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A Review of Mental Health
Acute Admissions
Dr R Belgamwar, Mrs L Wrench, Mrs R
Purkayastha, Dr R Johnston and Dr J Christie
- GP Trainees, Dr M Abdelrahman -F1
Trainee
1. National Service Framework for Mental Health: Department of Health, September 1999.
‘Acute inpatient care is a core and integral
component of the National Service Framework for
mental Health to which all the NSF standards are
relevant…reshaping the organisation of inpatient
services to provide a more effective, safe and
therapeutic inpatient experience built around the
needs of the service users, their families and carers is
a NSF priority’ 1
Background
According to the Mental Health Policy Implementation Guide,
it has been reported by service users that admission to acute
inpatient care is in itself distressing and demeaning, therefore it
is paramount that assessment, care delivery and discharge
planning should be wholly focused around the service user.
Locally major changes have taken place e.g.
– The abolition of inpatient services in two mental health resource
centres
– Reconfiguration and reduction of beds within Harplands Hospital
– The changes to single sex ward environment.
– Increase in the multidisciplinary therapy and activities provision
– Role of crisis/HT team in gate keeping admissions
– Providing named care-coordinator
– 7 day follow up in the community
– The ward changes have occurred via a phased approach
starting from October 2005
Aim
To evaluate the new service model with a view to improving Acute Adult
Mental Health Care.
Objectives
• To compare NSCHT adult mental health inpatient statistics against national
performance indicators and statistics.
• To ascertain the current level of service provided to adult mental health
inpatients.
Method Part 1
Electronic Reporting Comparison of Before and After Ward Restructuring
The following samples were identified by the North Staffordshire Health Intelligence
Service (HIS) using the Combined Healthcare Hospital Information Processing System.
All patients discharged from Harplands wards and resource centres between
•1st January 05 to 30th June 05
•1st December 06 to 31st May 07
•1st September 2007 and 29th February 2008
Data included:
–General demographic details
–Length of stay (episode)
–Number of occupied bed days
–Admission rate
–Type of patient (formal / informal)
–Referral source
–Discharge diagnosis
–Readmissions within 28 days
–No of incidents for the period
Method Part 2
Review of Acute Admissions and Assessments
All patients discharged from the following locations between 1st September
2007 and 29th February 2008 (inclusive)
•Harplands Wards 1,2 and 3
•County Resource Centres (Ashcombe and Lymebrook)
•City Resource Centres (Sutherland and Bennett)
•A random sample of 50 patients was selected from the Harplands Wards (1, 2
and 3) and another 50 patients were selected from the Resource Centres.
•Casenotes of a final sample of 86 patients were reviewed from admission to
discharge.
In the last 30 years…..
The key aim of mental health care has been to support people
to live independent lives through better care and treatment in
the community
E.g.
•
•
In-patient psychiatric beds has fallen dramatically – 87,396 beds in 1980 to
29,802 beds in 2005-06
Rise in the community services – Includes CMH Teams, assertive outreach
teams, crisis teams, community rehabilitation teams, home treatment teams
etc.
How many inpatient beds?
– Depends on several factors including deprivation, other
community and support services such as crisis/HT, community
houses, day centres/hospitals etc, local drivers and financial
provisions.
– Gate keeping procedures and facilitation early discharge
– Any report giving an estimates become quickly outdated in view
of rapidly changing scenario.
– Inpatient beds are most expensive component of mental health
services
– Growing Independent and private sector inpatient provision
– Some reports of increased number of mentally ill people in prison
and ?Inversely proportional to the available psychiatric beds.
Nick Nalladori, a carer
•
•
•
•
•
In 2005/2006, more than two-thirds of the NHS budget for clinical mental
health services in England was spent on in-patient psychiatric hospital care.
However, in England, there are fewer in-patient beds now than at any other
time.
The Mental Health Act Commission found that between 2005 and 2007, 37% of
all wards they visited were running at over 100% bed occupancy.
Crisis resolution teams are intended to reduce the need for hospitalisation.
However, as yet, they do not have sufficient staff to meet this aim.
High bed occupancy does not arise only because the numbers of in-patient
beds has been reduced but also because of ‘bed blocking’.
