Abstract
Keywords
In England and Wales, 100 of the 130 mental hospitals which existed until 1975 have now been closed. This fact alone suggests that they can be dispensed with, but the replacement of mental hospitals with communitybased services has met with scepticism from the public, the media and from many psychiatric professionals. For instance, Harold Lamb has documented a rise in the proportion of the USA prison population with psychiatric illness, which he interprets as evidence for transinstitutionalization: the replacement of one custodial institution, the psychiatric hospital, with another, theprison [1]. Some of the poor outcomes of downsizing institutions, such as those associated with Board and Care in America [2] and with the use of seaside boarding houses in the UK [3], show that attempting to achieve the change on a low budget can lead to inhumane consequences. The central question is whether the functions of the psychiatric hospital can be replaced by community services with an improvement in the patients' quality of life.
In order to answer this question adequately, we need to take account of the various functions provided by the psychiatric hospital. These relate to at least four different patient groups: acutely ill patients spending a limited period of time on the admission wards, long-stay patients with functional illnesses under the age of 65, those with the same characteristics over 65 and patients with dementia. Each of these groups has been the subject of a separate study by the Team for the Assessment of Psychiatric Services (TAPS), which was established in 1985 to evaluate the UK Government's policy of closing psychiatric hospitals.
The functions of the psychiatric hospital in relation to the variety of patients catered for are listed in Table 1.
The functions of a psychiatric hospital
Acute admission services have proved to be the most problematic to reprovide in the community and will be discussed last.
Long-stay patients
The Team for the Assessment of Psychiatric Services has completed a 5 year follow up of 670 patients who stayed more than 1 year and were then discharged from two London psychiatric hospitals, Friern and Claybury, in the process of closing. These patients represented a residual long-stay population in that both these hospitals, in common with others in England and Wales, had already reduced their beds by two-thirds when the TAPS study began in 1985. Nevertheless, the remaining patients encompassed a considerable range of disability, and the least disabled patients were selected for dischargefirst [4]. The annual cohort of patients discharged in 1985 had a median of two severe behavioural problems, while the cohort discharged in 1993 immediately prior to the closure of Friern Hospital had a median of six. There was a group of even more disabled patients who were considered by the staff too disturbed and disturbing to be discharged to the standard community homes. These difficult-to-place patients have been the focus of several TAPS studies, and will be discussed later.
The 5 year follow up of this large sample of long-stay patients revealed few problems: there was no increase in the death rate compared with other samples with the same diagnoses, only a handful of patients became homeless, and no more than 2% committed assaults over the 5-year period [5]. Nearly 80% had been placed in staffed homes, most of the remainder were discharged to unstaffed group homes, while only a small proportion were able to live independently. Most residents in the group homes had their own bedroom, and the environment in the community homes was far less restrictive than that in the hospital wards. Patients were very appreciative of the greater freedom they enjoyed, and compared with 30% who wanted to stay in the hospital when asked prior to discharge, 84% wished to remain in their homes in the community. Those desiring to move wanted to live independently, although this was generally unrealistic.
The mental state of the discharged patients remained remarkably stable over the 5-year period, as did their problems of social behaviour. However, they acquired domestic skills and became able to utilize community facilities such as public transport, post offices and cinemas. Their social networks remained very restricted in size, but they gained friends during the first year after discharge and increased the number of intimate relationships by the end of 5 years [6]. A comprehensive evaluation by the Centre for the Economics of Mental Health showed that these improvements in the patients' quality of life were achieved within the capital and revenue resources released by the closure of the psychiatrichospitals [7].
The social integration of patients
Therefore, we can conclude that the custodial function of the psychiatric hospital for the majority of long-stay functionally ill patients is unnecessary and impairs their quality of life. There are a number of reservations that need discussion. First, it was only a minority of patients who managed to develop social relationships with ordinary citizens outside the mental health network. The establishment of sheltered homes was almost always accomplished as quietly as possible, partly due to considerations of normalization and partly to avoid opposition from prejudiced neighbours. The disadvantage of this strategy is that it fails to mobilize social support for the new residents from neighbours having a fund of goodwill towards them [8]. In order to build on this resource, Wolff et al. [9] mounted an education campaign for the neighbours in a street in which a sheltered home was being developed. The campaign comprised an educational video about the closure of psychiatric hospitals, handouts about mental illness and community care, a meeting for residents in a local church hall, door-todoor canvassing by the hostel staff, and social events for the neighbours in the sheltered home. A comparison was made with a street in a similar area in London in which a hostel was also being set up, but in which no approaches were made to the neighbours. This showed that the campaign was effective in increasing neighbours' knowledge about mental illness, in reducing their fear of patients, and in strengthening their intentions to socialize with the new residents. These changes in knowledge and attitudes were translated into action, since some of the patients developed friendships with their neighbours in the experimental street, whereas none did so in the comparison street [9]. This result suggests that small-scale local education campaigns should be mounted in connection with the establishment of sheltered community homes, and are likely to achieve further improvements in the patients' quality of life.
