Author
GLASBY Jon; LESTER Helen;
Title
On the inside: a narrative review of mental health inpatient services.
Journal citation/publication details
British Journal of Social Work, 35(6), September 2005, pp.863-879.
Summary
This review focuses on part of the literature identified for a much broader review of mental health services in England, and is based on 27 documents relating directly to hospital inpatient mental health services and 51 relating to the experiences of women and ethnic minority groups. Four main themes are identified: increasing pressure on beds; negative service user experiences; discharge problems; and the emergence of new service alternatives. General recommendations for both policy and practice are offered.
Context
The widespread de-institutionalisation of people with mental illness over the past 40 years has ensured that 'professional, political and managerial attention has focused more on the consequences of the alleged failure of community services' than on the experiences of those who are cared for in acute psychiatric wards. This review forms part of a wider review commissioned in 2002 by the National Institute for Mental Health in England that was published as ten separate online booklets under the overall title Cases for Change (details at the end of this abstract).
Methods
A more detailed account of methods is given in the Introduction booklet in the online Cases for Change series, and forms the basis of this section.
What sources were used?
The following databases were searched: ASSIA (Applied Social Sciences Index and Abstracts), CareData [now Social Care Online], the Health Management Information Consortium (HMIC) Database, HealthSTAR (Health Services, Technology, Administration, and Research), Medline, Social Sciences Citation Index and TRIP (Turning Research Into Practice). 'Seminal documents' identified by the review team and a panel of ten experts in health and social care were also used 'to guide the review', and a listed range of websites was searched.
What search terms/strategies were used?
Keywords for the part of the overall Cases for Change review reported in this paper included terms relating to mental health, combined with terms relating to hospital, inpatient, bed, ward, forensic, gender and ethnicity. The Cases for Change Introduction booklet states that terms were selected on the basis of thesauri, the authors' own knowledge, and input from an expert advisory panel and an additional list of named mental health practitioners, researchers, managers and policy makers. A sample search from the HMIC database is given and suggests that searches of professional quality were carried out. Studies published between January 1997 and January 2002 were sought, whether published as peer reviewed articles or as reports (grey literature). The authors' decision to include a wide range of academic and non-academic material was deliberate, in particular to give voice to service users.
What criteria were used to decide on which studies to include?
A wide range of exclusion criteria was applied to the material identified in the searches. Only studies relating to England were selected, with the following excluded: services for older people; services for people with learning difficulties; services for young people aged under 14; sex offenders; people with personality disorders; substance misuse; opinion pieces; inspection reports or service reviews; pharmacological interventions directed at individuals; serious and untoward incident reports and public inquiries; most purely theoretical papers; most training interventions and materials; press releases; documents summarising material already selected for review; outcome scales; probation services not dealing specifically with mental health; clinical governance issues not dealing specifically with mental health; protocols and guidelines; clinical audit; the management of violence unless specific to mental health delivery; and postnatal mental health issues.
Who decided on their relevance and quality?
The total number of hits from the initial searches is not given. Both authors scanned these against the exclusion criteria on the basis of titles and abstracts, independently in the case of the first 200 documents. Selected documents were obtained in full text and classified according to the hierarchy of evidence laid down in the National Service Framework for Mental Health. The authors also drew on referenced approaches to assessing the quality of qualitative research. However, they state that 'There has been no attempt to provide a strength of recommendation based on the categories of evidence since the potential power and impact of a study lies beyond a description of the basic design. Human testimony and single site experience can sometimes be as influential in policy terms as systematic reviews and randomised controlled trials.'
How many studies were included and where were they from?
A total of 653 documents relating to England was analysed for the purposes of the complete Cases for Change review. The part of the review reported in this paper is based on 27 documents relating directly to hospital inpatient mental health services and 51 relating to the experiences of women and ethnic minority groups.
How were the study findings combined?
The studies were analysed using two referenced methods: grounded analysis; and triangulation to compare qualitative and quantitative data from different studies. Key themes and issues were identified and 'constantly tested and re-tested against the literature in order to ensure that they continued to provide a satisfactory explanation of the empirical data.'