References
http://www.rcpsych.ac.uk/campaigns/fairdeal/whatisfairdeal/in-patientservices.aspx
The Mental Health Act Commission (2008) Risk, Rights and Recovery. Twelfth Biennial Report 2005–2007. TSO
(The Stationery Office).
National Audit Office (2007) Helping People Through Mental Health Crisis: The Role of Crisis Resolution and
Home Treatment Services. TSO (The Stationery Office).
Local factors
• Deprivation above average
• High unemployment
• High mortality rate – Sentinel report dt: 01/12/2009– Stoke 204, North Staffs 170, South Staffs 171, Central Cheshire 161 (Per
100,000)
Adult available beds/ 100,000 of total population
46
45.12
44
44.46
43.37
42
40
38
38.8
38.68
39.45
CHC
36.17
36
England
38.36
37.91
34.75
34
35.96
34.3
32
30
2002-3
2003-4
2004-5
2005-6
2006-7
2007-8
Current bed availability: 35.96/100,000
Excluding Rehab/Neuropsychiatry: 24.41/100,000
Excluding Community beds: 17.44/100,000
(Harplands and EMU)
(England Reference 34.3/100,000)
Bed availability 2007/8
•
•
•
•
•
Derbyshire MHT- 233 beds
South Staffordshire FT – 292 beds
North Staffordshire – 165 beds
Cheshire and Wirral – 194 beds
Birmingham and Solihull - 583 beds
Perinatal Psychiatry, Forensic Psychiatry,
Eating disorders
Neuropsychiatry, Addiction,
Rehablitation Psychiatry
Bed Availability Data source
http://www.performance.doh.gov.uk/hospitalactivity/
data_requests/download/beds_open_overnight/be
d_06_detail1.xls
http://www.performance.doh.gov.uk/hospitalactivity/
data_requests/beds_open_overnight.htm
Population reference - Mid 2006 Estimate:
England: 507.6 (100,000)
CHC: 4.588 (100,000)
(North Staffs 21.12 + Stoke 24.76)
Where are 181 beds?
In 2005-06 we had
General Adult
109 beds
Rehabilitation
35 beds
Neuropsychiatry
25 beds
Addiction
12 beds
Total
181
• Changing adult inpatient bed availability
Speciality
2005-06
current
1
General Adult
109
96
2
Rehabilitation
35
28
3
Neuropsychiatry
25
25
4
Addiction
12
10
Total
181(39.45/100000)
159 (34.66/100000)
1. KH03 returns for 2009 will show 167 available beds (36.4/100000). For EMU we reported 14 beds instead of
10 and for Harplands ward 1( including PICU) we reported 24 beds instead of 20.
So we have reported 8 extra beds.
2. KH03 England 2008 data for adult inpatient beds shows 17,411 available beds (34.3/100000)
Conclusions
• In England, the number of available beds are reducing year
on year, the trend is likely to continue particularly when
significant financial cuts are expected.
• Over last 5 years, CHC Trust have reduced more beds
compared to the average England beds for adult mental
Illness.
• Our area has high rates of mortality, morbidity, deprivation
and low life expectancy.
• In last 5 years, average bed occupancy rate has not
significantly altered even with bed reductions.
• Locally, a third of our adult beds are for rehabilitation and
neuropsychiatry services. This is probably much higher to the
national average. These beds can be an income source for
our Trust if there is an out of area commissioning/interest.
•Results from electronic data
Patient Admissions by Ward and Resource Centre
Patient Primary Care Trust
Length of stay (days) per finished Consultant Episode
Period
1
Period
2
Period
3
Total FCE Length of Stay
(days)
19121
14632
15974
No of FCEs
575
628
550
33.25
23.30
29.04
Average
Length
Stay/FCE (days)
of
Readmissions within 28 days of discharge from previous admission
Readmissions within 28 days
Period
1
Period
2
Period
3
Readmissions - count
60
48
46
Readmissions - patients
50
34
37
1 x readmissions
41
28
33
2 x readmissions
8
2
2
3 x readmissions
1
2
1
4 x readmissions
0
1
0
6 x readmissions
0
1
1
Total
50
34
37
Patient Analysis:
Conclusion – Part 1
The restructuring in provision of adult mental health care has resulted in a
number of positive outcomes. There has been a clear reduction in number
of patient admissions across all service areas. The length of stay of
admitted patients has also reduced and once discharged, the patients
have less frequently been readmitted. Clinical outcome measure are not
recorded.
