Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Dr Trevor Turner (DD 28)


  1.  I am writing as a Consultant Psychiatrist (General Adult Psychiatry) working in East London, both as a clinician and clinical director, and as an Executive Committee member of the General Adult Faculty of the Royal College of Psychiatrists. These comments derive from the collective experience of members of the Committee, all of whom are clinical psychiatrists working throughout Great Britain.

  2.  Delayed discharges are seen, unanimously, as being the key problem for acute psychiatric wards, particularly in inner city areas where many individuals have no fixed abode. They derive essentially from the lack of appropriate aftercare facilities, whether "half-way house", rehabilitation units, or hostels able to provide relatively high-dependence care for individuals with considerable levels of need.

  3.  Current figures on our acute wards in East London show that some 50 to 70 per cent of patients, often more, have been admitted under the Mental Health Act, usually Section 3 (treatment order). At least 30 per cent, often more, have no abode to go to, and another 30 per cent have come in from hostels/rehabilitation accommodation, that has been unable to continue to support them. The demands of "risk management" and the lack of appropriately trained staff (especially nursing staff) in such units exacerbates their refusal to accept or cope with problematic individuals.

  4.  An additional problem, especially in London, are the increasing numbers of refugees and those with uncertain asylum status. Not only do they have a range of often long-standing psychiatric and psychological problems (for example associated with torture or other forms of physical and psychological abuse), but the their lack of family support, funding and housing make them especially vulnerable.

  5.  Shortages of staff, both nursing and medical (especially consultant psychiatrists in some areas) limit one's ability to develop much more than drug interventions and containment on acute wards. The need for occupational therapists, cognitive behavioural therapists and experienced mental health nurses, both in the ward and in the community teams, impairs the quality of care that can be given so as to enhance the likelihood of earlier discharge.

  6.  The bureaucratic structures of the Care Programme Approach (CPA) limit flexibility in discharge. The need for statutory second opinions, for example, or forensic or psychological opinions, as well as specialist investigations (for example brain scans) further delays the process. It should be noted that a five year survey (from the Patients Council) of patients on the acute wards of Homerton Hospital (East London) show that compliments far outweigh complaints by some 3 or 5 : 1, in most areas of patient concern (ie quality of staff, environment, food), but the necessity for CPA meetings was exceptional in that complaints outnumbered compliments.

  7.  Certain perversities within the specialist arrangements (eg homeless teams, community mental health teams) can mean that they simply are unable to take on new patients. A specific problem in central London is the refusal to accept patients who do not have a CAT number (as used by homelessness agencies), yet people admitted directly to the wards are deemed to be "within" secondary psychiatric care and in some sense not to quality for this number.

  8.  An increasing number of those with severe mental illness, compounded by both forensic and drug dependence problems, has led to the virtual closure of medium secure units, all of which are full and many of which have waiting lists. Yet such patients are deemed, via the "risk assessment" and "risk management" processes to be unacceptable for discharge, everyone being fearful of potential untoward incidents/homicide inquiries that might follow discharge into the community.

  9.  The gross shortage of appropriate housing resources, particularly in the inner city areas; but elsewhere also for those with limited means, further compounds these problems.

  10.  The failure to develop appropriate numbers of 24 hour nursing staffed units (as promised some three years ago) has led to a plethora of voluntary, private, and mixed-funding units taking on the aftercare role. These are often out-of-district from the referring hospitals, of varying quality, extremely expensive, and strongly reminiscent of the "private madhouses" of the eighteenth/early nineteenth century. Abuses in such units were a key factor in developing the Victorian asylum system.

  11.  Because of bed shortages, and some reductions in the size of inpatient units, patients may well be admitted to units far from their own area, and there is a large (no one knows the number) number of patients regularly admitted to private units, all over the country, but particularly in London. Difficulties in engaging with psychiatric teams, organising discharge planning, and distances between sites, enhance the potential for delayed discharge.

  12.  The development of new services (eg Assertive Outreach or Crisis Intervention) has perversely enhanced the pressure on inpatient units. These innovations tend to deplete other units of staff (who are attracted to a new style and better-funded team), tend to have rather lengthy assessment periods, as well as complex interface meetings, and by increased contact enhance sensitivity to risk factors and thus the demand for admission! There is no evidence whatsoever that Assertive Outreach or Crisis Intervention reduce the demand for admission within the British context.

  13.  There is no objection to this information being made public, and myself or other members of the Executive Committee would be very happy to give oral evidence if required.

20 January 2002.

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