Shouldn’t mental health units be part of general hospitals?

I’ve been working in liaison psychiatry for the last six months. For those of you who haven’t heard of it before, it’s the branch of psychiatry that see patients who are in hospital with physical health problems. Some hospitals have a dedicated liaison department, some have a team that only visit if they’re called, some have no service at all.

There’s a very instructive video about the speciality by CNWL NHS Trust available here.

Anyway, I’ve enjoyed my job, and think that every hospital should have a liaison psychiatry service – but I got to wondering, why should we need to liaise in the first place? Why should every speciality except psychiatry have their patients under one roof, with psychiatry visiting from outside to help out, while people with mental health problems are usually admitted to separate hospitals often miles away?

I tweeted about it:

Having mental health wards as part of general hospitals is something that already happens in other countries. There appear to be positives and negatives to it.

On the plus side, patients would get a higher quality of physical health care. So many patients who have a mental health problem also have physical health problems, and many need treatment for both simultaneously. Sometimes the cause of the mental health problem is a physical health problem. Being seen by doctors from a range of specialities would be easy; so would getting all the relevant tests. It would be a far better situation than currently, when patients who are unlucky enough to have both a mental and a physical health problem are often shuttled back and forth between hospitals in a time consuming, inefficient, untherapeutic and potentially risky game of musical beds.

Furthemore, some might argue that having mental health units as part of general hospitals might lower the stigma of being admitted. I’ve met so many patients who were quite happy to come into a general hospital but not into a mental health hospital, just because of the negative connotations. Having mental health patients and indeed psychiatrists mixing in the general hospital environment might serve to demonstrate that we are deserving of respect and equality and do not live up to our distorted stereotypes.

On the negative side, perhaps it would reinforce what some feel is already too ‘medical’ a model. Maybe having our mental health hospitals physically separate from general hospitals enables, or at least encourages, us to treats our patients less like disease-bearing entities and more like people. Personally I’m not sure I agree though. I don’t see why a mental health ward placed on a general hospital site couldn’t still have a holistic, non-biological ethos, and I’m not sure our mental health units are even slightly holistic currently as a result of being separate. In fact, I might argue the opposite – that by isolating mental health units, we stagnate in comparison to our forward-thinking relatives in other specialities, hide away our deficits and struggles and encourage insular practice.

So those are my initial thoughts, but there is so much left to be said. What do you think?

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About Alex Langford
I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

11 Responses to Shouldn’t mental health units be part of general hospitals?

  1. Hope says:

    As someone who has a psychiatric disorder and a severe, chronic physical illness, I can tell you from experience that having a psych unit in a regular medical hospital doesn’t increase the quality of physical care. In fact, my experience has been just the opposite. When I was at a specialized psychiatric hospital and became seriously ill, the medical staff on my unit took my illness very seriously and eventually transferred me to a medical hospital. Since then, I’ve had to go to the emergency department at my local hospital a number of times because of my physical illness, and I usually receive substandard care once they see I’m a psychiatric patient. I’ve been told it’s psychosomatic, despite labs and imaging studies that demonstrate it couldn’t be, and I’ve been accused of being drug-seeking when all I was asking for was IV fluids and steroids. (Who wants to be on steroids if they don’t have to be? All they do is make you swell up and get really moody.)

    Perhaps instead of debating where we should warehouse psychiatric patients, we should be talking about how to integrate people with mental illnesses and the care they need into their communities and how to decrease the stigma they face every day.

  2. Vaughan says:

    “Having mental health wards as part of general hospitals is something that already happens in other countries.”

    It happens a lot here. In fact, as far as I understand, the majority of inpatient psychiatric care now happens in units within general hospitals. Certainly many can be found across the UK. Dedicated NHS psychiatric hospitals are a bit of a London anomaly.

    • Hi Vaughan. I’d be interested to see some stats on exactly how many MH units are incorporated into general hospitals both geographically and systemically. But I doubt those numbers exist. Perhaps I have a biased sample, in SLaM we only have one borough (Lewisham) where the psychiatric wards are on the same site, and the fact that we’re a different Trust with different systems still ensure that it feels like a different site. I also trained and did my F jobs in places where some, if not all, psych wards were distant from other services. Have you had experience both ways, and what are your thoughts?

