Would expanding the number of beds available for mental health users reduce existing pressures on services?
The national service framework for mental health says that each service user who needs a period of care away from home should have 'timely access to an appropriate hospital bed'.
The government's consultation paper on the national beds inquiry says: 'In some localities, especially the inner cities, there are currently severe pressures on acute mental health beds. The main focus should be on supported accommodation in the community, medium-secure beds, and local intensive care beds. In the longer term, this may enable a reduction in acute mental health beds. In the shorter term, some health communities may need to invest in additional acute beds to relieve current pressures.
2The pressure on acute mental health beds is well known. A recent national study undertaken by Greengrass et al found that 70 per cent of service providers sometimes or often had no beds available.
3An earlier study by Shepherd et al found excessive levels of bed occupancy occurred in areas of high social deprivation and low bed availability.
4It also found that a quarter of inpatients were judged not to need hospital care but were in a bed because of a lack of rehabilitation places, domiciliary and community support or appropriate housing.
So, does the NHS need more mental health beds, or are there other ways of meeting the needs of people who are acutely mentally ill?
Last year the inner cities mental health group (ICMHG) became increasingly concerned about pressure on beds. The group, which now comprises 26 trusts, was started in 1995 to promote improvements in services and to measure trusts'progress towards defined goals. The group has developed indicators for assessing performance, looking at staffing, activity, costs, organisational issues and resources.
5Our key performance indicator (KPI) data showed that for 1997/98, bed occupancy ranged between 69 per cent and 130 per cent in different inner city trusts.
The proportion of the acute admissions that took place outside the patient's local trust ranged from 0 per cent to 45 per cent.
All these variations occurred in the inner cities - with broadly similar levels of deprivation and high levels of need. If we could understand why the variations occurred, we might be able to find the best solutions: more beds, more community services or other ways of meeting needs and managing demand.
ICMHG decided to undertake a project re-analysing the 1998 key performance indicators data that had been collected by the 26 participating inner city trusts. The indicators were originally collected as part of our benchmarking work rather than for this project. They cover many aspects of specialist mental health services for adults, drawing on the NHS performance assessment framework. They relate to access to services, patient/carer experience, effective delivery of services, efficiency, health outcomes, health improvement and risk management.
We also examined population and mental illness needs index (MINI) scores for each of the districts, and the total number of beds and staff per 1,000 MINI-weighed population.
6This would allow us to say whether the pressure on beds was a result of the level of needs of the population or the level of available resources.
We measured the pressure on the services in terms of the number of blocked beds and the number of acute admissions that took place outside the trust.
Figure 1 shows our initial hypotheses - what we expected to find, which was that pressure on beds would result from a lack of resources and a lack of alternatives to inpatient treatment.
In fact, we found that high levels of admissions outside the trust - our main indicator of pressure on the acute beds - were related to:
poor coverage of the care programme approach;
poor accessibility to a range of community mental health services;
high costs per community case;
a low number of nurses per inpatient; and inappropriate bed use - large numbers of very short or very long admissions.
Figure 2 shows what we actually found, and how we interpreted the data. High levels of need, a limited range and quality of services, and low levels of hospital resources all resulted in high levels of admissions outside the patient's own district. This in turn was associated with inappropriate services, high costs per case and inefficient use of resources.
The most surprising finding was that there was no statistical relationship at all between the number of acute beds per 1,000 MINIweighted population and the level of admissions outside the trust.
Patients in districts with a large number of beds were just as likely as patients in other districts to be admitted away from their home and their local services. So what do we make of this?
The lack of relationship between the number of beds and the number of admissions outside the trust suggests very strongly that opening more beds is not, by itself, the answer to pressure on services. More inpatient services are not, by themselves, the way to meet people's needs.
More important than beds is the total range and quality of services.
Inpatient services and community services must be provided together to meet people's needs. The quality of clinical decision-making helps people access appropriate services.
We may need more beds, especially in the hardest-pressed inner city areas. But we also need more community mental health services, and to invest in a comprehensive range of inpatient and community services, that work together in flexible and integrated ways.
High-quality services and the focus of the care programme approach on the individual are the best way of meeting the needs of people who are acutely and severely mentally ill.
1 Department of Health, National Service Framework for Mental Health. 1999
2 Department of Health, Shaping the Future NHS : Long Term Planning for Hospitals and Related Services. 2000 (paras 64 and 65).
3 Greengrass P, Hollander D, Stanton R, Pressure on adult acute psychiatric beds. Psychiatric Bulletin. 2000;25 :54-56.
4 Shepherd G, Beadsmoor A, Moor 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. British Medical Journal. 1997;314 :262 - 266.
5 Clarke, P. . McCarthy, T. Called to the Bench. HSJ September 14 2000.
6 Glover G R, Robin E, Emami J, A needs index for mental health care. Social Psychiatry and Psychiatric Epidemiology. 1998;33 :89 - 96.