Acute services absorb two-thirds of the mental health budget, yet provision is unpopular with both users and staff. The time is right to do something about it, writes Richard Ford

Acute psychiatric inpatient care is failing. Users dislike the environment, are bored and often feel unsafe, despite half of them having been admitted under the Mental Health Act because of concerns about their safety, or the safety of others.

1 Occupancy levels remain above 100 per cent and staff are voting with their feet, leaving high numbers of unfilled nursing vacancies.

2 Standards four and five of the National Service Framework for Mental Health - Modern Standards & Service Models , published last month give everyone an opportunity to reflect on how acute treatment, which consumes two-thirds of the mental health budget, can be better provided.

3 The service model requires a balance of hospital beds - including some secure beds - staffed and supported accommodation, day places and home treatment.

There is evidence that acute treatment for emergency psychiatric problems can be delivered in several settings including home, day hospitals, crisis centres, inpatient wards and intensive care units.

When reviewing acute psychiatric treatment services, the place to start is need. The people who need acute treatment will usually be at risk of suicide, self-neglect or violence to others; have severe psychological distress or disturbance; and have experienced recent significant social or environmental changes in their lives. Typically, these factors lead to an emergency need for psychiatric treatment for severe problems.

A useful start is to measure local services against national averages. How many beds are available? How many admissions a year? How long do people stay? How many people are readmitted?

The box below shows the averages and ranges that the Sainsbury Centre for Mental Health has found in recent reviews of services for more than 6 million people in the UK. But benchmarking raises questions and should not be used on its own for service reprofiling. Just because something is 'average' does not mean it is good , or bad .

A review of acute treatment services also has to consider how users progress through care stages. 'Pathways' studies can be useful.

4 How are acute needs identified in the first place? The role of primary care and the relationship between GPs and mental health services are particularly important. Are there link worker systems between the two? Are assessments multidisciplinary? Do assessments take place at the user's home? Are there agreed protocols between mental healthcare and primary care? Do senior medical staff get involved with assessment or is this left to junior staff in a hospital setting? How is risk assessed and are alternatives to hospital available and considered?

Acute psychiatric inpatient beds do not function in a vacuum. It is important to review services that interact.

Do community teams provide out-of-hours home-based assessment and treatment? Are community teams involved in planning discharge?

Do acute day hospitals provide an alternative to inpatient care? A day hospital that keeps people on its books for several years or has a waiting time of several weeks is not functioning as an acute treatment setting.

Is a range of housing with support, including 24-hour staffed care, available? Suitable accommodation with high staffing levels may not be available, as often this was planned for former, fairly elderly, long-stay patients.

Younger people with long-term mental health problems have not usually had long periods of institutional care and have different needs.

Acute mental health treatment services need to consider their relationships with forensic services, police, courts and probation services and need to work with accident and emergency departments.

Having reviewed acute psychiatric treatment services, a development plan can be agreed. Planning should cover one or more primary care groups. No locality will be able to afford everything, but should pick elements most likely to meet its needs.

Planning should involve users and carers, the staff who will deliver the service and GPs who will be the main source of referral, as well as senior managers from the trust, health authority and local authority.

Inpatient care will remain an essential part of the service. How many wards on how many sites? The more dispersed the sites, the more local the service. But units will be small and 24-hour on-site medical cover will be costly across many sites.

The Royal College of Psychiatrists recommends about 50 beds on one site, run as three wards.

5 Each ward can then have a different function with different case-mix and staff mix, based on local need. But local need is the key factor. A 50-bed unit may be too large for a dispersed population in a rural area and too small for an inner-city district.

Another possibility is smaller 12 to 15-bed, so-called 'step-down' units, which have 24-hour nurse staffing but do not rely on 24-hour on-site medical staffing.

6 These can provide care following a stay on an acute ward, and acute care for cases which do not warrant a more restrictive environment.

Acute treatment day hospitals should also be considered.

Despite clear evidence that they can provide a useful alternative to inpatient care for many people, 6most day hospitals studied as part of Sainsbury Centre for Mental Health's reviews do not function in this way. They tend to provide either long-term support for people with enduring mental illness or short-term psychotherapy for people whose problems are not severe.

If the day hospital is to function as an acute treatment setting, strong links must be established with other acute services such as inpatient wards and community teams.

Active treatment programmes should operate every day.

Consideration will also need to be given to opening the service seven days a week and into the evenings.

Community teams can provide acute treatment in clients' homes. They should be linked to other acute services as they will not be able to meet all needs. Many people will still require more intensive care in a more restricted environment.

The main question is, should there be a dedicated home treatment team, should the function be part of the role of a generic community mental health team or should staff from several generic teams be rostered to a home treatment service covering a larger area?

A dedicated team is a likely option for an inner city area, whereas a generic team that provides acute home treatment would be preferred in a rural locality. A critical mass of staff must be available to cover different shifts and staff absences.

Community staff have traditionally looked to hospitals to provide acute treatment and may not have the skills or confidence to provide this service in the community. To be successful, a home treatment team will have to work at evenings and weekends. It should include doctors, nurses and social workers.

The final question is how to get the parts of the acute system of mental healthcare to act as a whole. The consultant psychiatrist role will be crucial. They will be in a leadership role that extends well beyond direct individual care. It is essential to have agreement with the main referral agencies, such as GPs and A&E, as to which services potential users will be referred. It often makes most sense, and is in keeping with the framework standard, to make the community acute treatment service the first point of contact for all referrals.

This is the most accessible, as well as being the least restrictive part of the system. If the community service can make the initial assessment many admissions to hospital can be prevented. This can in turn reduce the pressure on inpatient services and be an important part of making acute psychiatric inpatient wards part of a comprehensive system of mental healthcare of which we can be proud.

REFERENCES

1 Acute Problems: a survey of the quality of care in acute psychiatric wards . London: Sainsbury Centre for Mental Health, 1998.

2 Ford R et al . One-day survey by the Mental Health Act Commission of acute psychiatric inpatient wards in England and Wales. Br Med J 1998; 317: 127983.

3 National Service Framework for Mental Health - Modern Standards & Service Models. NHS Executive, 1999.

4 Minghella E, Ford R. Focal Points. Health Service J 1997; 107 (5583): 26-27.

5 Not Just Bricks and Mortar . A report of the Royal College of Psychiatrists Working Party on the size, staffing, structure and siting, and security of new acute adult psychiatric inpatient units, 1997.

6 Creed F et al . Randomised controlled trial of day patient versus inpatient psychiatric treatment, Br Med J 1990; 300: 1033-7.

Key points

The publication of the national service framework for mental health provides a good opportunity to review acute psychiatric services, which are unpopular with patients and understaffed.

The framework recommends a balance of hospital beds, community provision and home care.

Planning should usually cover one or more primary care groups.

Acute psychiatric inpatient care: a national view An average 42 beds are available per 100,000 population aged 15-64 (range 12-101).

There are an average 363 finished consultant episodes a year per 100,000 population aged 15-64 (range 115-692).

67 per cent of inpatients stay 30 days or less (range 48-81 per cent), 24 per cent stay 31-90 days (range 16-33 per cent) and 9 per cent stay 91 days or more (range 3-19 per cent).