Amazingly, the headline on the 07.00 radio 4 news this morning was about the shortage of mental health beds. There was more detail on the BBC website, including details of a patient being admitted to a ward for deaf people, other patients in London being sent to B&B accommodation, and patients being sent hundreds of miles for an inpatient bed.
Why do I say amazingly? Well, because none of this is exactly new. Ten years ago I knew of mental health patients having to ‘hot bed’ in a major university teaching hospital – i.e. when a patient was allowed home on leave for a few days another acute patient would be admitted to that bed. Then if the patient who had gone home needed to return to hospital early (or sometimes at all) they were not able to do so because there was no bed for them. Psychiatric inpatient bed occupancy around the country runs at well over 100%, whereas a generally accepted optimum level of bed occupancy is 85%.
A paper in the Health Service Journal published in 2001 discusses issues of bed occupancy and ‘turn away’ (literally patients who require admission but are turned away from their local hospital because there is no bed available), thus confirming that this is not suddenly headline news in 2014.
‘some 38 mental health trusts are operating at higher than 5%
turn-away. No acute trust (>100 beds) operates above 20% turn-away while this is the
case for several mental health trusts. In the 38 locations where turn-away is greater than
5% there is the possibility that the community-based services are inadequate to meet the
demands being placed upon them. In these 38 locations additional hospital beds may
prove the most effective option to minimise the total healthcare cost’
Last October the BBC reported that mental health services in England were in crisis, and, as he did today, the health minister Norman lamb said that this was unacceptable. Of course it is unacceptable, as is continuing to close mental health beds whilst the demand for them is rising.
It is unacceptable that, due to the huge pressure on the diminishing number of beds available, the threshold for admission steadily rises. It is unacceptable, that without anything else about the illness changing, the threshold for admission to eating disorders units, often young people at a vital stage of their education, is rising. You now have to be thinner, physically sicker, and more entrenched in your illness to access inpatient care.
It is unacceptable that because the threshold for admission to acute units is higher, in practice virtually all the patients in them have been sectioned under the Mental health Act. Indeed, I know that some patients have been asked by their psychiatrists if they would agree to be sectioned because that would be the only way to find them a bed. If you didn’t think that you were losing your grasp on reality before, then the idea that you have to agree to be sectioned (by definition to be detained against your will) might just tip the balance.
It is unacceptable that because the patients who do access a mental health bed are now so sick, and the staffing levels of the wards so minimal, that the only real care offered is crisis care. In practice this is largely containment. Inpatient mental health units in the NHS can be dehumanising for staff and patients alike. Unfortunately, at least in the geographical areas that I have knowledge of, the idea that an inpatient mental health unit offers safety, sanctuary, and a therapeutic environment is confined to the private sector.
The situation is Sussex illustrates the problem:
In Sussex, the number of patients sent out of area increased from 28 in 2011-12 to 227 last year.
Lisa Rodrigues, chief executive of the Sussex Partnership NHS Foundation Trust, said rising demand for mental health services and cuts to community services by councils were creating problems.She said: “Mental health services are a barometer of how the system is operating and if you remove some of the lower levels of support that people rely on to maintain their lives, it’s not surprising that they’ll present in crisis.
“We are seeing people coming to hospital who are much, much iller when they arrive so we have higher numbers of detained patients but, much more than that, we’re seeing people have to stay in hospital for longer.”
We repeatedly hear ministers and health service managers telling us that it is better for patients to have good community services available to them, and that it is just a question of getting the balance right. Of course people with mental health problems need good community services, just as patients with kidney failure need good community dialysis services. People who are more unwell but who don’t need hospital care might very well manage with the care of someone like a Macmillan nurse. Unfortunately for them, CPN services (community psychiatric nurses) have been cut, just like hospital beds. A friend of mine had her CPN withdrawn as she was ‘no longer actively suicidal’ and therefore didn’t justify having a CPN. The whole service is being underfunded and overstretched. Budgets are being cut for community mental health teams at the same time as they are cut for inpatient care.
Unfortunately, even with the very best community care, people with mental health disorders, just like those with asthma, diabetes, multiple sclerosis, respiratory diseases, cancers, heart disease and a multitude of other physical illness, get relapses and flare ups. At these times they need inpatient care. The best community care in the world cannot do away with the need for dedicated inpatient units.
The unpleasant truth is that our society, our politicians, and sadly many of our doctors and nurses, just don’t care about mental illness. It is thought of as a stigma, a weakness, somehow a sign of poor morality, of inadequacy. Go into hospital as a successful professional for a planned surgical procedure and an overnight stay, and you will be guaranteed flowers, cards, good wishes. Go into a psychiatric unit and you will find a deafening silence from your friends and colleagues (in my case with a couple of honourable exceptions). We worry about the standard of compassion and care in the nurses in our acute hospitals, but little is said about the callousness and cruelty that psychiatric patients can receive from staff in psychiatric units. A MIND survey a couple of years ago reported that not only had some patients been raped by other patients on psychiatric wards, but there were also incidences of abuse from the staff. Similar accusations were reported by the BBC.
I really don’t know what it will take for this complete double standard of care to end. Mental health is all too often viewed as of lower priority that physical health despite an abundance of evidence that the two are inextricably entwined. It is common to hear people with severe and enduring mental health diagnoses (bipolar disorder, depression, schizophrenia, and others) asking whether they should tick boxes on application forms to say that they have a disability. It is equally common to see mental illness isolated as a separate category under ‘disability’ as though it wasn’t a ‘real’ disability. Nobody would expect a person with a physical health emergency to have to travel over 100 miles to a hospital, but it is ok for someone with a mental health emergency to do so. Nobody should assume that because you have a mental health diagnosis you are also lacking capacity or intelligence to run your own life, but they do.
Answers on a postcard please – but I’m not holding my breath expecting anyone to listen or act.