How having, or not having, an NHS Psychiatric Bed can Kill You
Raj Persaud and David James
An investigation by BBC News and Community Care magazine into 53 of England’s Mental Health Trusts reveals that 1,711 mental health beds have been closed since April 2011, including 277 between April and August 2013, representing a 9% reduction in the total number of mental health beds available in 2011/12.
The BBC News website reports possible consequences including the tragic case of 39-year-old Mandy Peck who told clinicians she was feeling suicidal, but her local mental health service centre initially claimed no beds were vacant. She jumped to her death from a multi-storey car park shortly afterwards.
As psychiatrists who have worked in the NHS, we have both experienced the chaos of trying to find a bed for a patient who needs one urgently.
The enormous pressure on the staff to find a bed means that the modern NHS becomes a constant fight for beds, creating stressful conflict with other clinicians. Even if you (eventually) secure an admission for your patient, this is at the expense of the patient who was previously in that bed, who, in order to accommodate the new admission, gets moved to another part of the country, or is discharged, or sent on leave prematurely.
Providing any kind of therapy in this frenzied environment is not possible. Admitting someone in a fragile mental state into this siege atmosphere means you are only arranging an admittance to prevent suicide or harm to others, rather than offering help to the mentally ill in need of care. You have become a form of warder, not a clinician.
The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness at the University of Manchester, published in July 1013, reports that during 2001-2011, in England, 13,469 deaths (28% of general population suicides) were patient suicides. These are persons who had been in contact with mental health services in the 12 months prior to death.
There has been a projected rise in 2011 (the last year for which data is available). In 2001 there were 1261 suicides by people in contact with mental health services and this figure had risen to a projected number of 1333 by 2011, during a period when it now looks like more beds were being lost.
Patrick Keown, Gavin Mercer and Jan Scott published a recent analysis in the British Medical Journal, finding that between 1996 and 2006 in England the number of NHS psychiatric beds decreased by 29%. Entitled ‘Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006’, their investigation found involuntary patients occupied 23% of NHS psychiatric beds in 1996, but 36% in 2006.
The authors conclude that inpatient care transformed considerably in the decade from 1996 to 2006; more involuntary admissions to fewer NHS beds. The case mix shifted further towards psychotic and substance misuse disorders, altering the atmosphere of inpatient wards.
One interpretation of this data, and our personal experience supports this, is that the ambience on wards has changed, and for the worse, in terms of providing a therapeutic environment. Psychiatric in-patient units are now much more likely to be precarious containment areas for the extremely seriously mentally ill, not a haven, nor asylum from stress for those who need help.
For these reasons, being admitted to a psychiatric ward today may in fact be an added source of stress – not a therapeutic experience at all.
Some evidence for this comes from a recent investigation of a consecutive series of individuals aged 18 to 65 who died by suicide between the 1st January 2001 and 31st December 2006 in England, the date of death being within seven days of the date of admission to a psychiatric ward.
The study entitled, ‘Suicide in recently admitted psychiatric in-patients: A case-control study’, found around a quarter of all in-patient suicides occurred within the ﬁrst week of admission to psychiatric in-patient care. 46% of cases died on the ward itself; the majority by hanging. 40% of suicide cases died within the ﬁrst 3 days of admission. A ﬁfth of all suicides were on authorised leave at the time of death, but 34% were off the ward without staff agreement, compared to only 1% of controls.
The authors, Isabelle Hunt, Harriet Bickley, Kirsten Windfuhr, Jenny Shaw, Louis Appleby and Nav Kapur, conclude that contrary to previous relevant research, this investigation examining wards in England found a short length of illness (less than 12 months duration) was independently predictive of suicide in the immediate admission period.
The study, published in the ‘Journal of Affective Disorders’ in 2013, contends that it may be that receiving a psychiatric diagnosis requiring in-patient treatment is particularly stressful, plus the experience of entering an environment that patients have described as ‘‘frightening’’ and ‘‘intimidating’ probably increases, rather than diminishes, suicidal feelings.
The authors considered there could also be an association between being admitted to a psychiatric ward and a heightened sense of being stigmatised.
Given that those on authorised and unauthorised leave account for such a large proportion of in-patient suicides from their data, the authors of this study point to two recent court cases in England after the suicide of a detained patient who absconded (Savage v. South Essex Partnership NHS Foundation Trust, 2008) and a voluntary patient who died by suicide whilst on leave (Rabone v. Pennine Care NHS Trust, 2012).
The authors of the study point out that these cases were viewed as a breach of Article 2 of the European Convention on Human Rights (which safeguards the right to life), resulting in a new obligation for health authorities and hospital staff to protect patients where there is a ‘‘real and immediate’’ risk of suicide.
The danger of the current headlines over fewer beds is that it’s not just the numbers that are important – the quality of the bed, as it were, is vital. What is the point of offering a bed if the quality of the experience is so poor, aspects of it contribute to feeling worse?
The NHS neglects quality of care, which has been sacrificed on the altar of numbers, because numbers are so political.
Numbers of beds dominates the debate – and numbers are important because we have had too few beds for the system to be safe for some time now. And the decline in bed numbers appears to continue inexorably. But we should be looking beyond numbers to human beings, focusing as well on the quality of what patients get, when they actually get anything at all.