Provision of Mental Health Beds in York

7/27/2019 Provision of Mental Health Beds in York

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How do we know if York has enough Working Age Adult Acute Inpatient Mental Health beds

to meet population needs?

Context

Acute inpatient mental health services in York are run from Bootham Park hospital, the last 'County

Lunatic Asylum' to still be used for its original purpose (National Archives, 2012), covering a

population of 285 000 across an area of 400 square miles, in York and rural North Yorkshire

(Foundation School, 2012). The number of inpatient beds at Bootham has been in decline for many

years, with cuts in 2011 including Ward 3 for acutely unwell patients (Catton, 2011) and the Mother

and Baby unit from Ward 1 (BBC News, 2011). It is now a matter of some concern amongst service

users and staff as to whether Bootham has sufficient beds to meet population needs, for example in

May then Ward 1 (Women's acute ward) was at capacity of 13 beds, with an additional 8 womenplaced out of area (Personal communication, 2012).

What does need mean in this context?

Need is defined in the context of a Health Needs Assessment as the capacity to benefit from

healthcare interventions. It should be differentiated from demand, since many patients in acute MH

wards will not 'express a felt need' to make use of services. This essay is not an attempt to conduct a

needs assessment; rather, it is a summary and evaluation of what information is available, and

would be necessary, to conduct such an assessment. Stevens et al (2012) describe three methods of

assessing healthcare needs: Corporate, seeking views of stakeholders and key informants;

Comparative, where service provision and use across different areas is compared; Epidemiological,

which extrapolates need from characteristics of the population to be served, treatments available,

and current service provision.

What is the 'capacity to benefit' from MH beds?

A full review of the uses of acute MH wards is beyond the scope of this essay, but if there are such

wards, they should effectively provide tertiary prevention and treatment. The Royal College of

Psychiatrists (2011) is clear that bed occupancy should be below 85% to allow patients to be safely

treated in a local bed without undue delays, but half English wards have occupancy rates above

100%.

Do 'alternatives to admission' remove the need for beds?

Intensive community treatment has been suggested by the Trust as an alternative to hospital

Exam number Y8311672 Page 1 of 9


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admission, fulfilling the same need as inpatient beds at lower cost. However, most studies on the

'intensive home treatment / crisis team' approach were conducted decades ago, when such

approaches were first introduced across England, against a background of higher inpatient beds than

now exist.

York currently has 29 acute beds for a population of 285 000 (10 beds / 100 000 population).

Minghella et al (1998) reduced bed days by 48% through intensive home treatment, but retained

25.6 acute beds per 100 000 population. Bracken & Cohen (1999) found that home treatment

resulted in a 25% drop in admissions, against a background of 84 beds to a population of 380 000

(22 beds / 100 000 population), but stated that '[residential] places of genuine asylum are still

needed in a crisis', with 11% of the sample originally offered home treatment needing hospital

admission. Tomar et al (2003) found 46% of patients with first-episode psychosis assessed by ahome treatment team nevertheless required admission. Gould et al (2006) found that despite well-

established home treatment services, by three months 72% of patients assessed for home treatment

had been admitted.

For schizophrenia and related 'severe mental illness', a Cochrane metanalysis of eight controlled

trials with total 984 patients (Murphy et al, 2012) found that 45% of those initially allocated to

home 'crisis care' had experienced admission, with no significant difference between groups who

did and did not receive crisis care found in number of admissions, nor in use of the mental health

act, nor in days in acute care, at six months. For borderline personality disorder, Borschmann et al

(2012), in a Cochrane review, were unable to find any RCTs of the benefits of any form of crisis

intervention other than hospital. Burns et al (2001), in an extensive systematic review, found that

home treatment reduced days spent in hospital by only about five per patient per month, a result that

did not reach statistical significance.

Intensive home treatment has been rolled out across the whole of England since about 2000,

allowing Jacobs et al (2011) a large epidemiological study. Whilst admission rates across England

fell with declining bed availability, no significant difference in admission rates was found between

areas which had and had not yet implemented crisis teams. Service provision may be a more

important determinant of admission than need.

