with relatives was thought particularly important.

It was envisaged that the team would go on working with the patients several months after they moved in order to provide continuity and ensure care programmes were working well.

Patients still at Claybury in July 1995 included several who were difficult to place and some who had simply refused to leave with earlier cohorts.4 When the transition team began their contact, there were 19 elderly continuing care patients remaining in the hospital. They ranged in age from 70 to 97. Five were men.

During the winter months leading up to the move from the hospital, six patients died (five women, one man).

The 14 people who were eventually moved out of the hospital at the end of March 1996 ranged in age from 70 to 96. Three had primary diagnoses of schizophrenia and had first been admitted to hospital between 38 and 66 years previously. One woman had diagnoses of schizophrenia and depression, with a first admission seven years previously. The remaining patients all had diagnoses of dementia and had been in hospital for between eight months and seven years with a mean of 28.8 months. Excluding the one woman with a stay of 7.5 years reduced the mean length of time since first admission to 20.9 months.

There were thus two clear sub-groups within this transition group: those who had been in hospital for a very long time and were probably disabled by the effects of institutionalisation as well as by the effects of their psychotic illnesses; and a larger group of people with organic illnesses of relatively recent onset.

Those in the latter group were likely to display higher levels of physical dependency and to have relatively greater needs for physical nursing care.

Members of the transition team spent long periods of time with patients, talking to them and reassuring them. They augmented the information gathered in the earlier assessments through further meetings with relatives, social services and hospital staff, and by structured observation of the clients and scrutiny of medical notes and other records. The information was then condensed into a briefer, more accurate format which identified the factors relevant to community placement and included a risk assessment.

They also spent time with relatives discussing the changes and allowing them to express any feelings of bereavement or loss. In one case, the team was instrumental in ensuring that a physically frail

man still living in the community was offered a place in the same nursing home as his mentally frail wife.

Relatives and staff were involved in discussions about how to handle the moves. The possibility of patients visiting the community homes before the final move was discussed but rejected on the grounds that it was likely to be upsetting.

Members of the transition team went with patients and helped settle them into their new homes. The appointment of one of the ward managers at Claybury as manager of one of the new nursing homes helped provide continuity. The involvement of the transition team in the practical arrangements of the move was consistent with evidence that engagement of this kind may be particularly helpful to people with dementia.5

Large photographs of Claybury and its grounds were given to the nursing homes in specially prepared albums for the care staff to use in their future work with their new clients.

The transition team continued to visit the clients for up to three months after their move in order to provide continuity, to identify needs and to liaise with the new staff in meeting those needs.

All of the 14 elderly patients were still alive six months after their move to the new reprovision units. This represents a very successful outcome. The death rate among a comparable group of hospital patients over the same period was 4 per cent a month.

These figures point to the success of careful preparation and transition in maintaining the physical well-being of this vulnerable group of patients. A further follow-up, 18 months after the move, showed 10 of the transition patients were still alive. The four who had died were aged 97, 86, 76 and 71. Three had diagnoses of dementia. The fourth had a diagnosis of paranoid schizophrenia.

Lessons

Detailed assessments and painstaking attention to clients' strengths and needs are essential for a successful transition of elderly mentally ill clients from hospital to the community. A person-centred, needs-led approach was a fundamental tenet of the work of the Claybury reprovision transition team and the guiding principle for those engaged in it. A resource- led approach might not have achieved the same successful outcome for these clients, among whom a 100 per cent survival rate at six months was both unusual and unexpected.

The project has demonstrated that increased risk of mortality among frail, elderly people is not inevitable following relocation from hospital to the community. Research indicates that an improved environment and careful preparation for the move are both important factors in reducing risk.

Other factors should also be considered. Efforts should be made to avoid mixing elderly functionally ill patients with those with dementia. The rationale is that the higher functioning patients may be reduced to the lowest common level of functioning, rather than being encouraged to maximise their residual cognitive and behavioural skills.

Community homes for elderly people should be designed in such as way as to provide maximum support. Attempts at normalisation are laudable but need to be balanced with this group's needs for nursing care. A policy of radical demedicalisation is not advisable.6

The patients in this project were among the most vulnerable of Claybury's long-stay population and were the last to be relocated before the closure in 1996. The work of the reprovision team shows that such moves can be ethical only with careful planning and attention to individual needs. Anything less would be negligent.