Findings of the review
Four major themes emerged from the literature:
Pressure on inpatient hospital services
A decline in the number of inpatient beds has led to an increase in throughput per bed, with 'many studies' showing bed occupancy rates above 100%. However, the rates are not uniform and appear to be particularly high in the south (especially London ) and in inner city areas. At the same time, as many as a third of admissions may be 'inappropriate', while significant numbers are emergencies resulting from the 'revolving door syndrome'.
The forensic mental health services are under similar, possibly greater, pressure, with 'a high rate of unmet mental health needs in the prison service': one estimate suggests that 90% of the prison population has a diagnosable mental condition, substance abuse problem or both. At the same time, other studies suggest that existing forensic mental health beds are often blocked because of difficulties in transferring prisoners inappropriately placed in maximum or medium security prisons to lower security facilities.
Negative service user experiences
While some people 'undoubtedly receive high-quality care that meets their needs', there is evidence that many more perceive inpatient treatment as an 'extremely negative' and sometimes traumatising experience. Concerns about the physical environment, cleanliness, privacy, lack of information, lack of occupation, food, personal safety and other issues have been widely expressed. Hospital services 'were felt to be particularly unsafe for women', a 'substantial proportion' of whom may have been sexually abused and may be open to the same danger as inpatients. Sexual harassment is described as 'still common', and there is evidence that too little is done to prevent its occurrence.
People from ethnic minorities face additional problems. Those from African-Caribbean and Asian backgrounds have higher rates of admission to psychiatric hospitals but despite attempts to promote more culturally sensitive services, 'there is widespread evidence' to suggest that, for many of them, the experience is a negative one. For example, a majority of wards appear to have no policies for dealing with racial harassment, or for race equality training, and while more have policies on the provision and use of interpreters, not all use trained interpreters.
Discharge problems
Although some mental health patients may be discharged too early, and become part of the revolving door syndrome, others 'may remain in hospital much longer than they need to because of a lack of community services', including rehabilitation and housing. These problems can be particularly acute for the forensic mental health service because of a lack of formal relationships with community services, and inadequate skills in the latter to cope with 'complex and multiple needs'.
Alternatives to hospital admission
Current government policy promotes functionalised community mental health teams, but the literature suggests the potential of other forms of community-based provision that could help reduce the need for admission, or act as an alternative to it. These include volunteer befriending schemes, greater link working in the community, intensive home-based support and emergency day care services. 'There is also a small but growing body of evidence' that user-led crisis houses can provide an alternative to inpatient care.
Authors' conclusions
The review 'suggests that the recent focus on developing community services has resulted in a relative neglect of inpatient settings', and much of the literature points to the need for a longer term, 'whole systems approach' to resolve the problems of pressure on beds, negative user experiences and problems with discharge.
Implications for policy or practice
Although structural and resource issues need to be tackled by government, cultural changes are also needed to address 'the value base of the people working in mental health services' to ensure that patients are treated sensitively and with respect. This would do much to improve the quality of the inpatient experience. The government also needs to commission further research and issue further guidance on inpatient care to avoid a situation in which it will once again be 'subject to the scrutiny and criticism that cast a shadow over psychiatric services in the 1960s and 19070s. At ground level, frontline practitioners in mental health and social care also need to reflect on how they can make the existing system work more effectively, by making closer contacts with each other. Job shadowing would be one useful mechanism. The new provision of mental health services by integrated health and social care mental health trusts also offers frontline social workers opportunities 'to challenge the negative features of inpatient services from within rather than, as now, from the outside.'
Related references
The full Cases for Change review was published as a series of ten user-friendly booklets, including a methodological introduction and separate analyses of mental health policy, primary care, community services, hospital services, forensic mental health, user involvement, partnership working in health and social care, anti-discriminatory practice, and emerging areas of service provision. These, as well as two further papers on additional aspects of the full Cases for Change review are detailed on Social Care Online:
CLARK Marion; GLASBY Jon; LESTER Helen;
Cases for Change: user involvement in mental health services and research.
Research Policy and Planning, 22(4), 2004, pp.31-38.
GLASBY Jon; LESTER Helen;
Cases for Change in mental health: partnership working in mental health services