Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists
June 2, 2014 22 Comments
Some aspects of the crisis in mental health care, like the 1,700 bed closures and 101% ward occupancy rates, have been relatively easy to estimate. But worrying practices associated with the strain on resources, like patients being sent home in the absence of a bed or being sectioned to secure one, have been far harder to quantify – until now.
The Royal College of Psychiatrists Trainees Committee has surveyed all junior doctors working in psychiatry in the UK for their experiences over the last 6 months. These doctors are fully exposed to the problems, having an unrivalled view of care from 9am to 5pm and often making decisions about admitting or sectioning patients themselves when consultants are at home in the evenings and at weekends.
576 such doctors responded, and what they told us was deeply concerning.
Over 70% had experienced difficulty finding an appropriate bed for a patient. In child and adolescent services (CAMHS), that number was 83%. Sadly these findings weren’t unexpected, but the rates of various practices associated with the scarcity of beds certainly were.
A shocking 37% told us that a colleague’s decision to section a patient under the Mental Health Act had been influenced by the likelihood of finding a bed – perhaps that by doing so it would legally force the provision of a potentially otherwise unavailable bed. 18% were even willing to tell us that their own decisions had been influenced in such a way. A Health Select Committee report published to widespread concern last summer suggested that patients had been deprived of their liberty to secure a bed in isolated cases, but the true rate seems to be far greater.
Doctors usually use the Mental Health Act as a last resort for patients who desperately need hospital care but are so unwell that they refuse. Now they are presumably beginning to use it increasingly often for patients who aren’t actively refusing an admission, because it’s their last remaining option to make sure very unwell people get the care they need. And it’s no wonder they have to do so, when 24% reported that a bed manager had told them that beds were closed to all patients except those under section. Again, a policy of desperation in the face of pitifully limited resources.
Even if a bed is somehow found, it could be absurdly far away. 80% of respondents had been forced to send a patient outside the boundaries of their trust, with over a quarter sending a patient over 100 miles away. In CAMHS, this was a heart breaking 37%. Unsurprisingly, such transfers were reported to be detrimental to care. Dragging a mentally exhausted, fragile and often acutely distressed person away from their families is not a form of care I recognise – especially if that person is a child.
As an alternative to being exiled hundreds of miles, three out of ten doctors had seen a patient admitted to a ward but without a bed, presumably leaving them to sleep on a sofa. One in five reported that they’d admitted people to beds belonging to patients on periods of trial leave – at least giving a temporary fix. But when the original owner of the bed comes back, as they often do, out comes the sofa again.
After a decade in medicine the only circumstances in which I have known patients to be admitted to hospital without an official bed have been whilst volunteering in the developing world and in UK mental health.
Still, a sofa may be better than sending a critically ill patient home because no bed can be found. An alarming 28% admitted to doing that. The rate in CAMHS was even higher at 37%. If just one paediatrician reported that they’d sent a sick child with asthma or appendicitis home simply because there wasn’t a bed, the reaction would be swift and scathing. But if the child has a mental health problem, their suffering appears not to warrant the same level of concern.
It would be easy to conclude that the answer to this nightmare is additional beds. That would certainly help, as would providing emergency support to forestall the plans to close more beds in some places, but the cause of this crisis is more pervasive. A chronic institutional bias against mental health has suffocated the funding of our speciality in every area. Community teams have seen their funding plateau in the face of a 13% increase in referrals despite the fact that a recent report suggested that for every £1 invested in early intervention we could save £15 in later hospital admission costs.
As reassuring as it is to read the recent Closing the Gap and Crisis Care Concordat policies, only a clear, urgent and substantial pledge of extra funding will convince mental health professionals that things are about to get any better. Despite the heartening rhetoric, such funding has not been forthcoming.
In fact, following February’s NHS England announcement that mental health services would ironically be subject to greater tariff cuts than our counterparts in acute services, Professor Dame Sue Bailey suggested that the frankly dangerous levels of under-resourcing might lead us to become the next Mid Staffs.
Based on these stats, I would go further. What will it take for us to admit that we’re already there?