Elderly functionally ill patients
In selecting patients for the follow-up study of the long-stay functionally ill, we attempted to exclude those with dementia [10]. This proved to be no simple task. There were many patients in both hospitals who had originally been admitted decades earlier with a diagnosis of schizophrenia but who were now deemed by the staff to be dementing. A considerable proportion of these, known ironically as the ‘graduates’, had been transferred to the psychogeriatric wards, most of the occupants of which had been admitted a few years previously with Alzheimer's dementia. At Friern, a pilot study revealed that one-fifth of the patients on four psychogeriatric wards were ‘graduates’ [11]. We were not convinced by the distinction made by the staff between dementing and non-dementing patients with schizophrenia and carried out a survey of the total population of Claybury hospital aged 70 and above [12]. The two instruments used were the Mini Mental State Examination [13] and the Modified Crighton Royal Behavioural Rating Scale [14]. It emerged that, while the ‘graduates’ almost invariably showed some cognitive deficit, it was less profound than that of the patients admitted with Alzheimer's dementia. The mean score on the Mini Mental State Examination achieved by the ‘graduates’ was 15 whereas many of the patients with dementia scored zero. Furthermore, there was no difference in scores between the functionally ill who had been transferred to the psychogeriatric wards and those who still remained on the long-stay wards. What distinguished these two groups of patients was their scores on the Behavioural Rating Scale. These findings make it clear that the ‘graduates’ were not moved to the psychogeriatric wards because of their diminished cognitive function, but on account of their disturbed behaviour. We considered this policy detrimental to the welfare of the ‘graduates’ because they were treated by the staff as though they were as deficient in cognition as the patients with true dementia, whereas they had a much greater awareness of the world around them.
Our view was supported by a follow-up study TAPS conducted of the patients transferred from the psychogeriatric wards to nursing homes in the community. I will present the effects this move had on the patients with dementia below, but here will consider the changes shown by the ‘graduates’. They were moved to the homes in company with the patients with dementia with whom they had shared the psychogeriatric wards. The homes were superior to the wards in respect to the privacy and comfort of the living space, in providing a homely atmosphere, and in the quality of the furniture anddecoration [15]. A group of 35 ‘graduates’ who were transferred to six newly developed elderly mentally ill (EMI) care facilities in the community were compared with 36 similar patients who remained in Claybury hospital during a 3-year follow-up period [16]. The ‘graduates’ remaining on the hospital wards showed a marked deterioration in their behaviour in contrast to those living in the community homes, whose behavioural functioning did not change over the follow up. There was also a significant difference in cognitive function: while both groups of ‘graduates’ suffered a decline, this was much more rapid for those remaining in hospital than for those transferred to the community. We conclude that the cognitive decline experienced by ageing patients with functional psychoses can be slowed down by a more stimulating and reality-based environment. Furthermore, we consider it advisable that elderly ‘graduates’ are not mixed indiscriminately with patients with dementia, since the care staff tend to treat them all as having little or no awareness of their social milieu. It appears that a more interactive environment can stabilize the ‘graduates’ behavioural problems.
Patients with dementia
As noted above, a high proportion of hospitalized patients with dementia have little or no appreciation of their surroundings. Consequently we could not ask for their opinion of the care they were receiving. Instead we interviewed their relatives where available. We also conducted an observational study of activities and interactions with the patients in the hospital wards and in the community homes [15]. In both settings residents were observed sitting doing nothing for the majority of the time; on average 73% of the time in hospital and 64% in the community homes. Residents in the community had almost double the amount of contact with people as those in hospital. Community residents spent more time in social contact with staff and with their relatives than hospital residents. There was much more freedom of choice and flexibility of routines in the community homes.
