Saturday, 19 October 2013

Is the Concept of Informal Psychiatric Admission in Jeopardy? A Commentary on the Current Crisis in Mental Health Beds

"Well, they've finally located a bed. Just need to get an ambulance now."
There has been a gratifying media response to the excellent investigation conducted by Community Care and the BBC into the drastic shortage of acute psychiatric beds across the country. This investigation has confirmed what AMHP’s already know: the cuts in psychiatric beds are leading to unsafe and possibly illegal practices, which are often harming patients.

Around 1,700 mental health beds have been closed since April 2011, which amounts to an overall reduction of 9%. However, the changes to community mental health services which are occurring all over the country, which are often driven by the need to make drastic cuts in budgets, do not lend themselves to a reduction in demand for beds, but rather an increase in the demand for acute admissions.

It was reported that “three-quarters of the 1,711 bed closures were in acute adult wards, older people’s wards and psychiatric intensive care units. Average occupancy levels in acute adult and psychiatric beds are running at 100%, while half are over that and all are above the 85% limit recommended by the Royal College of Psychiatrists.”

Andy McNicoll reports in Community Care about the various ways in which this crisis is affecting service delivery and patient care. These include possibly avoidable patient deaths, the use of expensive private beds, and many examples of inherently poor practice, which can have a seriously adverse effect on patient care and outcomes.

Examples of poor practice include admitting people to a hospital when there is no bed for them, the use of leave beds, premature discharge which then leads to early readmission, and the use of inappropriate beds, such as placing people under 18 in adult wards.
In my own experience, one of my service users, who was a voluntary inpatient in her 40’s, went on home leave. The leave did not go well, and she needed to come back into hospital. However, her bed had been taken by an emergency admission, and she was placed overnight on a dementia ward.

Overcrowded wards lead to stressed staff and poor experiences for patients which in turn leads to slower recovery, and an increase in incidents of violence and exploitation.

It appears that one of the worrying consequences of bed shortages is that preference may be being given to patients detained under the Mental Health Act as opposed to informal admissions, presumably based on the assumption that informal admissions are less urgent.

A report in Community Care in August 2012 (Mental health detention rise amid ‘pressure on hospital beds’) quotes an anonymous AMHP as saying that detention under the MHA is “the only way to get a bed these days.” I have certainly had it said to me on more than one occasion that a bed is only available for patients detained under the MHA. I have had to argue the case forcefully in order to obtain the bed.
There is more than anecdotal evidence of this practice. Michael Knight committed suicide on 28th August 2012, at the age of 20. He was assessed under the MHA, and agreed to be admitted informally. However, there was no bed available anywhere in the county in which he lived. This led to an overnight delay in his admission, during which he killed himself.
The Coroner in the case stated: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available. I am of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”
It was reported that “following Mr Knight’s death a serious investigation report was compiled, which found that staff followed the ‘right pathways’. It said an acute bed would have been found for Mr Knight if he had been sectioned.” (my italics)
The Mental Health Act is very clear in its views on informal admission. Sec.131 deals specifically with informal admission. Sec.131(1) states categorically:
“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.”
This essentially means that if a patient needs a bed, and they are agreeing to be admitted, then no requirement can be made that they should only be admitted if detained under a Section of the MHA. Any hospital imposing such a condition is therefore acting expressly in contravention of the MHA.
The Reference Guide to the Act devotes a chapter (Chapter 37) to informal admission, and begins by saying (37.2): “Nothing in the Act prevents people being admitted to hospital without being detained, and this is expressly stated in section 131. Compulsory admission under the Act has always been intended to be the exception, not the rule.”
The Code of Practice (Para 4.9) reinforces this: “When a patient needs to be in hospital, informal admission is usually appropriate when a patient who has the capacity to do so consents to admission.”
AMHP’s are legally required to satisfy themselves that detention in a hospital “is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need”, and informal admission is seen as a valid alternative to compulsory detention. Simply because an AMHP concludes that formal detention is not necessary, this does not necessarily mean that the patient does not need to be in hospital.
There is no doubt that hospital beds are expensive. Properly funded community based alternatives, such as Dementia Intensive Support Teams, may not only save money, but also provide patients with appropriate support in their own homes, and minimise disruption to them. Many Mental Health Trusts are relying on allegedly improved and enhanced community based crisis services to obviate the need for more hospital beds, and to justify a reduction in beds.
But there is a problem with this. I have been working in the mental health field for long enough to remember the plans in the 1970’s and 1980’s to close the long stay hospitals in which people with mental illness and learning difficulties would spend many years.
These plans were admirable. These asylums were mostly daunting and depressing Victorian edifices, deliberately built away from communities, and institutionalised the hapless inmates. Most of the inpatients didn’t need to be there, but there were few alternative community services. I was involved in a small way in moving some of these patients into the community myself when I started out as a social worker in the 1970’s.
The problem, however, was that community services were supposed to be funded with the money saved from closing the hospitals, but they had to close the hospitals first in order to get this money. It was like having a plan to buy a cow with the money raised from milking the cow. You had to have the cow first, but you couldn’t get the cow until you had sold the milk the cow would provide. Mental Health Trusts appear to be trying to pull off the same trick.
The now long defunct Mental Health Act Commission, in their Biennial Report for 2003/05 (p.204), advised:  “ In our view… the focus on establishing community interventions to keep patients from hospital admission must not blind us to the continuing need for inpatient care that patients will enter and reside in voluntarily”. That statement still holds today


