Few physical treatments in psychiatry require an inpatient setting, so building hospital facilities for mental healthcare is the wrong approach, writes John Owens.
There is general agreement that major changes are imminent in the management and delivery of health services in Ireland. Even more radical change can be anticipated in the mental health service with the implementation of the remainder of the Mental Health Act, 2001.
However, in all the discussions on health service reform that have taken place there is typically a concentration of discussion on hospital structures, hospital beds and hospital staffing. In these times of major strategic change in mental health services it is important to shift the focus of thinking from beds to the community.
The concentration of discussion arising from the reports on reform is on hospital size and location. Much of this discussion is now irrelevant to mental healthcare due to new models of care that are evolving. Advanced community care models, including the use of home-based treatment and crisis houses, all help to reduce the need for acute beds.
The need for psychiatric units in general hospitals will still exist, but the bed requirement will be lower than existing recommendations.
The current national planning document, Planning for the Future, now 20 years old, recommended 40 acute beds per 100,000 population. Modern international practice, utilising the alternative models described above, recommends in the region of 10 beds per 100,000.
The recent Hanly report suggests hospitals of 360 beds serving populations of 350,000. Such hospitals will need, therefore, psychiatric units of 35 beds.
The ability to provide a comprehensive service with this smaller number of acute beds is dependent on the availability of a range of adequately staffed, specialised, multidisciplinary community mental health teams, together with a range of appropriate community facilities.
These teams are still being developed. An excessive provision of acute beds will distort the delivery of more effective mental health care. Continuing to build big inpatient hospital facilities is simply the wrong approach.
At any one time little more than 2 per cent of people with mental health problems are being treated as inpatients, yet hospital beds consume more than 50 per cent of mental health budgets and unfortunately, an equally disproportionate amount of interest of service providers.
From a user and carer perspective, admission to hospital is frequently unwelcome and is not an answer to their problems.
Despite being inpatients, many users feel excluded from treatment decisions, find their time in hospital stressful and stigmatising and, paradoxically, often have less access to their therapists.
Women in particular can find their inpatient stay intimidating.
Carers stress lack of information and support in coping with a sick relative and lack of consultation on key matters such as discharge planning.
The uniformity of these criticisms suggests that the bed-based model of care is the underlying problem. Given the manifest shortcomings of the inpatient model of care it is surprising that it continues to be the dominant area of interest of many care providers.
Treatment of psychiatric illness must take into account psychological and social factors in addition to biological factors. Psychological and social problems are best recognised and understood in the context of home and community.
Likewise, it is in the home and community that such problems are best addressed.
Few physical treatments in psychiatry require an inpatient setting. This recognition has led to the development of the community-based, multidisciplinary mental health team and an acceptance that this should be the basic vehicle of care delivery.
This applies equally to most specialties within the mental health domain. Although some of these specialties require the urgent provision of acute beds, the number of beds required is relatively small. Apart from funding, the main issues in their provision relate to regional placement and siting.
Planning for the Future emphasised community care alternatives to long-stay mental hospital beds. This resulted in a dramatic decline in the number of occupied psychiatric beds, from 11,000 in 1984 to 3,700 in 2003.
It is only recently that a similar approach has been applied to the treatment of acute illness, with the availability of home-based treatment teams for acute illness in crisis and assertive outreach teams in the specialty of rehabilitation psychiatry.
Where this model has been developed in Ireland there has been, likewise, a dramatic reduction in occupied acute beds.
These new advanced models of community care have been evolving in recent years in other countries. The evidence is that they are as effective as more traditional acute bed-based models, but are superior in preserving social and vocational adjustment.
The cost of these models of care is roughly equivalent. Currently, an expert group established by the Department of Health and Children is drawing up a new national mental health service strategy and it seems likely that these types of advanced community care models will be considered.
Mental health services have many problems, including inadequate development of specialties, insufficient funding and not enough staffing.
It is important not to lose sight of the core philosophy underlying successful mental health service delivery. Service providers need to continue to focus on the development of community-based mental health services and not to be distracted unduly by the issue of hospital beds.
Dr John M. Owens is chairman of the Mental Health Commission, which is releasing its Strategic Plan 2004-2005 today