Relatives confirmed the findings of the observational study, and expressed a preference for the community homes in a number of areas. They felt encouraged to take the residents out for a walk or to have them home for the weekend. They considered that there were more opportunities for privacy in the facilities and more encouragement to retain personal possessions. They were also appreciative of the opportunity to make tea and coffee. Our conclusion is that the community homes offer patients with dementia a superior quality of life compared with the hospital wards.
Acutely ill patients
In the UK during the 1950s, University Departments of Psychiatry began to be established, with their own inpatient wards in general hospitals. As the psychiatric hospitals were closed down, the existing pattern was followed and inpatient facilities were made available in the district general hospitals, if they did not already exist. This was the nature of reprovision for the admission wards in Friern and Claybury Hospitals. The change in services for Friern Hospital was the subject of a TAPS study [17, 18]. For reasons which were not made explicit by the planners, the number of replacement beds in the general hospital was less than the admission beds which existed in Friern. Consequently one of the foci of the study was on the number of people referred for admission for whom a bed could not be found. To investigate this we monitored the emergency referrals to on-call junior doctors outside of working hours. We also collected data on the use of day-care services, and sought the opinions of patients and nurses on the change in the service.
Out-of-hours referrals
Data were collected over the 3 years preceding the closure of Friern Hospital, during which time the reprovision of acute services took place. Over this period of time there was a 33% increase in the number of admissions to acute psychiatric wards and a 27% decrease in length of stay. Occupancy rose from 83% to well over 100%. In the two health districts studied, Bloomsbury and Islington, the number of out-of-hours referrals increased by 19%and 21% respectively. The total number of these referrals not admitted doubled in Bloomsbury following the changes in the service and increased by one-third in Islington. The pressure on beds in Bloomsbury led to the use of private beds for the first time, paid for by the National Health Service (NHS).
In response to the crisis developing in the acute services, day hospital staff shortened the length of stay of their clients and altered the diagnostic distribution. There was a reduction of one-third in the duration of attendance for all patients. The number of patients with psychotic illnesses referred over the period of study doubled, while the number of patients with neurosis increased by one-third. The day hospital could not cope with the demand from psychotic patients and admitted only 56% more than previously.
Patient and nurse satisfaction
The patients' views on the care environment in the admission wards was sampled before and after the change in the service. Patients in the psychiatric hospital were more satisfied with the ward atmosphere and the hospital grounds than those in the district general hospital (DGH) units. Patients in the DGH units showed a decrease in satisfaction with the hospital grounds after the change and fewer felt better as a result of treatment. The patients' discontent was echoed by the nursing staff. Before the closure of Friern Hospital, nurses on the admission wards there were more satisfied with their working conditions than their colleagues in the DGH units. In particular, they were more positive about the hospital grounds and surrounding streets, the crowding on the ward, and the availability of a doctor. One of the biggest differences related to the level of violence, with 20% of the hospital nurses expressing dissatisfaction compared with 64% of DGH unit nurses. Following the service change, nurses in the DGH units showed reduced satisfaction with crowding, noise and violence from the patients. They expressed greater fear for their own safety, and felt patients were being discharged too early. Their morale, already low before the change, fell even further, with only 15% showing a positive attitude to the service.
The source of the problems
It is evident from our studies of the acute services that a crisis situation developed in parallel with the closure of the admission wards in the psychiatric hospitals. This was not confined to north London but affected services throughout the country [19]. Many admission wards have been operating at 120–130% occupancy during the past 10 years. The only way found to cope with this is to send patients needing admission to private hospitals, a solution causing the haemorrhage of millions of pounds from the NHS every year. In addition to the financial loss, very few private hospitals have established aftercare services so that when patients are discharged they often drop out of care. This is particularly deleterious for patients making their first contact with psychiatric facilities, for whom engagement with the statutory services may then pose difficulties.
In the case of Friern Hospital, one of the obvious causes of the crisis was the reduction in admission beds at the time of the changeover of the service. This measure to reduce costs was not based on rational planning and soon had to be reversed by the opening of an additional ward to cope with the demand for beds. Another source of the problems was the failure to make provision for the readmission needs of the discharged long-stay patients. The TAPS follow-up study foundthat 15% of them were readmitted at least once in the first year after discharge, and over one-third during the 5-year follow up. Gooch and Leff [20] calculated that to cope with this demand, 10 admission beds were needed for every 100 discharged long-stay patients. This use of admission beds does not seem to have been taken into account in planning acute services.
