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THE MENTAL HOSPITAL EFFECTS OF AN ALTERNATIVE PSYCHIATRIC SERVICE
644
Special
Articles
for special treatments such continuous narcosis.
as
prefrontal leucotomy
an(
The
THE MENTAL HOSPITAL EFFECTS OF AN ALTERNATIVE PSYCHIATRIC SERVICE
A. ORWIN L.R.C.P.E., D.P.M. CONSULTANT HOLLYMOOR
PSYCHIATRIST, HOSPITAL, NORTHFIELD, BIRMINGHAM
M.D.
M. SIM Edin., D.P.M.
CONSULTANT
PSYCHIATRIST, MEDICINE,
DEPARTMENT OF PSYCHOLOGICAL
UNITED BIRMINGHAM HOSPITALS
development of psychiatric services by general hospitals, though fairly recent, is increasing. These new units have met with general approval, but some apprehension has been expressed lest the mental hospital be relegated to an inferior position. The papers by Garratt et al. (1958) and Tooth and Brooke (1961) met with considerable criticism not only because some doubted the conclusions-in the former, that there were large numbers of patients in mental hospitals who did not require the full resources of a hospital; and, in the latter, that the long-stay population of the mental hospital was rapidly falling-but because of the implications that the mental hospital as THE
such would cease to exist. The mental hospitals have not shirked the challenge of the general hospital and over the past sixteen years they have initiated a variety of measures which have been successful in rehabilitating the chronic patient and in effectively treating the recoverable. These achievements have in themselves contributed to the running down of the mental hospitals, and it is understandable that their medical and nursing staffs should be anxious about their future. It is often claimed that the new general-hospital units are " creaming off " the more readily recoverable patients and leave the aged, the chronic, and the highsecurity risk to the care of the mental hospital. Such a role has in fact been advocated by Little (1963) in his " rational plan for integration of psychiatric services to an urban community ". He divides patients into shortstay, medium-stay, and chronic, the last being cared for in the mental hospital by resident medical officers of clinical-assistant grade, with the help of visiting general practitioners. Others have refused to accept the decline of the mental hospital as inevitable and Baker (1958) has suggested that the major handicap is the large size of the institution and proposed it be divided into smaller and relatively independent units of 200-300 beds. Clark (1958), whose hospital serves a largely rural area and must therefore be considered in a different light, sees the mental hospital as a continuing institution and has revitalised the role of the medical superintendent through the medium of what he terms " administrative therapy ". Kidd (1961) in an attempt to bring the mental hospital into line with general-hospital practice has advocated the " team system " where the consultant is in charge of beds, sees and admits his own patients, and is assisted by a team of junior medical and ancillary staff. Carse et al. (1958) adopted an intermediate position by basing their district mental health service on the mental hospital, but made free use of domiciliary consultations, outpatient treatment, and day hospitals. Mental hospital admission is reserved
population structure of the mental hospitals including admissions and discharges, is readily available through the Registrar General’s Statistical Reviews; bu it has not been possible, to date, to get adequate figure! for those independent units that admit selectively. Their bed states do not give a realistic account; for, as they ar( usually sited in densely populated areas, much of their work is done at the outpatient department and the da) hospital. It is clear that, for the intelligent planning of the psychiatric services, it would be helpful tc know what impact these units may have on the mental hospital. This would not only confirm whether the fears that are now expressed are valid, but would provide valuable information
psychiatric services,
an
" consumer choice " in the aspect which has hitherto received
on
consideration. Data on which the above conclusions can be reached will depend on a study of independent psychiatric units operating in the catchment area of a mental hospital. Even then there are other factors which will influence the findings: admissions and discharges to a mental hospital can be modified by changes in the nature as well as the size of the catchment area; drives to reduce the chronic population; community-care services of the local authority; outpatient and day-hospital services; geriatric services; and turnover of beds. To illustrate further this complexity, the bed turnover can be influenced by (a) complement and quality of medical and nursing staff; (b) effective treatment; (c) a suitable domicile to which patients can be discharged and which in turn may be influenced by mobility of population; (d) the type of patient admitted, in terms of age and the nature of the illness. scant