      • Alex Dr Jim Bolton is I think a lead for the liaison specialty group at RCPsych or once was. I did some work with a group years ago and he had so many stats on who did what nationall. He may will have up to date stats. http://www.epsom-sthelier.nhs.uk/healthcare-professionals/consultants-directory/?entryid5=16542
        I have mixed views I will share another day.

  3. Olivier says:

    I’ve worked in a hospital with a psych ward as part of the general hospital (it’s common in France). We still had a liaison service, very usefu eg when a patient needs surgery and the surgeons struggle to cope with the patient’s behaviour, or to identify and treat depression of hospitalised patients.
    I visited once a ward in Geneva that goes even further in integrating both physical and mental health: they had both internists and psychiatrists on the same ward for patients that had complex physical and mental health needs.

  4. bertie mcelfluff says:

    In N.I. there has been a great shift from the exterior psychiatric hospital model (always in my lifetime there was an acute ward on nearly all main hospitals but things changing much quicker these days) yet it is much further on in some trusts than it is in others.

    My local trust has acute inpatients and outpatients on the main hospital site but still a separate unit amongst many other ‘separate’ units on the site like oncology etc. It works quite well in that the unit is new (less than 20 years) so some thought has gone into it-the physical speciality comes to the patient as it’s only a 20 minute leisurely walk from the main hospital complex while only PICU, addictions, community mental health teams and learning disabilities, longer-term stroke units and memory clinics are on the old psych. hospital site 12 miles away (plus other community services).

    Belfast hospitals all have an attached acute unit but that doesn’t mean a dignified/untramatic passage through A&E straight to the specialists but that’s for another day… They though soon became stigmatised as a ward title just as the large institutions of yesteryear did, even visitors to nearby wards would take the ‘scenic’ route. The outlying large sites with the psych. hospitals now are mainly things like longer-term brain injury units and clinics like psychotherapy etc. plus other community trust services.

    I chose to reply to this post specifically because we did a series of meetings in another trust about moving one of the few still operational psych. hospitals to its main general hospital site about 3 miles away a while back; the business case stacked up, the staff were mostly in favour and we thought going in that the patients, service users, carers etc. in the groups asked would like having a better, newer, more spacious psychiatric hospital/wards but the idea of leaving the site was not liked (the stigma of the name and place was obviously disliked very much) and as a former inpatient (it’s how I got into this line of work) I can understand why:
    when an inpatient, as privileges to leave the ward-almost exclusively secured are acute wards as I’m sure you know-become less restrictive, on separate grounds which are often more tranquil, spacious outside and secluded, patients find the ward overall less restrictive and hence they are less under pressure when not allowed out, which has a host of benefits for both the patient and the ward. When on a main hospital site, you are just that, on a busy, fast-paced aggressive environment and there’s enough of that in the secure garden!

    This is my long-winded way of saying there are solutions/changes in psychiatry that look good on paper but in terms of what is important to patients’ time in hospital and care in general, be careful what you wish for: [a case study] in one trust after the move of most acute inpatient services for the area to the main hospital, one patient was ready to be discharged psychiatrically 10 days post-admission but their physical difficulties meant they were there 4 months later because there was nowhere to meet their psychiatric and physical needs together since the old hospital (which could have met both) was closed; this leads to, for example, acutely psychotic patients being treated in side-rooms on couches and someone else having to be discharged the next day to give them a bed, but not the original person with the complex needs who is not needing to be on an acute psychiatric ward because they have nowhere to go

    I’ll not delve into the last few overs of today’s Test match!

  5. I don’t think that physical health care improves if you have medical problems and the ward is aprt of the acute hospital 20 years ago at the Royal Free the MH wards were in the main uilding. Did I find my car was better there with my physical health stuff – even when I was under medics there I was not treated any better or worse than in a MHU . However what I can say is a few years ago when I was very unwell wit cellulitis and the high dose of oramorph in the acute medical bed gave me hallucinations ( I thought the junior docs hand was a huge spider- poor guy ran so fast when I screamed!) that scared the shit out of me- I asked to see the liaison psych. The nurses conveniently “forgot” to bleep the doctor concerned and called security as I was becoming aggressive as I was scared. When my consultant heard the next day what had happened he told the staff off and the duty liason psych came within 15 minutes and I was treated really well. I could not have asked for a speedier response and he was very kind and came back and saw me every day as did the psych liaison nurse specialist who was a/e based (and happilly gave me her bleep number so I was in control in view of incident before) . So that was a real added advantage. Thankfully the hallucinations stopped when the morphine was cut and the infection was under control. How I would have coped without the liaison team I don’t know but I valued the fact they were in the same building and the psychiatrist was able to ring my consultant psychiatrist at another hospital and help me in a timely manner. So from a medical perspective I am all for any integrated care that helps on both sides. Alex thank you for a thoughtful post.

