Acute mental care consumes two-thirds of all mental health resources. But if there were alternative services for inpatients who no longer need intensive support, costs could be halved, suggest Christina Moore and Judith Wolf

There has been a dramatic decline in hospital beds for mental healthcare since a peak of 155,000 in the mid-1950s. The number of available beds in NHS hospitals has more than halved in the past decade or so to around 37,000, although most of the beds that closed were for long-stay patients.

Around 22,000 of the remaining beds are for acute care. At the same time, demand has been rising. Throughput in psychiatric beds has more than doubled to 5.7 patients per bed per year over the 10 years up to 1994-95.

The severity of problems of people treated in hospital has also increased.1 The number of admissions each year increased from 200,000 in 1983 to 236,000 in 1993-94 and 270,100 in 1994-95. Finished consultant episodes for the year 1997-98 were 236,000.

Several surveys have pointed to wide variations in bed occupancy rates, which often approach or exceed 100 per cent as patients are placed in beds belonging to other patients temporarily on leave, or even sleep in interview or seclusion rooms.

The one-day census by the Mental Health Act Commission and the Sainsbury Centre for Mental Health put occupancy rates at 96 per cent, but this excluded patients on leave. When these patients were included, there were 99 patients for every 100 beds, with 36 per cent of wards declaring they had more patients than beds.2

One annual census over four years in greater London has shown occupancy rates averaging 97.5 per cent across the capital, with rates exceeding 100 per cent within inner London.3

The first stage of the acute care inpatient study, carried out in 1995 by researchers at the Sainsbury Centre, confirmed this picture. A survey of 38 acute wards in England and Wales identified occupancy rates for the past 12 months averaging 93 per cent and ranging from 61 to 127 per cent.

The highest rates were found in inner cities, particularly in London. Across the wards, throughput in psychiatric beds ranged from eight to 14 patients per bed per year.

The first stage of the study supported the conclusion that the shortage of beds in acute wards was related both to social deprivation and the number of available beds.4

The wards with low bed availability in the most socially deprived areas appeared to have the highest bed occupancy levels.

In all, 27 per cent of the patients (603 out of 2,215)were judged not to need continuing admission. This proportion was significantly larger among those with stays of longer than six months.

The most common problem preventing discharge was the non-availability of various community and residential options, in particular the lack of suitable supported housing.

In the second stage of the research, carried out between September 1996 and April 1997, we studied nine of the 38 wards, and the issue of delayed discharge was investigated in more detail.

Key findings

The study found that a large majority of patients were admitted for emergency psychiatric treatment, usually for relapse of an existing illness.5 Some 89 per cent were unplanned emergency admissions.

But more than one in 10 patients was admitted for social reasons or for respite care. Forty per cent of patients had been admitted to the same service in the past 12 months and 13 per cent in the past six weeks, clearly revealing a revolving door effect.

Most admissions were voluntary, although 15 per cent were admitted under the Mental Health Act. There was considerable variation (4-37 per cent) across the wards in the proportion of people admitted under the act, although this variation is not associated with deprivation or location.

Many patients receive only limited therapeutic input, and multidisciplinary care is absent for the majority. Patients had remarkably few contacts with staff other than doctors and nurses, and there was little evidence of the timely and effective use of psychologists, occupational therapists or social workers.

Of the 215 patients in the second stage of the study, 209 had been discharged by its end. Those who were discharged stayed an average 38 days on the wards, with a median stay of 25 days. Average length of stay across the wards ranged from 20 to 48 days, with 57 per cent staying for a month or less.

Delayed discharge

Many patients could have left the wards earlier if alternative accommodation or care had been available. Each week that such a patient remained on the ward, their named nurse was asked by the researchers to determine whether, in the opinion of the multidisciplinary team, the patient still required the facilities of an acute inpatient ward. If the answer was no, the nurse was asked to indicate the main reason preventing discharge or transfer to a more appropriate setting.