From the above, which indicate only a few of the difficulties, it is evident that statistical analysis by someone other than a psychiatrist who is experienced in the ways of that particular mental hospital, and who understands its organisation both material and human, is likely to be
unreliable. SOURCES OF OUR DATA
The mental hospital.-Hollymoor Hospital, which is situated to the south-west of the city of Birmingham and approximately 7 miles from the centre, had 745 beds (377 male and 368 female). Until 1960 it shared a common catchment area with its neighbouring mental hospital (Rubery) with 781 beds (329 male and 452 female) each admitting patients on alternate weeks. In November, 1960, the common catchment area was divided in two, and that of Hollymoor contained a population of 293,300, of mixed social grades and within a distance of 7 miles from the hospital. Since November, 1962, the catchment area has again been changed and Hollymoor now serves a population of 303,000 within a distance of 7-15 miles and including the newly created county borough of Solihull. In view of these changes and particularly the last one with relative inaccessibility to the new catchment area, the year 1961 was selected for study. The
independent psychiatric units.-The department of psychological medicine of the United Birmingham Hospitals in 1961 consisted of 31 beds, 20 at the Midland Nerve Hospital and 11 at the Queen Elizabeth Hospital. A day hospital at the Midland Nerve Hospital had 20 places; but these were used with great flexibility (the
645
patient attending according to his immediate needs) and TABLE III-ADMISSIONS BY DIAGNOSTIC CATEGORY DURING 1961 therefore served a larger population than the number of places would suggest. Outpatient treatment was highly developed, particularly for the more acute patient, and physical treatments could be arranged, daily if necessary. An outpatient social club was well established, and evening clinics were held to attend to those patients who were working during the day. The Uffculme Clinic had, in addition to an active outpatient and day-hospital service of 18 places, 34 inpatient beds first fully utilised in 1959. The accent of this clinic was shifting towards psychotherapy, and thereto 201 affective states, giving an index of 1 ’2. In Uffculme, fore by 1961 the day-hospital and outpatient units did not it was 15 to 99 or 0’15, while in the United Birmingham have quite the same impact on the mental hospital it was 40 to 318 or 0-12. Hospitals admissions as those of the United Birmingham Hospitals. Senile and presenile dementias accounted for 76 out of 652 admissions to Hollymoor (11-6% of the total). In THE DATA the United Birmingham Hospitals there were 15 out of Of the 102 patients attending the day hospital of the 547 (0-3%), while Uffculme admitted none. This United Birmingham Hospitals during 1961 (table i), table shows that there was a preponderance of schizo60 (59%) were schizophrenic or manic-depressive, while phrenic, senile, and psychopathic states admitted to post-leucotomy states, alcoholism, and drug-addiction Hollymoor with a relative reduction in affective states, indicating the character the hospital is assuming vis-a-vis the independent units. Another item of interest is that 31 patients with alcoholism and drug-addition were admitted to the United Birmingham Hospitals compared with 17 to Hollymoor and 2 to Uffculme. These figures suggest that the general hospital is already playing an important part in the treatment of these problems and that, when special units or accounted for another 8. Only 30 patients (29%) were DECREASE IN BED OCCUPANCY OF HOLLYMOOR diagnosed as having neurotic disorders, whiph suggests TABLE IV-PERCENTAGE HOSPITAL COMPARED WITH REGIONAL HOSPITALS that most of these patients would, in the ordinary way, have been the responsibility of the mental hospital. The number of new outpatients (349) and the subsequent attendances (4479) indicate the volume and intensity of the work of the outpatient department. Table II shows that, of the patients admitted to the Uffculme Clinic, 140 (62%) were diagnosed as affective TABLE V-ADMISSIONS TO HOLLYMOOR HOSPITAL COMPARED WITH THE REGIONAL AVERAGE states, while only 15 (7%) were diagnosed as schizodisorders. These with contrast figures phrenic sharply those of Hollymoor (see below). The relatively large proportion of new outpatients compared with their subsequent attendances (1017 to 4816) suggests that the outpatient department was a diagnostic centre as well as a
treatment
clinic.
