According to a study published on bmj.com, there has been a marked increase in the number of compulsory admissions to inpatient psychiatric care in the UK and a significant increase in the number of patients that seek psychiatric care for alcohol and drug problems. However, these increases have been accompanied by a decrease in the number of NHS beds available.

Desinstitutionalization beginning in the 1950s left the country with less than 55,000 psychiatric beds in 1995 compared to about 150,000 in 1955. Part of this is due to inpatient psychiatric care’s high cost, low popularity, and often mediocre results. Recent research, though, has shown that involuntary admissions are on the rise, and we may be entering a new era of reinstitutionalization.

In an investigation of how psychiatric care changed in England between 1996 and 2006, Patrick Keown (East Community Mental Health Team, Newcastle upon Tyne) and colleagues analyzed data from the NHS Information Centre, the Department of Health, and the 2006 ‘Count me in’ census.

A main finding of their research was that over a ten-year period, there was a reduction in both total psychiatric admissions and NHS bed numbers, but a 20% increase in the number of patients involuntarily admitted. Keown and colleagues also noted a threefold increase in the likelihood of admission to private facilities for these involuntary patients.

Between 1996 and 2006, the proportion of NHS beds occupied by patients admitted under a section of the mental health act increased from 23% to 36%, respectively. During this same time period, the researchers noted a 29% decrease in the number of psychiatric beds. These “sectioned” patients were 15 times more likely to be in an NHS facility than a private facility in 1996-7 but only five times more likely by 2006.

In 1998, a peak of 214,000 patients was admitted to NHS for mental disorders before these numbers began to fall. The reductions in admissions were primarily driven by a 58% decrease in patients with learning disabilities, a 33% decrease in patients with depression, and a 28% decrease in patients with dementia. Although the number of admissions for drug and alcohol problems has increase by 29% since 2003, admissions for those with schizophrenia and manic disorders have remained pretty stable.

“Psychiatric inpatient care changed considerably from 1996 to 2006, with more involuntary patients admitted to fewer NHS beds and increasing proportions of involuntary patients admitted to private facilities,” conclude the authors. “The inpatient case mix has shifted further towards psychotic and substance misuse disorders, which has changed the milieu on inpatient psychiatric wards.”

Professor Scott Weich (Professor of Psychiatry at the University Warwick) argues in an accompanying editorial that health care professionals should focus on quality of supervision rather than numbers. “Global bed numbers, like average rates of bed occupancy, length of stay, and needs adjusted spending conceal substantial – and poorly understood – differences between places and service users,” he writes. They also say nothing about the quality of services and the experiences of users, carers, and staff.

Weich concludes: “Numbers will always matter, but the greater need is for improvements in the quality of services. This will only happen if users’ and carers’ voices are heard and acted on.”

Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006
Patrick Keown, Gavin Mercer, Jan Scott
BMJ (2008). 337:a1837
doi:10.1136/bmj.a1837
Click Here to View Journal Web Site

Written by: Peter M Crosta