MENTAL HEALTH SERVICES: A survey of medium-secure units raises questions about their planned growth, report Jeff Jaycock and Tony Bamber

About a third of patients in high-security hospitals could be more appropriately cared for in a less secure environment, according to a report published in February last year.

The review, chaired by Sir Richard Tilt, called for a national review of medium-secure units.We undertook a survey in England and Wales in 2000.

It examines:

nthe capacity and capability of existing mediumsecure services for adults;

nthe relationships of those medium-secure services with other parts of the network;

nhow it is planned to develop medium-secure services and other parts of the network.

As there are no nationally agreed definitions of what constitutes a medium-secure service, it was agreed that the NHS forensic service leads in each English region and in Wales should identify which services should be included. The survey covers inpatient profiles, beds and services, activity, staffing, facilities, women's services, service costs, service gaps and planned developments.

The survey identifies 29 facilities providing 1,939 beds, of which 99 per cent were open. The NHS provides approximately two-thirds of beds, and one-third is provided by the independent sector.

Average occupancy is more than 90 per cent and no facility records occupancy below 80 per cent.

Sources of admission

The NHS and the independent sectors record different admission profiles.Approximately 67 per cent of NHS admissions come from prisons and high-secure hospitals, compared with 33 per cent of independent sector admissions. Similarly, 19 per cent come from low-secure and intensive care services, compared with 44 per cent in the independent sector.

These different profiles may arise for several reasons. The NHS units may have better links with high-secure hospitals and prisons, and the independent providers may be more responsive to urgent admissions from lower levels of security.

Twenty-two per cent of all NHS inpatients had been in their unit more than three years. Patients staying between two and three years occupied five per cent of shorter-term beds.A further 9 per cent of such beds were occupied by patients staying more than three years. It is not possible to determine whether such placements are appropriate or not, and it is recognised that they may occur for a variety of reasons.

Demand for longer-term care may exceed supply or there may be inappropriate designation of beds.

The independent sector has a number of facilities specialising in longer-term care that have been operational for only a short time and could therefore not provide a useful point of reference.

Around 14 per cent of NHS patients were considered suitable for discharge/transfer, but almost 80 per cent of them had no place identified to which they could be discharged, and 57 per cent had been waiting for a placement for more than three months. This compares with 3 per cent of independent sector patients who were considered suitable for discharge/transfer, of whom 70 per cent had no identified destination, and 24 per cent had been waiting for more than three months.

Waiting-list management varies greatly between services, so the survey provides only a broad indication of waiting-list issues. The NHS had 154 patients waiting for admission, who required 12 per cent of the supply of NHS beds.

The independent sector had 105 patients waiting - who required 16 per cent of the supply of independent beds.Of the patients on the NHS waiting lists, 43 per cent had been waiting for more than three months, compared with 20 per cent of the independent sector lists.While very long waiting times are rare, two patients had been waiting two years.

Service providers identify costs either as a single cost per patient week, or as a cost band. It is possible that where a fixed cost is identified, higher costs may occasionally apply, governed by the needs of individual patients.Also, in bands it is not possible to identify typical costs within that range.

Seventeen per cent of services are within a cost band of£1,500-£2,000 per patient week.

Sixty-six per cent are within a£2,000£2,500 band, and 14 per cent appear to primarily be above£2,500 per patient week.

Of the 11 independent providers, nine were in the top 14 highest-cost services.An NHS medium-secure service records the highest costs.

This survey suggests that while some capacity may be released by improving the use of existing beds, this would probably require investment in other parts of the forensic network, and patients admitted from waiting lists may quickly absorb the capacity released.

Overall, it would seem there was little immediate capacity to absorb significant additional demands from other sources, such as the high-secure hospitals.

Planned developments

NHS participants were asked to identify their development plans and the stage of preparation they had reached. For the purpose of analysis, NHS plans that have reached full business-case stage are considered to have a medium to high level of certainty of implementation. Independent providers provide their own assessment of the level of certainty of implementation.

The NHS has schemes either at full business-case stage or under construction that would increase total sector capacity by 9.5 per cent - 185 beds - by the end of 2003, and have plans to develop a further 152 beds after 2003.

The independent sector has schemes which would increase sector capacity by 12.9 per cent - 250 beds - by the end of 2003, and have plans to develop a further 100 beds after 2003. These plans would increase the market share of the independent sector (in terms of total beds) from 34 per cent to 38 per cent by the end of 2003.

In the event that all identified plans by both sectors are implemented, total capacity would increase from 1,939 beds (September-October 2000) to 2,626 beds over the next three to four years.

Schemes with a low chance of implementation

The NHS also has schemes at outline business case stage that would increase sector capacity by a further 40 beds - 225 in total, or 12 per cent of total sector capacity - by the end of 2003. The independent sector has no schemes at a low level of certainty of implementation before the end of 2003. After 2003, further growth in capacity - 348 beds - is primarily planned by the NHS. The independent sector plans a further 100 beds. If all identified plans are implemented, total capacity would increase from 1,939 beds (September-October 2000) to 3,074 over the next three to four years - an increase of 1,135 beds or 59 per cent.While estimates of future growth must be treated with caution, there seems to be considerable potential for expansion.

Conclusions

How will the expanding service be staffed during the next three to four years? The survey indicates that 85 per cent of NHS medium-secure services are not fully staffed, 59 per cent have significant recruitment problems and 52 per cent are limiting their service. Similar figures were recorded for the independent providers, though none claim to have significant recruitment problems.

How is growth to be funded?

A crude indication of the additional revenue costs can be guestimated by multiplying the number of additional beds planned by an estimated cost per patient week.

Assuming an average cost of£2,000 per patient week for NHS facilities and£2,300 for independent facilities, all planned mental illness developments would cost an additional£77m, excluding cases in which the development of a bed removes the need to commission one from somewhere else.

Does the growth planned for medium-secure services meet the needs of patients in the three highsecure hospitals, taking account of appropriate care pathways and a networked approach?

Is investment too focused on one part of the network, at the expense of the remaining parts?

Is there effective partnership between the sectors?

The survey indicates some synergy between them, as suggested by the analysis of sources of admission and an increase in the supply of longerterm beds by the independent sector.

However, the NHS appears to be planning developments that could have an impact on existing independent sector operations and there are indications that some independent developments are moving ahead without full commitment from NHS commissioners, but with an expectation that the beds will be filled.

What next? While there is interest in increasing the supply of beds, there is also a need to ensure that existing services are used as effectively as possible, and that developments are agreed, well-focused and affordable.

Also, a sufficient number of qualified staff must be available.

Key points

A survey of medium- secure units in England and Wales found a total of 1,939 beds.

Two-thirds were provided by the NHS and one-third by the independent sector.

Average occupancy was over 90 per cent.

The bulk of units cost£2,000-£2,500 a week per patient.The independent units were among the most expensive.

The units were planning expansions that would provide an extra 1,135 beds over the next four years.