If, in admissions to the various units, the affective states be seen in relation to the schizophrenic states, one can arrive at an index of the type of admission. Table ill shows that in Hollymoor there were 241 schizophrenics can
TABLE II-UFFCULME
CLINIC, 1961
facilities are being contemplated, the general hospital’s role should be carefully considered. While other mental hospitals in the Birmingham Region have shown a decrease of 7-5% in bed-occupancy since 1959, those in the City of Birmingham had a decrease of 11-6%, while Hollymoor had one of 17-2% (table iv). As there were no big changes in the populations served, it can be assumed that the independent units were effectively treating patients who might otherwise have gone to Hollymoor, and that Hollymoor was not behind in its
discharges. Table v shows that the other mental hospitals in the region had a 255;o increase of admissions since 1959, whereas Hollymoor had a 14% decrease, illustrating the impact of the independent units. The total admissions in 1961 from Hollymoor’s catchment area by the independent units were 164 (120 to the United Birmingham Hospitals and 44 to the Uffculme
646 was approximately 25% of Hollymoor’s admissions in that year. The total does not include the many patients treated either at the day hospitals or outpatient departments of these units who might otherwise have had to be admitted to Hollymoor.
Clinic). This
New day patients from Hollymoor’s catchment area who attended the independent units (United Birmingham Hospitals and Uffculme Clinic) exceeded those who attended Hollymoor’s own unit (52 to 48).
Of the total psychiatric outpatients from the Hollymoor catchment area, nearly 40% (311) attended the independent units, compared with the 493 who attended the outpatient clinics organised by Hollymoor. This would account for the discrepancy between Hollymoor’s outpatient figures (1 per 600 of the population) and the regional average which in 1961 was 1 per 350. When one compares the admissions to regional hoswith those of Hollymoor and the independent units, it is seen that (per 100,000 of population served) the 56 admitted by the independent units from Hollymoor’s catchment area almost exactly equals the difference between Hollymoor’s admissions (223) and those of the regional hospitals (274). A reasonable explanation would be that the independent units were admitting patients who would otherwise go to Hollymoor.
pitals
When formal (compulsory) admissions to Hollymoor are compared with those to other mental hospitals in the region, it is seen that those of Hollymoor (34%) exceed not only those of regional hospitals outside Birmingham (21 5%) but those of the other Birmingham mental hospitals (31%). Evidently, the impact of the indepen-
dent units is
not limited to Hollymoor, and a similar study of the other city mental hospitals would probably yield further support for this assumption.
In 1959-62, among
Hollymoor (table vi),
patients there
of 65 years and over in rise in males of 6%
was a
TABLE VI-PERCENTAGE OF PATIENTS AGED
65
YEARS AND OVER IN
HOLLYMOOR AND REGIONAL HOSPITALS
(23-29%) and in females of 12% (44-56%). In regional hospitals, the rise for males was 3% and for females 5%. Thus, compared with the regional hospitals, Hollymoor was retaining a larger share of geriatric problems and its empty beds are apparently being used for geriatric rather than psychiatric purposes. These figures further emphasise the changing character of that hospital. DISCUSSION
These figures suggest that the psychiatric units of the United Birmingham Hospitals and the Uffculme Clinic treated a substantial number of patients who might otherwise have been referred to Hollymoor Hospital, and that they also influenced the high proportion of formal admissions, the age structure, and the type of mental illness of patients admitted to that hospital. These findings in themselves cast serious doubt on Jones and
Sidebotham’s (1962) prediction that general-hospital units are unlikely to cater for the average mental patient. The P.E.P. (1963) broadsheet, in its look into the future of the psychiatric services, said that perhaps the mental hospitals will take on the character that they long hoped to outgrow-that of chronic custodial institutions. The results of our inquiry suggest that if the trend continues, the word " perhaps " may be deleted, so far as this mental hospital is concerned. They also illustrate that, when a choice in mental treatment is available, the patient, his relatives, and his doctor often prefer the smaller and certainly no more attractive general-hospital unit. While it may be too early to argue from this particular study to the general impact of such units on mental hospitals, there is enough evidence to suggest that planning authorities should give serious consideration to the effects these units may have on the mental hospital and its staff. These new units can no longer be seen as one of those extensions of the National Health Service which are designed to meet a hitherto unsatisfied demand (e.g., cardiac surgery or neurosurgery) for they now compete directly with the mental hospital. Small as their bed numbers may be, they are in many respects providing an alternative service and are thus making a major contribution to the running down of the mental
hospital. At first these units were mainly attached to. teaching hospitals and the staff had no formal link with the local mental hospital. Besides the mental-hospital psychiatrist, there was now a new type of specialist, the general-hospital psychiatrist. The independence of the units may have contributed to the enthusiasm that pervaded them, to the rapid turnover of beds, and to the urgent development of comprehensive outpatient and day-hospital services for which, geographically, they were well suited. The debit side is partly reflected in the insecurity of those working exclusively in mental hospitals which have been exposed to this type of competition, who are now fully aware of the changing nature of their