Another deficiency in the planning process was the failure to provide for rehabilitation. This was one of the key functions of the psychiatric hospital, which enabled the acquisition of living skills to occur over long periods of time. Rehabilitation is not only very difficult to arrange on an admission ward, but the current atmosphere is inimical to patients who are recovering from a psychotic illness. The pressure on beds has meant that the great majority of patients on admission wards are suffering from psychoses, and that many of them are acutely ill. This has led to an increase in the number of violent incidents, a hazard of which the nursing staff were apprehensive in our survey of their opinions. There was flexibility in the psychiatric hospital allowing patients to be transferred to rehabilitation wards from admission wards when they were deemed ready. In the absence of this provision, many patients are staying on psychiatric units in DGHs well beyond the point when they should be moved. The occupancy of acute beds by these ‘new long-stay’ patients obviously fuels the crisis. A number of surveys have estimated that up to one-third of patients on admission wards could be discharged immediately if suitable facilities existed [19]. These include a full range of sheltered housing in addition to rehabilitation facilities. Before discussing the possible solutions to this problem, we need to review the process of rehabilitation in the psychiatric hospitals.
Rehabilitation
The first wave of patients discharged from UK psychiatric hospitals in the 1950s were relatively competent at managing their lives and moved to independent accommodation. Notoriously, they included women who had never been mentally ill but had borne illegitimate children. As increasingly disabled patients were considered for discharge, it became necessary to establish rehabilitation programmes to equip them with the skills needed to cope with life outside the institution. These included training in self-care, buying food and preparing meals, and budgeting. The best developed and researched of such programmes has been running for several decades in California [21]. It is firmly based on a behavioural approach and is modular in form. It was recognized early on in their development that training settings needed to be as similar as possible to the situation patients were to live in, because of the difficulty people with schizophrenia have with generalizing. With the certainty of closure and the need to prepare every patient for discharge, intensive rehabilitation programmes were established in Friern and Claybury Hospitals, often with the involvement of staff already working in the community. The success of these programmes can be judged from the fact that the 5-year follow-up of the long-stay patients from the two hospitals revealed no change in behavioural problems over that time period [6]. We concluded that this was probably because the patients had reached their ceiling of improvement while still in hospital. Intensive programmes of this type are not available in the DGH units, and yet many of the patients would benefit greatly from them. However, as argued above, an admission ward is not an appropriate setting for rehabilitation. What is needed are dedicated facilities which provide as domestic an environment as possible. We have recently completed the evaluation of such a facility which was set up for difficult-to-place patients at the end of a hospital closure programme.
Rehabilitating difficult-to-place patients
While the great majority of long-stay patients in Friern Hospital moved into the community, there was one group remaining at the end of the closure process who were considered by the staff to be too disturbed and disturbing to the public to be discharged to ordinary staffed accommodation. These difficult-to-place patients, as they have been called, presented problems of aggression and sexually inappropriate behaviour, with a few other unacceptable behaviours such as urinating in public and stealing. They represented around 10 per 100 000 of the catchment area population [22]. There was no previous experience of providing for these patients outside of a psychiatric hospital with the result that each of the three health districts involved produced a different solution. One adapted two wards in a DGH, a second built three domestic style houses in the grounds of a small psychiatric hospital not scheduled for closure, while the third created a closed ward in an ordinary house in the local community. What was common to the three solutions was a high staffing level ranging from one staff member per patient to 1.7 to one. A 1-year follow-up revealed no overall change in the patients' behaviour problems or skills, but showed that the facilities could contain all these patients with the exception of two who were transferred from the open houses to secure units [23]. Ata 5-year follow-up there had been a significant reduction J. LEFF 425 in difficult behaviours, particularly aggression, and patients had acquired domestic skills and the ability to make use of community facilities such as public transport and the post office. As a result of these changes, it had been possible to move 40% of the patients to ordinary staffed homes in the community, with a substantial saving in costs [24].
