Published: 16/06/2005, Volume II5, No. 5960 Page 32 33 34

The shift of mental health resources to the community has taken its toll on inpatient units, where violent attacks on staff and low morale are becoming the norm. What can be done to attract staff back to this neglected area of the service? Emma Forrest reports

It is unthinkable to imagine a health service without inpatient beds. No matter how good health promotion and primary care can be, some people will always need the care that only a hospital can provide.

Yet in mental health services, inpatient care has been neglected to the point where some believe it is regarded as almost an embarrassment.

'Inpatient beds peaked in the 1950s and at some point the pendulum swung too far the other way so we had too few beds and the threshold for admission increased, ' says Dr Paul Lelliott, Royal College of Psychiatrists research unit director and a practising psychiatrist. 'There will always be a need for inpatient care at a time of crisis, but while community teams were developing, the development of acute wards happened in an ad hoc way. Wards became more disturbed places and admission began to be seen as a failure of community teams.' Dr Lelliott was speaking at the launch last month of a national audit of violence in mental health and learning disability units, carried out by the college for the Healthcare Commission.

The audIt is results make shocking reading: almost 80 per cent of all nursing staff, 41 per cent of clinical staff and one in three service users said they had witnessed violence or aggression, ranging from shouting to serious assaults. The report is filled with acute ward staff claiming that violence is a part of life for staff working in such places. 'My manager told me 'if you want safe, go and work in Safeway, '' is one memorable quote. Dr Lelliott said an incident of 'low level' violence or aggression would happen on average every two days.

The report attributes the violence to several factors, from a lack of staff - which leaves service users neglected and bored - to a poor environment.

In mental health (but not learning disabilities) alcohol and illegal drug use is thought to be the most common cause of violence, with staff reporting that service users on open wards often returned from a day 'outside' drunk or high.

This picture was reinforced later in the month with the publication of the Acute Care 2004 report from the Sainsbury Centre for Mental Health and National Institute for Mental Health in England.

It said that while the new community teams were doing what they were supposed to do in keeping all but the most acutely ill out of hospital, this meant that inpatient units were populated by the most disturbed and vulnerable.

'More than ever, the acute ward is a place offering critical assistance to people during episodes of extreme psychological distress and impaired functioning, ' says the report.

Yet it also says that these units are plagued by staff shortages that average 13 per cent for nursing staff and 22 per cent in London.

Just over half of all wards reported having a lead consultant, meaning a high number have only junior doctors attached. In 13 per cent of wards, there is no senior nurse or manager in charge. More than one in four ward managers said they had lost staff to a community service over the previous year.

Shortages of occupational therapists and psychologists are being exacerbated by the competing demands of community services - research shows that mental health staff are unlikely to move out of an area to take a job, so the pool of possible staff is usually limited. Nursing gaps are being plugged by agency and bank staff who often have little experience of life on an inpatient unit.

As many community teams have been funded by the closure of inpatient units (on the premise that the new teams would lead to a reduced need for beds) this would seem to be rubbing salt in the wound.

It is not disputed that it is always preferable for patients to be treated at home if admission is not essential, but managers feel that the sector is being at best neglected and at worst forgotten.

'Inpatient units get a hard time. I would not want to work on one, ' says one NIMHE regional lead on acute care, who did not want to be named.

'But there are pockets that are working very well.

There has been an increasing amount of redesign work done over the past two years and there is an increasing sense of leadership on units. The work they can do to make very ill people better can be remarkable, but it is not recognised.' Malcolm Rae, joint programme lead of NIMHE's acute inpatient care programme, says: 'It is a recent thing that inpatient units have not been considered the place to be for staff. Ten or 20 years ago everyone wanted to work in inpatient care. It was a growth area.

'Now they are being staffed by nurses and more junior doctors and are not being supported by other disciplines because they have concentrated on community-based care. Good inpatient care needs a multi-professional approach and effective teamworking but that is not always present, ' he adds.

Mr Rae hopes national programmes such as Agenda for Change will create more senior nursing positions in inpatient care.

'There are some able, motivated and competent staff in this field, but the past five years has seen their numbers reduce. With the targets outlined in the mental health national service framework it was inevitable community teams would get a lot of attention, but it is time to address that balance.' Other commentators say that inpatient care is still thought of as a place to get some experience, but only until you get the chance to leave and join a community team.

Inpatient managers complain that units are seen as training grounds rather than places to build a fulfilling career, although many point out that mental health staff need experience of inpatient nursing to be able to deal with the complexity of today's patient mix.

'It has traditionally been seen as a training ground for newly qualified staff, but the patients who are coming in now need quite high levels of care and that demands a much higher level of skills in the staff, ' says West Sussex Health and Social Care trust nurse consultant Theresa Dorey.

'We need to question why inpatient care has not been allowed to develop like community teams have. To me it is the most challenging place to work.' Her call for making inpatient care a specialty is backed up by Dr Lelliott, who wants this to be extended into clinical roles.