institutions. There seems to be a good case for staffing new psychiatric units in general hospitals with doctors and nurses from the neighbouring mental hospital. This does not mean that the new units should be administered by the mental hospital, which, in spite of its much larger number of beds, may be treating fewer patients than the generalhospital unit. Full integration with the parent general hospital would not only ease the running down of the large mental hospital but would shift the accent from bed state to work done. But what of the mental hospital ? It is generally agreed be too large. Garratt et al. (1958) have shown that many people could leave the mental hospital if they had somewhere else to go and that the elaborate structure of the institution is not necessary for the majority of its inmates, while others have shown that it may indeed be harmful. When the Mental Health Act, 1959, came into force, it was expected that local authorities would shoulder much of the responsibility for aftercare, and that there would be an adequate number of hostels for patients not requiring the full resources of the mental hospital. Unfortunately these have not been forthcoming in anything like the number required. Yet many patients in mental hospitals could be adequately cared for in such
to
647
hostels. They should preferably be small (about 20 beds) and as such could eventually become a useful accessor) in the conduct of general practice, enabling the genera: practitioner to admit his own patients directly or tc receive patients from either the mental or general hospital, As they would probably be near the patient’s home, this arrangement would promote a more intimate atmosphere and keep the patient close to his relatives and general cultural background. The patient would also be attended by his own doctor, who is familiar with his previous history. An indirect advantage would be the provision of an outlet for those senior nurses from the mental hospital who may not wish to transfer to the general hospital and who often have a special liking for their long-stay
patients. As these hostels would be substituting for mentalhospital beds, local authorities may, understandably, be reluctant to subsidise the running down of the mental hospital. This highlights one of the weaknesses of the Mental Health Act, 1959, in that two of the most important functions in mental health-namely, prophylaxis and aftercare-are specifically delegated to local authorities which lack the resources to fulfil them. These functions are far removed from the traditional field of public health and cannot be separated from the hospital service. It is difficult to understand why they were ever handed over to the local authority, for it merely frees the Health Service from the responsibility of treating patients once they have left the institution. There are still patients who will require long-term residential treatment and are therefore unsuitable for the short-stay general-hospital unit. These include psychopathic personalities, uncooperative alcoholics and drugaddicts, and security risks. There are also the younger schizophrenic patients who through many years of institutionalisation cannot lead an independent life in the community or in the sheltered conditions of the hostel. All these form only a small proportion of the total mental-hospital population which is rapidly becoming geriatric (see table vi) and therefore do not justify the preservation of the mental hospital in its present formwhich, in any case, caters rather ineffectively for their special needs. The general-hospital unit also has formidable problems. Its development, particularly in the teaching hospital, has been hampered by financial stringency; for, in most instances, boards of governors have had to find the money from their own limited budget. Any expansion could take place only after competing with other more entrenched departments of the hospital. The Minister may say that he would view with favour the extension of general-hospital psychiatric services, but until he sets aside special grants for capital expenditure, establishments, and maintenance, these units will be unable to develop to their full potential. Even where a board of governors finds the money from its own budget, it is not always desirable that a new department should siphon off capital to which other departments feel they have a prior claim. This could destroy the goodwill on which the very future of the new department depends. In any case, as has been shown, a generalhospital unit does much of the work of a mental hospital and should be given the financial support to continue with and expand this work. The above suggestions still leave much unsolved. As has already been stated, this study applies to a densely
populated urban area only. It remains to be seen what the impact of a general-hospital unit will be in a rural or semirural area. A factual study reveals information which would otherwise not have been suspected, and there is no adequate substitute for the patient assembly of facts. The time has probably come to experiment. SUMMARY
1. The
psychiatric
impact units
mental working in
on a
hospital by independent its catchment
area
is
described. 2. Suggestions are made for the smoother run-down of the mental hospital and for the integration of its staff into the general-hospital unit. 3. The
problems arising from the delegation to the local authority of prophylaxis and aftercare of mental illness are
discussed.