Building on the lessons learned from this natural experiment, we designed an intensive rehabilitation programme and evaluated it for a group of 22 difficult-toplace patients in a psychiatric hospital on the outskirts of London which was near to closure. The elements of the programme were: a domestic-scale building with single bedrooms, a high staff : patient ratio, a training programme to teach the staff to deal with difficult behaviours, substitution of multiple conventional antipsychotic drugs at high dosage by a single novel antipsychotic, and an individualized cognitive–behavioural programme for each patient [Leff J, Szmidla A: unpublished data]. Although not all the elements in the programme were fully realized, at a 1-year follow-up the experimental patients had improved significantly more than the comparable Friern difficult-to-place patients in social behaviour problems and in social skills. However, none had been discharged to ordinary staffed accommodation.
We conclude from these studies that there is a need to provide slow-stream rehabilitation for the most disabled patients in every community service. This type of facility eases the blocking of beds on admission wards, and can cope humanely with problematic patients without the need to recreate the psychiatric hospital.
Work-like activities
Work not only provides financial remuneration, but can give the worker a sense of self-fulfilment, and represents an additional social milieu in which friendships can be made. There is the added advantage for patients with psychosis that delusions and hallucinations are less obtrusive when concentrating on a task. For all these reasons, many of the psychiatric hospitals ran industrial therapy departments. The one in Friern Hospital was particularly well developed, making wooden furniture designed in the department and running a horticultural section which was very popular with the patients. Altogether 120 workers attended daily, some of them commuting from the community since nothing comparable existed near their homes. In fact it proved impractical to relocate the industrial therapy department in the community when Friern closed. Because patients were resettled in a very wide geographic area, it would not have been possible for them to travel to the department in the numbers needed to sustain the variety of work projects. Furthermore, sheltered workshops entail a major disadvantage of isolating the workers from the general public. Projects such as shops selling craft work, or cafes run by patients are preferable in fostering social integration.
Jobs in open employment would be even better, but it is extremely difficult for someone with a history of psychiatric hospitalization to compete successfully in the job market. One mental health trust in London has pioneered the employment of patients: a scheme which has been highly successful. Another approach, widely adopted in Italy, is the creation of social firms, in which patients and professionals work in partnership to provide a service to the public [25]. Rather than attempting to reproduce the traditional working environments of the psychiatric hospital in the community, it is preferable to pursue these novel schemes which do not segregate patients and which give workers the satisfaction of catering to the needs of the public.
Solutions to the problems of admission wards
We have already stressed the need for rehabilitation facilities to move long-staying patients from admission wards to more suitable environments. A full range of sheltered housing including 24 h nursed care is also essential to cater for the varying dependency of patients at time of discharge. At the other end of the chain, ways of avoiding admission should be sought. The acute day hospital had been shown to be able to deal adequately with at least one-third of potential admissions [26] although it is important to ensure that relatives are supported in their caring role by trained personnel. Users are keen to see the establishment of crisis houses staffed by users themselves, although the evidence for the effectiveness of these is lacking. Another model is the crisis intervention team which goes out to the patient's home and provides care there instead of resorting to admission. One example of this type of service used to exist in London, based in a psychiatric hospital, but was discontinued with the closure of the hospital. It has been more widely employed in Italy following Law 180, which forbade admissions to psychiatric hospitals. However, it demands a great deal of dedication by the staff who have to be available on a 24-h basis for the service to function. Both patients and their relatives would prefer to avoid an admission to a psychiatric ward if possible. There is a need for creative thinking and experimenting with novel solutions to resolve the unacceptable state of admission services in the UK, but much could be done immediately by providing a rehabilitation unit and an acute day hospital in every district. The investment of money would pay off in the long term by halting the flow of NHS funds into the private sector.
Conclusions
Considering each of the functions of the psychiatric hospital in turn and studying their replacement with community services and options has shown that nowhere in the UK is a completely satisfactory reprovision in place. Each function has been provided for with an established or experimental service somewhere, but no comprehensive integrated network of the necessary facilities exists. However, it is now clear that with sufficient will and investment of finance it can be done. There is no question that it should be done: to improve patients' quality of life, to reduce the stigma of mental illness which is inextricably linked in the mind of the public with the forbidding asylums, and to set an example to those countries, such as Macedonia and Chile, where patients still languish in inhumane and degrading custodial institutions which should vanish from the face of the earth.