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
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
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
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.