  6. elvis jones says:

    Mental health units should be situated at the heart of general hospitals as a political statement: Everyone’s welfare is important without exception. Research will be of exceptional quality. This is the future.

  7. Judy says:

    Surely most important is what works for the patients. Even in new , purpose built units, many of the facilities are outside the wards so only accessible when you are basically well on the way to recovery. Struck me at the Warneford in Oxford, the old Victorian (?) walls round the site had been knocked through to make open access and presumably a statement, but that means the only outdoor space available to patients is a wired off ‘smoking’ yard and most patients are confined to the ward.

    Just had a friend on an open ward, but she was on one to ones so was actually much more restricted than when she was in a locked ward…………………..

    At least parking is usually easier at dedicated mental health units than it is at general hospitals :-)

  8. elvis jones says:

    What works and doesn’t work for patients is often unclear.

  9. Jonathan Bindman says:

    This is a well written and thoughtful post but you might want to look at the recent history of psychiatry and put it into context. As far as I understand it (as a general psyhciatrist since the 80s with some interest in models of care but not a liaison specialist), developing mental health units in general hospitals was quite common in the 50s and 60s as the mental hospitals were closed. Some of the ideas you express about integrating psychiatry better with medicine, just another speciality etc were part of that, as well as a desire to recognises as ‘real’ doctors of the white coated sort. As you suggested this does often go together with an enthusiasm for biological models, technology, ECT and psychosurgery and drug based models, none of which really convinces scientific doctors that psychiatry is ‘real’. I dont think it did as much as people hoped to integrate psychiatry, and as Fenella and other commenters point out, stigma survives structural solutions quite well. try Simon Sinclairs ‘Medical Apprenticeship’ if you havent already to see how early that gets ingrained in doctors. Some of the psychiatrists involved also found that putting psychiatry together with medicine ensures funding is diverted to the ‘real’ medicine, A and E etc even quicker than it is under the current system- a reason Tom Craig and others suggested that a merger of Trusts within Kings Health Partners would be a really bad idea. The development of the current trust structures in early 00s saw a tendency for mental health and acute trusts to separate out and although some psych units still survive in general hospitals now, in London and elsewhere, they tend to be run by different Trusts and inevitably mental health Trusts tend to consolidate onto mental health specific sites and pull wards out of the DGHs, who charge rent, and are often happy to have the space back. So integration is neither the future nor the past but one of the many models which have been tried without having a huge impact on stigma, or fundamentally changing the divides between mental and physical health care. What would make a difference? Probably clear financial incentives to integrated care and similar funding models for both. But to get to that point the extent of stigma and lack of parity of esteem need to be flushed out, and at present they are much to strong to allow integration. Another problem in my view is the general misuse and misunderstanding of psychiatric diagnosis which underlies such ideas as ‘1 in 4 people have a mental disorder’, and the tendency to use the poorly defined boundaries of mental disorders to argue that that they are very common. To a commissioner, quite rightly, anything that affects ‘1 in 4′ is something that must be managed in primary care and the risk of funding secondary care to do things which cannot clearly be differentiated from primary care is too great. Hence parity of esteem cannot be afforded and will not be risked. While done with the best of intentions (well, sometimes….other times it is blatantly about expanding markets), the sort of epidemiology which always discovers vast areas of unmet need for mental health services actually ensures that these services will not be provided. perhaps some focused work on smoking cessation in people with psychotic disorders,and incentivising it financially, will achieve more than another cycle of moving wards on and off DGH sites. Though im a bit irritated by the political line on this that CQUINS are new money to incentivise this sort of thing. They aren’t, they are recycled money that is cut off other things.

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