4. Suggestions are made for improved financial provisions for general-hospital psychiatric units. to thank the Medical Superintendent of Hollymoor the Medical Director of the Uffculme Clinic, and the Board of Governors of the United Birmingham Hospitals for permission to use their statistics and extract the relevant data.
We wish
Hospital,
REFERENCES
Baker, A. A. (1958) Lancet, ii, 253. Carse, J., Panton, N. E., Watt, A. (1958) ibid. i, 39. Clark, D. H. (1958) ibid. i, 805. Garratt, F. N., Lowe, C. R., McKeown, T. (1958) ibid. i, 682. Jones, K., Sidebotham, R. (1962) Mental Hospitals at Work. London. Kidd, H. B. (1961) Lancet, ii, 703. Little, J. C. (1963) ibid. ii, 1159. P.E.P. (1963) Psychiatric Services in 1975. Political and Economic Planning, Queen Anne’s Gate, London, W.1. Tooth, G. C., Brooke, E. M. (1961) Lancet, 1, 710.
Public Health Poisoned Food
Gainsborough Urban District Council has been warned by its medical officer of health, Dr. William Ward,’ that food may be contaminated by price tags stuck into it. Unless the food is to be cooked later, he advises people not to buy it. Infectious Diseases in England and Wales
*
Not 1.
including late
returns.
Times, March 15, 1965.
Special
Articles
for special treatments such continuous narcosis.
as
prefrontal leucotomy
an(
The
THE MENTAL HOSPITAL EFFECTS OF AN ALTERNATIVE PSYCHIATRIC SERVICE
A. ORWIN L.R.C.P.E., D.P.M. CONSULTANT HOLLYMOOR
PSYCHIATRIST, HOSPITAL, NORTHFIELD, BIRMINGHAM
M.D.
M. SIM Edin., D.P.M.
CONSULTANT
PSYCHIATRIST, MEDICINE,
DEPARTMENT OF PSYCHOLOGICAL
UNITED BIRMINGHAM HOSPITALS
development of psychiatric services by general hospitals, though fairly recent, is increasing. These new units have met with general approval, but some apprehension has been expressed lest the mental hospital be relegated to an inferior position. The papers by Garratt et al. (1958) and Tooth and Brooke (1961) met with considerable criticism not only because some doubted the conclusions-in the former, that there were large numbers of patients in mental hospitals who did not require the full resources of a hospital; and, in the latter, that the long-stay population of the mental hospital was rapidly falling-but because of the implications that the mental hospital as THE
such would cease to exist. The mental hospitals have not shirked the challenge of the general hospital and over the past sixteen years they have initiated a variety of measures which have been successful in rehabilitating the chronic patient and in effectively treating the recoverable. These achievements have in themselves contributed to the running down of the mental hospitals, and it is understandable that their medical and nursing staffs should be anxious about their future. It is often claimed that the new general-hospital units are " creaming off " the more readily recoverable patients and leave the aged, the chronic, and the highsecurity risk to the care of the mental hospital. Such a role has in fact been advocated by Little (1963) in his " rational plan for integration of psychiatric services to an urban community ". He divides patients into shortstay, medium-stay, and chronic, the last being cared for in the mental hospital by resident medical officers of clinical-assistant grade, with the help of visiting general practitioners. Others have refused to accept the decline of the mental hospital as inevitable and Baker (1958) has suggested that the major handicap is the large size of the institution and proposed it be divided into smaller and relatively independent units of 200-300 beds. Clark (1958), whose hospital serves a largely rural area and must therefore be considered in a different light, sees the mental hospital as a continuing institution and has revitalised the role of the medical superintendent through the medium of what he terms " administrative therapy ". Kidd (1961) in an attempt to bring the mental hospital into line with general-hospital practice has advocated the " team system " where the consultant is in charge of beds, sees and admits his own patients, and is assisted by a team of junior medical and ancillary staff. Carse et al. (1958) adopted an intermediate position by basing their district mental health service on the mental hospital, but made free use of domiciliary consultations, outpatient treatment, and day hospitals. Mental hospital admission is reserved
population structure of the mental hospitals including admissions and discharges, is readily available through the Registrar General’s Statistical Reviews; bu it has not been possible, to date, to get adequate figure! for those independent units that admit selectively. Their bed states do not give a realistic account; for, as they ar( usually sited in densely populated areas, much of their work is done at the outpatient department and the da) hospital. It is clear that, for the intelligent planning of the psychiatric services, it would be helpful tc know what impact these units may have on the mental hospital. This would not only confirm whether the fears that are now expressed are valid, but would provide valuable information
psychiatric services,
an
" consumer choice " in the aspect which has hitherto received
on
