Has a new era of reinstitutionalization in mental health care begun?

October 10, 2008

Research paper: A retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and the number of psychiatric beds in England 1996-2006
The number of compulsory admissions to inpatient psychiatric care has increased dramatically but the number of NHS beds has fallen, and there has also been a significant increase in the number of patients admitted for alcohol and drug problems, finds a study published today on bmj.com.

In addition, inpatient psychiatric care is expensive, unpopular, and often unsatisfactory, says the author of an accompanying editorial.

Since the 1950s deinstitutionalisation has resulted in the number of psychiatric beds declining from 150,000 in 1955 to less than 55,000 in 1995. But evidence suggests that involuntary admissions are increasing and that perhaps a new era of reinstitutionalisation has begun.

Patrick Keown and colleagues examined the changing face of psychiatric care in England between 1996 and 2006 by analysing data from the NHS Information Centre, the Department of Health, and the 2006 'Count me in' census.

Overall, they found that while total psychiatric admissions and NHS bed numbers fell during the decade, the number of patients sectioned increased by 20%, with a threefold increase in the number of these involuntary patients being admitted to private facilities.

They report that as the number of NHS psychiatric beds decreased by 29%, the proportion of NHS beds occupied by patients admitted under a section of the mental health act increased from 23% in 1996 to 36% in 2006. In 1996𔃅 sectioned patients were 15 times more likely to be in an NHS facility than a private facility, but by 2006 they were only five times more likely.

Total NHS admissions for mental disorders peaked in 1998 at around 214,000 and then began to fall. Reductions in admissions were confined to patients suffering from learning disabilities (decreased by 58%), depression (33%) and dementia (28%). Admissions for other groups such as schizophrenic and manic disorders have remained relatively stable, however, and since 2003 those for drug and alcohol problems have increased by 29%.

The authors say that the change in case-mix towards psychotic, alcohol and substance misuse disorders has changed the environment on inpatient psychiatric wards.

In an accompanying editorial, Professor Scott Weich, Professor of Psychiatry at the University Warwick, argues that the focus should move away from numbers to the quality of service provision. The absolute bed numbers, he writes, say nothing of the differences between places and service users, or the quality of services and the experiences of users, carers, and staff.

The greater need is for improvements in the quality of services and "this will only happen if users' and carers' voices are heard and acted on", he concludes.

Source: British Medical Journal

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