Private care's win-win

Mental Health Nursing,  Oct 2000  by Simpson, Alan

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The newly appointed mental health 'tsar', Professor Louis Appleby, reportedly suggested that the NHS should send mentally ill patients to private hospitals for intermediate care, following discharge from acute wards.1 But the NHS already depends heavily on the independent sector. Alan Simpson argues that community mental health and acute in-patient services are locked into an ineffective and inefficient cycle that benefits only private health care

Volume 20 No 8 pp6 - 9 Mental Health Nursing

Psychiatric inpatient units are in crisis. The number of psychiatric beds in NHS hospitals has been slashed to around 28,000 from nearer 123,000 in 1970 2 whilst rates of admission have risen.3 Throughput more than doubled to 5.7 patients per bed per year over the 10 years up to 1994-95 as the number of admissions increased. 4

As a result, bed occupancy rates are frequently reported to be unmanageably high with 100 per cent occupancy commonly exceeded. 4-7 While London is worst hit, over two thirds of UK NHS trusts outside the capital experience bed shortages and over 17 per cent report frequent difficulties. 8

Perhaps unsurprisingly, reports have highlighted the poor and deteriorating quality of care given to those admitted to in-patient units. 9-11 Acute care often becomes acute control and little else. The increasing presence of those with dual diagnoses of mental illness and substance misuse 12 and an increase in aggressive and violent behaviour add to the problems.

Staff turnover and the use of bank and agency workers is high 4 as an increasing number of staff are assaulted and stress and sickness levels deteriorate.

Education, training and development of inpatient staff are often neglected and there are minimal opportunities for meaningful therapeutic activities to take place. 9 10,11

Studies examining psychiatric bed use have found that almost 30 per cent of admissions to acute mental health beds would not have been necessary had resources been available to provide care at home or in another community setting. 2,13

The National Beds Inquiry 2 notes that between 24 per cent and 58 per cent of patients may stay longer in an acute bed than necessary because of shortfalls in suitable services. These include secure provision, ordinary housing, home-based community support and rehabilitation services. The report concludes that the pressures on acute beds `appear to reflect a wider mismatch of provision and need'.

Between 60 and 70 per cent of admissions are re-admissions which supports the suggestion that there is difficulty in maintaining the treatment of those discharged to the care of existing community services. 14

Private beds

Additionally patients are often admitted or transferred to hospitals out of area or, increasingly, to private hospitals. s 7 The use of private psychiatric hospital beds has multiplied with the subsequent loss of millions of pounds from the NHS kitty The seven MILMIS surveys of inner London acute in-patient services found consistently high use of private hospitals that far exceeded the numbers transferred to other NHS trusts, despite an increase in NHS bed numbers within the trusts studied. 5

The situation is not unique to London. Forty-three per cent of English NHS trusts outside the capital resort to the use of beds outside their own area, although the number placed in the private sector is not recorded. Indeed, the Department of Health does not collect the figures nationally for the use of private beds, which begs the question, `why not?' In the southern regions, over 55 per cent of trusts excluding London rely on the use of extra-contractual referrals. 8

As an example of the costs involved, look at Brighton and Hove. In 1998-99 private referrals for acute mental health patients cost approximately 350,000. In 1999 - 2000, the number of referrals has dramatically increased and cost YI.7 million. 15 This figure is in excess of the 5 million paid to the local trust for adult inpatient beds and in addition to a further 85,000 spent on overspill beds with NHS providers.

Despite a bed management strategy 16 each month in Brighton and Hove an average of 16 people with mental illness are admitted to private psychiatric beds because of the lack of NHS beds, a fourfold increase from the previous year. 15 A private bed in Sussex costs an average of 290 per night, itself an increase of 15 per cent from the previous year, whilst a bed in the local trust is costed at 160 per night. 17

The average length of stay for patients at the local private sector hospital increased by half this year compared to last, 17 at a time when duration of stay dropped in NHS hospitals. 3 The health authority and trust have set in motion an action plan aimed at addressing the situation.

The local health authority say `the reasons for the increase in expenditure are not immediately apparent' 17 but will include beds 'blocked' by patients unable to be discharged without intensive community support. There has also been some reduction in the number of acute beds available since the opening of a new, purpose-built hospital to replace two older units. is