consideration. Data on which the above conclusions can be reached will depend on a study of independent psychiatric units operating in the catchment area of a mental hospital. Even then there are other factors which will influence the findings: admissions and discharges to a mental hospital can be modified by changes in the nature as well as the size of the catchment area; drives to reduce the chronic population; community-care services of the local authority; outpatient and day-hospital services; geriatric services; and turnover of beds. To illustrate further this complexity, the bed turnover can be influenced by (a) complement and quality of medical and nursing staff; (b) effective treatment; (c) a suitable domicile to which patients can be discharged and which in turn may be influenced by mobility of population; (d) the type of patient admitted, in terms of age and the nature of the illness. scant
From the above, which indicate only a few of the difficulties, it is evident that statistical analysis by someone other than a psychiatrist who is experienced in the ways of that particular mental hospital, and who understands its organisation both material and human, is likely to be
unreliable. SOURCES OF OUR DATA
The mental hospital.-Hollymoor Hospital, which is situated to the south-west of the city of Birmingham and approximately 7 miles from the centre, had 745 beds (377 male and 368 female). Until 1960 it shared a common catchment area with its neighbouring mental hospital (Rubery) with 781 beds (329 male and 452 female) each admitting patients on alternate weeks. In November, 1960, the common catchment area was divided in two, and that of Hollymoor contained a population of 293,300, of mixed social grades and within a distance of 7 miles from the hospital. Since November, 1962, the catchment area has again been changed and Hollymoor now serves a population of 303,000 within a distance of 7-15 miles and including the newly created county borough of Solihull. In view of these changes and particularly the last one with relative inaccessibility to the new catchment area, the year 1961 was selected for study. The
independent psychiatric units.-The department of psychological medicine of the United Birmingham Hospitals in 1961 consisted of 31 beds, 20 at the Midland Nerve Hospital and 11 at the Queen Elizabeth Hospital. A day hospital at the Midland Nerve Hospital had 20 places; but these were used with great flexibility (the
645
patient attending according to his immediate needs) and TABLE III-ADMISSIONS BY DIAGNOSTIC CATEGORY DURING 1961 therefore served a larger population than the number of places would suggest. Outpatient treatment was highly developed, particularly for the more acute patient, and physical treatments could be arranged, daily if necessary. An outpatient social club was well established, and evening clinics were held to attend to those patients who were working during the day. The Uffculme Clinic had, in addition to an active outpatient and day-hospital service of 18 places, 34 inpatient beds first fully utilised in 1959. The accent of this clinic was shifting towards psychotherapy, and thereto 201 affective states, giving an index of 1 ’2. In Uffculme, fore by 1961 the day-hospital and outpatient units did not it was 15 to 99 or 0’15, while in the United Birmingham have quite the same impact on the mental hospital it was 40 to 318 or 0-12. Hospitals admissions as those of the United Birmingham Hospitals. Senile and presenile dementias accounted for 76 out of 652 admissions to Hollymoor (11-6% of the total). In THE DATA the United Birmingham Hospitals there were 15 out of Of the 102 patients attending the day hospital of the 547 (0-3%), while Uffculme admitted none. This United Birmingham Hospitals during 1961 (table i), table shows that there was a preponderance of schizo60 (59%) were schizophrenic or manic-depressive, while phrenic, senile, and psychopathic states admitted to post-leucotomy states, alcoholism, and drug-addiction Hollymoor with a relative reduction in affective states, indicating the character the hospital is assuming vis-a-vis the independent units. Another item of interest is that 31 patients with alcoholism and drug-addition were admitted to the United Birmingham Hospitals compared with 17 to Hollymoor and 2 to Uffculme. These figures suggest that the general hospital is already playing an important part in the treatment of these problems and that, when special units or accounted for another 8. Only 30 patients (29%) were DECREASE IN BED OCCUPANCY OF HOLLYMOOR diagnosed as having neurotic disorders, whiph suggests TABLE IV-PERCENTAGE HOSPITAL COMPARED WITH REGIONAL HOSPITALS that most of these patients would, in the ordinary way, have been the responsibility of the mental hospital. The number of new outpatients (349) and the subsequent attendances (4479) indicate the volume and intensity of the work of the outpatient department. Table II shows that, of the patients admitted to the Uffculme Clinic, 140 (62%) were diagnosed as affective TABLE V-ADMISSIONS TO HOLLYMOOR HOSPITAL COMPARED WITH THE REGIONAL AVERAGE states, while only 15 (7%) were diagnosed as schizodisorders. These with contrast figures phrenic sharply those of Hollymoor (see below). The relatively large proportion of new outpatients compared with their subsequent attendances (1017 to 4816) suggests that the outpatient department was a diagnostic centre as well as a
treatment
clinic.