A lack of suitable accommodation was the major reason felt to be delaying discharge for patients for each of the first six weeks of the stay. Lack of domiciliary support was also a substantial reason for delayed discharge during the first few weeks of the stay.

Lack of rehabilitation places was identified as a problem during the first three weeks. This problem then decreased, but increased again for those staying eight weeks or more, perhaps indicating the difficulty of finding places for those with more complex or difficult needs and their accumulation on the acute wards.

For others staying longer than eight weeks, the major reason given for delayed discharge was a lack of home-based care rather than lack of accommodation. A small number of individuals were consistently rated throughout each of the weeks of stay as requiring higher psychiatric supervision.

Within the first week, just under one-fifth of patients were considered to be inappropriately placed. This had risen to half by the third week and more than two-thirds for those who were on the wards eight weeks or longer.

Estimated costs

Staying on an acute inpatient ward is expensive - about£924 per patient per week.6 This consumes about two-thirds of all mental health resources.

Using the data above, we estimated the cost to mental health services of delayed discharge. Of a total of 915 weeks, which brought 224 inpatient admissions (some were repeat admissions), the cost was£845,460.

The total excess cost of treating these patients when they were considered well enough for discharge or transfer to less intensive, and therefore less expensive, services was£382,536 (414 weeks of inpatient care) with a potential cost of£462,924 (501 weeks of care).

Alternative services are less expensive than inpatient care.

The graph (above) clearly shows how these costs are affected by the delay in discharge of people who could be better catered for in another part of the service.

Discussion

The second-stage data shows, as did the first-stage findings, that a simple expansion of acute beds will not effectively address the problem of over-occupancy. The study confirms that quite a number of patients stay longer on acute psychiatric wards than necessary for medical or therapeutic reasons. They remain inpatients mainly because of a lack of (usually less expensive) alternatives in the community and lack of home-based support.

In addition, the first-stage data showed that some patients with longer stays tended to block beds because they needed more specialised and highly supervised care, which was not available. But the data reveals that bed blocking is also due to a small group of patients with dangerous and violent behaviour who need more secure facilities, and a heterogeneous group of patients with a range of special needs (for example, patients with acquired brain damage, dual diagnoses and eating disorders) who tend to fall between different specialties.

Staying longer unnecessarily can have personal costs for the patient, such as loss of liberty, and postponed opportunities to reintegrate into society. It can also carry high material costs, such as loss of employment, accommodation or decreased benefits.

Delayed discharge also incurs high material costs for the service, as this study indicates.

In the short term, better bed management at every stage - at admission, throughout the patient's stay and at discharge - can relieve some of the pressures. To solve the problems of over-occupancy and costly delayed discharges in the longer term, a range of care options, with several ambulatory and residential alternatives for different levels of need and different kinds of problems, must be considered. Acute inpatient care should be viewed as one component of such a spectrum, operating a specific, well- defined function - that is to provide intensive 24-hour care for those patients whose needs are for intensive assessment, immediate treatment and stabilisation of symptoms.REFERENCES

1 Holloway F, Silverman M, Wainwright T. Not waving but drowning: psychiatric inpatient services in East Lambeth 1990. International J Social Psychiatry 1992; 38 (2):131-7.

2 MHAC/The Sainsbury Centre for Mental Health. The National Visit, 1997.

3 Powell R, Hollander D, Tobiansky, R. Crisis in admission beds. British J of Psychiatry 1995; 167 (6): 765-769.

4 Shepherd G, Beadsmoore A, Moore C, Hardy P, Muijen M. Relation between bed use, social deprivation, and overall bed availability in acute adult psychiatric units, and alternative residential options: a cross-sectional survey, one-day census data, and staff interviews. Br Med J 1997; 314 (7076): 262-266.

5 Beadsmoore A et al. Acute Problems. The Sainsbury Centre for Mental Health, 1998.

6 Netten A, Dennett J. Unit Costs of Health and Social Care. PSSRU, 1997.