  1. i dont know if i can continue to practice as an amhp with all this shit going on.......great piece sir masked one

    1. I would also like to say that I would not like to continue as a person with a mental health problem, but, unfortunately I cant. However, I can say that I will give the CMHT a very wide berth when unwell. People who work on the front line are literally rolling the dice with regard to who is at the most risk? Impossible situation. I empathise with your situation as its not your fault that there is no money.

    2. I would like to say that I know as a fact that professionals really try hard to make sure that these problems do not impact on service users. But if we do ont flag up these problems, then no-one is going to do anything about them.

    3. I agree that you should raise these issues and as hard as you try to protect service users, we already know. We are on the same side but the desperateness of the situation means that some of have to hide to avoid all this.I can understand why trained professionals would want to leave the profession which is in a way a "similar reaction" to an impossible situation. Risk management must be almost impossible yet without it someones head is on the block or could be and who can live and work with this sort of stress, I do not need protecting from reality, I need protecting from the distortions of that reality that try to hide what is actually going on.

      I was sectioned recently and it literally saved my life. The AMHP was excellent and quick to respond. I am glad to be alive and thankful that the AMHP took this action. I was in hospital 4 weeks and felt well when discharged. I think it is important to acknowledge the positives in this climate of cutbacks.

      I still have a good working relationship with this person.

    4. I dont give a damn anymore about 'professionals' dilemna . If such a dilemna then shout louder, go on strike, go public or all resign as AMHP's.

      1000 AMHP's distress at the above does not compare one iota with the distress caused to patients and their family and friends.

      You feel bad when you go home from your reasonably paid jobs? My heart bleeds.
      When you find someone close to you hanging from the bannister because the AMHP service wouldnt come out to assess because the hopsital didnt have beds to admit to - then you have the right to complain. When you have to deal with the grief and torment suicide leaves then you have the right to complain. When you have to listen to the patronising lies and cover ups of teams trying to protect their own backs rather than say 'we got it wrong - sorry' then you have the right to complain.
      Not before. You lost that right by not challenging the Trusts and hospitals that you claim drive your practices

    5. Your post hits right at the heart of just how desperate the situation is. I am so sorry to hear about your loss which must be even harder to bear given it could been prevented. I feel so very sad and angry on your behalf. You and your family have been let down. I am so scared about the whole situation, not just for me but for all the other people who are unfortunate enough to need Mental Health Support and Crises Intervention at certain times in their lives. Collective whistle blowers are needed to reverse this desperate situation which will continue to cost lives on a larger scale if it is not stopped. The Mental Health Services are going to do more damage to the people who they
      are supposed to help. This is a stage too far.

    6. Thank you Ruby.

      This was entirely preventable as she had actually and unusually asked for help albeit did not want hospital admission. Asking for help means you have insight so therefore are not unwell enough to be hospitalised, Despite having clear calm plans and means to do so and with serious attempts in the past.

      She was bounced between crisis house and crisis team who both said she was too ill for them to support. The AMHP service chose not to come out as they apparently decided that there was no urgency to assess someone who was too ill to be supported in the community. Because the hospital could not find a bed . So no one came out from any service as they used her as a leverage between teams and she got lost in the void between team boundaries

      They all let her down but the AMHP service especialy as they had the power to detain her and should have done so even if it meant sitting with her for hours waiting for a bed.

      Apparently protecting someones life is less important than protecting the relationship with the hospital managers . There is no other way to see it.