The introduction of the Home Treatment and Crisis Teams have enabled
some patients who may have previously been managed as inpatients, be
successfully managed in the community, and have supported inpatients
on discharge to prevent relapse and deterioration and subsequent
readmission.
Conclusion – Part 1
•
Patient demographics didn’t change much. They are all of similar age,
gender and ethnicity as compared to before service reform.
•
The proportion of admissions from each PCT is also comparable, as is the
admission source.
•
There is a small variability in primary diagnosis at discharge however, with
schizophrenia and delusional disorder being more commonly reported after
service reform and mood disorder less so.
•
The changes shows improved use of resources, accommodating bed
reductions and bed availability for the more acutely unwell patient have
benefits to the patients and clear financial benefits.
•
The success of the ward restructuring at the Harplands is also suggested by
the reduced number of reported incidents across. However more incidents
were reported in the community inpatient setting early transfer from
Harplands.
Acknowledgements
for Part 1
Data analysis has been provided with kind support from L J McDermott
and L Warrilow, North Staffordshire Combined Healthcare
References
•Information for Health. Department of Health, 1998.
http://www.staffordshire.gov.uk Key Statistics Summary Data
•HSE online
Type of admission and Average Length of Stay (n=86)
Harplands
County
City
44 days
17.5 days
63 days
Professional Recommending Admission (n=86)
Recommending
Professional
Number (%)
Harplands
(n=48)
County
(n=22)
City
(n=16)
Consultant
Psychiatrist
18(38%)
5(23%)
3(19%)
Psychiatrist
12(25%)
2(9%)
2(12%)
Crisis Team
6(13%)
2(9%)
2(12%)
Nurse
3(6%)
4(18%)
5(31%)
GP
3(6%)
2(9%)
1(7%)
Unable to
determine
4(8%)
4(18%)
3(19%)
Other
2(4%)
3(14%)
-
Observation level on admission and Detentions
Observation
Level
General
Constant visual
Close
intermittent
Number (%)
Harplands
(n=46)
County
(n=22)
City
(n=16)
28(61%)
21(95%)
15(94%)
3(6%)
-
-
15(33%)
1(5%)
1(6%)
•29% service users were detained at some point during their admission – most on
sections 2 and 3
CPA level on discharge (n=86)
Number (%)
Harplands
(n=41)
County
(n=26)
City
(n=19)
Standard
11(27%)
10(39%)
4(21%)
Enhanced
27(66%)
16(61%)
14(74%)
3(7%)
-
1(5%)
Not registered at time of
discharge
•Most common Care Coordinator was the CPN
•66/83 (80%) service users had a discharge planning
meeting prior to discharge
•In 39/50 (78%) cases the CC was present at the
meeting
Discharge Letter (n=86)
•In 61/86 (71%) cases there was a discharge letter present in the notes
•In 27/61 (44%) cases the name of the care co-ordinator was present in the letter
•In 19/61 (31%) cases the contact details of the care co-ordinator was present in
the letter
Discharge Letter sent to (n=61)
Number of Service Users
30
GP
25
20
Consultant
15
Service User
10
5
Other
0
Harplands
County
City
•Average length of time between date of discharge and date letter sent was 7 days
The pathway to recovery
• A review of NHS Acute Inpatient Services
• Provides benchmarking
• Report published in 2008 with the aim to
–
–
–
–
Support people to live independently in the community
Strengthening community services
Improvement in the quality of service
Emphasis on high quality care and pathways to achieve
best possible outcome
http://www.cqc.org.uk/_db/_documents/The_pathway_to_recover
y_200807251020.pdf
Health Care Commission
Assessment Criteria
• 1. Effective care pathway
– To insure appropriate admission and discharge is timely
– Providing appropriate and safe interventions
– Workforce development
– Monitoring and evaluating service e.g. outcome measures
• 2. Individualised whole person care
– Focus on personalised care
– Promotes recovery and inclusion
• 3. Involvement of service users and cares
– Users and cares involvement in strategic planning, operational,
evaluation and development
• 4. Safety
– The safety of service users, staff and visitors
THANK YOU and QUESTIONS