Simon Lawton-Smith asks whether community-based services will reduce acute admissions

Published: 15/07/2004, Volume II4, No. 5914 Page 29

Reading a December 2003 Commission for Health Improvement report on mental health trusts recently, I came across the following passage: 'CHI found bed capacity in many trusts under severe pressure.While new community-based services will reduce admissions to hospital over time, in some wards bed occupancy rates still exceed 150 per cent.'

It was not the comment on the pressures trusts are under, nor the 150 per cent occupancy that made me pause, but the assumption that new community-based services will reduce acute admissions to hospital, and the impact on acute beds and costs.

The premise that a significant number of admissions could be avoided if suitable alternatives were available has been around for many years. It appears logical when one considers the current programme of service development within the community.

At its forefront are the muchtrumpeted crisis resolution teams. These should be seen as increasing the options available for acute treatment and care in the community, as part of a whole-system framework.

Nevertheless, there is a clear expectation that they will reduce admissions. In the words of the National Institute for Mental Health in England: 'Crisis resolution and home treatment teams offer immediate care at home and also stay involved until the crisis is resolved, reducing the number of hospital admissions.'

But the creation of crisis resolution teams has progressed slowly. There are only around 130 against a target of 335. For 2003, the percentage of local implementation teams with crisis resolution teams in place ranged from 21 per cent (North West region) to 55 per cent (Northern and Yorkshire).

To help meet the target, the Department of Health has announced that all 85 trusts and primary care trusts with lead responsibility for mental health services provision may access a one-off payment of£200,000 (to spend on whatever they want) if they can show evidence of progress, from March to December 2004, in achieving effective, co-ordinated 24/7 crisis services.

The current incomplete picture makes it difficult to reach firm conclusions about their impact on bed numbers, but initial evidence from established teams suggests it is considerable.

HSJ recently reported a 40 per cent reduction in bed use following the establishment of the crisis resolution team at Newcastle, North Tyneside and Northumberland Mental Health trust ('Lost in liaison', pages 26-27, 1 April) (see box).

But there are a number of pressures to maintain levels of bed numbers. First, there is the argument that if beds are there, they can be filled. There are plenty of stories about how hard it is to find a bed for someone when they really need it.

In addition, are beds still blocked by patients who no longer need acute inpatient care but lack alternative community support?

Are patients presenting with complex needs that require more intense care and hinder early discharge? Are thresholds for admission changing? Why are there huge unexplained variations between different PCTs? What impact will proposals for community treatment orders have on admission and discharge?

There are also calls to increase psychiatric bed numbers from those who believe 'the pendulum has swung too far', often heard following media coverage of tragic care in the community incidents and cited by MPs through their contacts with constituents.

It begs the question, do we have too many beds or too few?

Twenty years ago there were 79,000 mental illness beds in England. Today there are around 32,000. Should we be looking at reducing bed numbers to, say, 20,000 over the next 10 years and reinvesting the money saved in alternative community services?

That would seem a neat solution, and would fit in with the wider thrust from the DoH to keep people out of hospital through more effective management of chronic conditions.

But if bed numbers stay broadly the same, as they have done over the past two or three years, the high costs of inpatient care will continue to run alongside the significant costs of new community services.

Once the new pot of mental health money targeted at establishing these services is empty, there is no guarantee of future funding.

Somewhere along the line, something may have to give. l Simon Lawton-Smith is a senior policy adviser on mental health at the King's Fund.

Downward drift Figures show the number of adult acute inpatient care beds in the Newcastle, North Tyneside and Northumberland Mental Health trust area has dropped from 146 in 1999-2000 to 121, with plans to reduce numbers further to 95 by the end of 2004.

In London, the Kensington and Chelsea (south) crisis resolution team was cited in a King's Fund inquiry as having removed the need for out-of-area referral beds.Previously it was using 10-15 out of area referral beds at any one time.

In the last year the team has avoided 390 admissions, leading to the closure of 11 of the 41 inpatient beds at its South Kensington and Chelsea mental health centre.

Further information

London's state of Mind, King's Fund.

www. kingsfund. org. uk