      They could have assessed and applied pressure . They decided instead to walk away from someone who then quietly decided to die. As what is the point of asking for help only to be told that your planned suicide does not warrant help. You might as well complete the act without the final indignity of knowing you are so worthless that the very people meant to help decide you should die instead.

  2. it sounds like the time is nigh for a judicial review of why trusts are not providing the services that the mha requires them to.

  3. I have had two assessments this week were a bed could not be found at all!! No beds in our locality and private hospitals refusing to take the client due to risk. I had two medical recommendations for Section 2 in both cases but unable to make a recommendation. I was able to walk away ( intending to come back when a bed was found) because they were in places of safety. god only knows what my options would have been in the community!

  4. I have a diagnosed mental health problem and this situation is very scary indeed. So, are we left with "you are lucky to have a bed" scenario? Does a place of safety actually exist given the desperateness of the situation with regard to the beds. I have certainly noticed changes in the way CMHTs operate. If I did become unwell again i would certainly try to keep under the radar of Mental Health services as I envisage it would be detrimental to me mental health. Nothing personal, just no money in the mental health pot.

  5. Good post. The Code of Practice might laud informal admissions as a good thing but most staff and organisations know that's a pious platitude and that coerced admissions are what really matter to funders, professionals and the limited regimes available for scrutiny. I thought it was patients who were the ones supposed not to be anchored in reality but the situation which obtains is like a bad chapter from Kafka: 'I want to go to hospital', 'Well you can't' / 'I don't want to go to hospital', 'Well you have to'. Pity the 2007 Act wasn't used as an opportunity to state a more positive endorsement of the service user seeking help in a timely manner and perhaps even having a positive right to support instead of the awkward a**e backwards formulation that: “Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.” I think the failure to do so was significant. Other desirable changes might have been the CQC being detailed to direct inspection activities to all patients in psychiatric units whether detained or not and the broadening of statutory advocacy to informal patients. Some of this was supposed to have happened with the Mental Health 'Measure' in Wales but I'm rather concerned that this has had perverse consequences too. Patients who've had previous contact with secondary mental health services are supposed to be allowed an automatic assessment by said services if in need in the future. Working on the margins of mental health services, I'm wondering if it's just me that thinks one response to this was some services just making it harder to get to see secondary service staff in the first place! These are fundamentally issues about the resources that are being allocated. It's government niggardliness that sets services in competition with each other and another term for this might be 'divide and rule'. Did I hear the health secretary the other day tut-tutting about it all and saying that health organisations had the discretion to re-direct their priorities as if it were all nothing to do with him? (In strict legal point of fact, since the NHS reforms this is very nearly nothing to do with him as the responsibilities of central government nearly got defined out of existence). Glad Ruby hasn't completely lost faith in services due to connections with effective staff (above) but we're edging towards the kind of stripped down reactive and containment focussed services that resemble public provision in the US.

  6. The above poster reminded me that 2 days before I was sectioned I had almost been persuaded to go into hospital on a voluntary basis but there were no available beds. Over the weekend I received a patronising call from a member of the Crises Team which I was not expecting. I asked them not to call me again because I was past the stage of having a bath and eating bananas as a way forward. I have to add that in the early days they have really helped and prevented a hospital admission. It has all changed in my area in that they are now the gatekeepers of beds so it reduces any quality of relationship between service user and professional. So, following on from the possible informal admission, the AMHP came on Monday and a GP arrived and by this time I refused to go into hospital and then I was sectioned. As this post is related to the concept of "informal admission" then I would doubt anyone would be allowed a bed on an informal basis. Like the above poster stated, if you agree to go into hospital then the urgency is not great and then if you refuse, a section may be applied. It happened to me. I would also like to add that the majority of the people on the ward were sectioned and prior to this things had become very desperate for them prior to this. I have to say that I am now really scared that I may become unwell because although I do have some sort of contact with CMHS, they are so stretched and it feels unsafe to me. I am slowly going under the radar. The AMHP was effective but he will not be allowed to continue to be effective in this present climate.

  7. Really sorry you've had this experience: thanks for your frankness. (And don't under-rate bananas, they're a super-food: it's the potassium I'm told). 'Anonymous, above'.

  8. I now have this image of CMHTs becoming a bit like grocery stores!!!!!!! and yes I do like bananas

  9. Well, I've thought about the bananas thing for a bit and people do seem to find this suggestion a bit irritating. Are bananas an intrinsically frivolous fruit? Not keen on them myself but don't mind them hidden inside a Tesco's smoothie. I've been doing some research and two alternatives might be: kippers (contra-indicated for high blood pressure) and baked beans (contra-indicated for association in polite company).