Keown et al (2011) found a strong association between bed closure and increased use of the Mental

Health Act, such that for every two beds closed, one more person in the next year would be



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involuntarily admitted. Whilst an epidemiological study cannot show causation, Keown et al (2011)

found a clear dose-response curve, across all beds and admissions in England for the twenty years

prior to 2008, despite many 'alternatives to admission'.

Intensive home treatment can at most reduce frequency and duration of hospitalisation, but that it

cannot eliminate the need for inpatient beds for some patients. In many of the above trials, the

patients most likely to need hospital admission were those with less secure living conditions, or

more severe illness. Patients with dual diagnosis, or a history of violence, were often excluded from

home treatment. A reduction in bed numbers below safe levels may exacerbate these health

inequities.

How do we know how many beds are needed?

Screening population directly for need

Ideally, mental health service provision would be determined directly by need. The Adult

Psychiatric Morbidity Survey (2007) is a household-based survey which attempted to screen for the

presence of diagnosed and undiagnosed mental illness, thereby establishing need as well as demand.

A household survey is likely to underestimate rates of severe mental illness, as people may be

homeless or living in an institution, and differential rates of responding by people with a mental

illness may also be problematic. As a member of the public I only have access to the final report for

all of England, so the implications for York of this potentially useful data source cannot be

discussed further here.

The Health Survey for England (Department of Health, 2011), another household-based survey,

uses the General Health Questionnaire (GHQ), a depression screening tool. The North East

Strategic Health Authority faces particular public health challenges, with a significantly higher

prevalence (17.5%) of possible mental illness than the English average (13.2%), and also

significantly more people drinking above recommended limits (32.3 vs 26.8).

Epidemiological - inferring need from related measures

Mental health needs are strongly predicted by social determinants, particularly deprivation

(Wilkinson et al, 2007). The Jarman index (Jarman, 1983) was originally developed as a measure of

need for primary health care, is often referred to as an index of deprivation, and is calculated from



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UK Census data. The Townsend index is a measure of material deprivation also reliant on Census

data. Dependency on the Census means the underlying data are often years out of date, and it may

under-represent groups commonly missed by the Census, who may be disproportionately likely to

have mental illness.

The York Psychiatric Needs Index (Smith et al, 1994) is used to allocate funding within the NHS,

and attempts to predict psychiatric need based on deprivation, using mathematical techniques to

simulate iso-supply. It therefore tends to be more redistributive than demand-led models.

Mental Illness Needs Index (MINI) (Glover et al 2004) is based on annually updateable data of

measures taken from the Index of Multiple Deprivation. MINI seeks to predict psychiatric

admission rates, which may be determined by supply or demand over need. However, the model did

not account for considerable residual patterning by administrative area, emphasising that bed use

may be influenced by health system factors other than need.

Comparative

An approach comparing York to areas of iso-need has several difficulties. The ecological fallacy

means that area-based measures do not necessarily provide good information about individuals

within that area, so people with high unmet need could be 'hidden' within an area with low need

indicators. Nationally there is a considerable underprovision of acute mental health beds, withoccupancy rates of between 100 and 140% (Royal College of Psychiatrists, 2011), so equal

provision for iso-need may still be considerable underprovision.

Community Mental Health Profiles

The Mental Health Observatory (2012) provides 'Community Mental Health Profiles', which bring

together a range of information about risk factors, prevalence, and service availability in each local

authority, from a variety of sources. The local authority for York does not map precisely onto the

catchment area for Bootham hospital, but there is considerable overlap. See Figure 1 for the

Community Mental Health Profile for York. The utility for each item as a predictor of mental illness

prevalence is discussed in the profile itself, and extensively discussed by Wilkinson et al (2007).

The Community Mental Health Profile shows York to be significantly better than the English

average for most wider determinants of mental health, using data mostly from accurate and

frequently updated sources, such as Department for Education records for Not in Employment,

Education or Training, or unemployment from claimant count. However, using the Index of

Multiple Deprivation to predict mental illness is problematic because the 'Health Deprivation and



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Disability Domain' is constructed using measures of mental illness.