'These are the most needy groups of patients in a service. We ought to be developing more specialised inpatient psychiatrists, of which there are currently only a handful. On some wards at the moment there can be four or five junior psychiatrists attached to them, which means four or five time-consuming ward rounds a week.' Ms Dorey says that when recruiting staff it is vital to check they are interested in actually working in inpatient care, 'and not just using it as a stop gap until they can skip off to the community; we are looking for people with a passion for it'.

Benita Christie, a ward manager at North Essex Mental Health Partnership trust's The Lakes unit, agrees that contrary to what she calls 'the myth' of inpatient care being a place most suitable for training, it can be a difficult place for newly qualified staff.

'You have to first work out what suits your style of working, ' she says.

Ms Christie has overseen the training of healthcare assistants who have experience of inpatient care, and have their training paid for by the trust on the proviso that they return to work in an inpatient unit.

Yet those who do choose to build a career in inpatient care can find it stalled when career planning and training are forgotten because staff are needed on the ward and cannot be released.

Work that has been done to prevent staff getting stale or falling into 'fire fighting' mode has included establishing senior management posts to oversee all 'acute' care, whether in the community or hospital. This can ensure continuity of patient care - for example, by enabling a service user's usual community psychiatric nurse to monitor their progress while they are undergoing a hospital stay, and thereby helping break down 'us and them' rivalries.

Ward manager at North Essex's Derwent centre inpatient unit John Logers says: 'I have tried to break down the 'us and them' mentality by working more closely with our community teams.

We are more and more involved in what the other is doing. The crisis resolution team acts as our gatekeeper, and we also look at continuing interventions that have begun in the community when someone is admitted, ' he says. 'Long stays in inpatient care are not beneficial and any help with getting patients back into the community is very helpful.' Those working in inpatient care admit they can be chaotic places: 'Staff shortages in some areas are such that all people think about is risk assessment, ' says another NIMHE regional acute care lead, who does not wish to be named. 'They feel it is all about making sure you do not lose someone on your shift, either from them going AWOL, or worse, attempting self-harm or suicide.

'You either thrive in the setting or you do not, ' says Ms Christie. 'A lot of it is crisis work; some find that dynamic, others find it stressful. Some prefer to work in a less reactive environment.' This busy, even frantic pace of life means it can be difficult for staff to get training for anything that is not considered essential.

Justine Faulkner, assistant director of development and training at Avon and Wiltshire Mental Health Partnership trust, says the training that does take place is often considered by staff to be less an opportunity to learn ways of enhancing patient care and more a box-ticking exercise.

'We have been doing work involving users and carers on changes they would like to see. Some simple but effective measures, such as improved medication information, came out of that. The creation of a new games room and more structural changes have also taken place as a result. But it was difficult to get people to be able to get away. In the end it was achieved thanks to a modern matron who made sure the time was protected, ' says Ms Faulkner.

'The expectations on mandatory training have gone up. This includes things like food hygiene and manual handling. When that takes up seven days a year all the training allowance is gone, but I do not think many staff regard them as motivating or refreshing.' No one working in inpatient services would pretend they are the most comfortable place to work. But it is clear that the time has come for more recognition for the work that can be done in an inpatient setting.

'Out of my entire career I have spent only eight months in a community setting. When you see people who are very unwell come in and get better, when your interventions can really make a difference, that is why people work in inpatient care, ' says Mr Logers. .


Being able to make the most of their day and spend more time with patients without the benefit of extra resources was the challenge faced at West Sussex Health and Social Care trust's Meadowfield Hospital in Arundel.

The hospital's three open acute wards took part in Acute Solutions, a three-year project run by the Sainsbury Centre for Mental Health in four mental health trusts to look at improving inpatient care.

Nurse consultant Theresa Dorey, who ran the latter half of the project at the unit, says the work was focused on care, access to staff and recruitment issues.

'When staff are always getting interrupted and pulled away every time they try to spend some time with a patient they can start to feel it is all hopeless. I was there to try to slow down the system, to look at how to go about approaching that and enable people to feel that they did have the space to do other things, ' she says. 'I was there to help staff develop those initiatives and see them through.' Daily planning meetings with patients and staff established what was needed each day and what staff skill groups were available so staff could make the most of what was accessible.

Although she had not worked on an impatient unit before, Ms Dorey is now a firm advocate for work in this area to be recognised as a specialised skill. She will not employ someone in one of her wards (she also oversees a unit in Chichester) unless they can demonstrate a passion for inpatient care (see main text).

Work done by North Essex Mental Health Partnership trust on increasing the amount of time available to spend with inpatients looked at protecting staff time.

'The reality of a 24hour service like an inpatient ward is that others are always able to access you, ' says Benita Christie, ward manager of the Gosfield ward at the trust's The Lakes unit, which also took part in the Acute Solutions project. 'There is an expectation - which other teams do not have - that we will deal with any enquiry. When the phones go straight through to the ward office no one can shield you from calls. Using admin support can help filter those calls. We had to stop being all things to all people.'

Key points

Almost 80 per cent of inpat ient mental health nu rses have witnessed violence or aggression.

Inpatient units have been starved of resources to pay for community mental health teams.

There are calls to make inpatient care a specialty as inpatients are by necessity the most needy.