York is at or better than the English average for risk factors. Whilst the physical activity levels for

children are based on a survey of PE time so should cover all children in school and be reasonably

reliable, the adult physical activity measure is based on a questionnaire which will have been

subject to considerable respondent bias. Homelessness is a particularly interesting variable, because

it is so closely linked to mental illness. One in three British patients with schizophrenia has been

homeless, and between a quarter to a third of street homeless people have a severe mental illness

(Rees, 2009).

For levels of mental illness, York has significantly more people than the English average on the GP

depression register, which could reflect prevalence or diagnosis. Dementia and learning disability

are unlikely to have a major impact on working age adult acute beds. It is unfortunate that levels of

severe mental illness, which must also be kept on a GP register under QOF, are not given here, since

these people will be heavy users of inpatient care. The GP severe mental illness register gives a

prevalence for North Yorkshire & York PCT of 0.7%, not significantly different from an English

average of 0.8% (NHS Information Centre, 2012).

For treatment, York has an average spend per head not significantly different from the English

mean, though it is in the lowest quintile. Significantly more people use secondary care, although

significantly fewer are on Care Programme Approach, and contacts with a Community Psychiatric

Nurse or other professionals are significantly less frequent, suggesting perhaps that resources are

thinly spread over many patients. York has significantly more beds days spent inpatient per head of

population than the England average, although it is still within the central quintile. This statistic is

prone to distortion by the small number of patients who have very long hospital stays.

Overall, although York has several socio-demographic features which should be protective against

mental illness, then it has more people with depression, more people in secondary care, fewer

contacts with services which might keep people out of hospital, and more bed days than the English

average. It could be that York health systems use a lower threshold for detecting and referring

mental health problems, such that those referred require less treatment. Perhaps over-reliance on

protective socio-demographic features is an example of the ecological fallacy, so that whilst most

people in York enjoy good mental health, then a substantial minority have considerable mental

health support needs. It does seem that York could be providing more intensive support for those

referred to secondary care, but this should not be at the expense of inpatient beds.



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The Mental Health Minimum Dataset

The Mental Health Minimum Dataset (MHMDS) (NHS Information Centre, 2012) is a record of

services provided in secondary care. This data is derived from routine care records in a similar way

to Hospital Episode Statistics, but includes contacts with community services. Independent sector

data is not included, which may particularly distort outcomes in areas with high bed occupancy and

consequent high use of out of area placement, and for specialist services which are often privately

provided.

Table 1. Comparison of service use in York and elsewhere, from the MHMDS.

York England 'Prospering Small Towns'

(iso-need)

Rate of people accessing secondary care, 3186 2789 n/a

per 100000 population

Percentage of people accessing secondary

care who are admitted to hospital 9.2% 8.1% 7.7%

Percentage in hospital detained under

Mental Health Act 28.4% 40.9% 35.1%

Percentage staying in hospital longer than 34.1% 46.5% n/a

30 days

All figures in Table 1 are 2010-11 data unless stated otherwise. 'York' data is for the former North

Yorkshire & York PCT. Rates would be preferable to percentages, but I do not have access to raw

data to calculate these.

York has consistently had fewer Mental Health Act (MHA) detentions than England or similar

towns. However, the average length of stay in hospital in York is consistently longer. This could

suggest that hospital beds might be better used by shortening stay.



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Conclusion

Whilst 'corporate' concerns from staff and service users reflect too few beds for patients referred,

comparative and epidemiological data is more difficult to interpret. High rates of diagnosis, and

longer inpatient stay, may reflect high need, better access, or different referral patterns. To assess

York's mental health bed needs as one part of a Healthcare Needs Assessment, I would need fuller

access to underlying databases to better establish comparison with areas of iso-need, and also the

ability to investigate causes of variations from comparators.

Word count: 2190

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Provision of Mental Health Beds in York