If, in admissions to the various units, the affective states be seen in relation to the schizophrenic states, one can arrive at an index of the type of admission. Table ill shows that in Hollymoor there were 241 schizophrenics can
TABLE II-UFFCULME
CLINIC, 1961
facilities are being contemplated, the general hospital’s role should be carefully considered. While other mental hospitals in the Birmingham Region have shown a decrease of 7-5% in bed-occupancy since 1959, those in the City of Birmingham had a decrease of 11-6%, while Hollymoor had one of 17-2% (table iv). As there were no big changes in the populations served, it can be assumed that the independent units were effectively treating patients who might otherwise have gone to Hollymoor, and that Hollymoor was not behind in its
discharges. Table v shows that the other mental hospitals in the region had a 255;o increase of admissions since 1959, whereas Hollymoor had a 14% decrease, illustrating the impact of the independent units. The total admissions in 1961 from Hollymoor’s catchment area by the independent units were 164 (120 to the United Birmingham Hospitals and 44 to the Uffculme
646 was approximately 25% of Hollymoor’s admissions in that year. The total does not include the many patients treated either at the day hospitals or outpatient departments of these units who might otherwise have had to be admitted to Hollymoor.
Clinic). This
New day patients from Hollymoor’s catchment area who attended the independent units (United Birmingham Hospitals and Uffculme Clinic) exceeded those who attended Hollymoor’s own unit (52 to 48).
Of the total psychiatric outpatients from the Hollymoor catchment area, nearly 40% (311) attended the independent units, compared with the 493 who attended the outpatient clinics organised by Hollymoor. This would account for the discrepancy between Hollymoor’s outpatient figures (1 per 600 of the population) and the regional average which in 1961 was 1 per 350. When one compares the admissions to regional hoswith those of Hollymoor and the independent units, it is seen that (per 100,000 of population served) the 56 admitted by the independent units from Hollymoor’s catchment area almost exactly equals the difference between Hollymoor’s admissions (223) and those of the regional hospitals (274). A reasonable explanation would be that the independent units were admitting patients who would otherwise go to Hollymoor.
pitals
When formal (compulsory) admissions to Hollymoor are compared with those to other mental hospitals in the region, it is seen that those of Hollymoor (34%) exceed not only those of regional hospitals outside Birmingham (21 5%) but those of the other Birmingham mental hospitals (31%). Evidently, the impact of the indepen-
dent units is
not limited to Hollymoor, and a similar study of the other city mental hospitals would probably yield further support for this assumption.
In 1959-62, among
Hollymoor (table vi),
patients there
of 65 years and over in rise in males of 6%
was a
TABLE VI-PERCENTAGE OF PATIENTS AGED
65
YEARS AND OVER IN
HOLLYMOOR AND REGIONAL HOSPITALS
(23-29%) and in females of 12% (44-56%). In regional hospitals, the rise for males was 3% and for females 5%. Thus, compared with the regional hospitals, Hollymoor was retaining a larger share of geriatric problems and its empty beds are apparently being used for geriatric rather than psychiatric purposes. These figures further emphasise the changing character of that hospital. DISCUSSION
These figures suggest that the psychiatric units of the United Birmingham Hospitals and the Uffculme Clinic treated a substantial number of patients who might otherwise have been referred to Hollymoor Hospital, and that they also influenced the high proportion of formal admissions, the age structure, and the type of mental illness of patients admitted to that hospital. These findings in themselves cast serious doubt on Jones and
Sidebotham’s (1962) prediction that general-hospital units are unlikely to cater for the average mental patient. The P.E.P. (1963) broadsheet, in its look into the future of the psychiatric services, said that perhaps the mental hospitals will take on the character that they long hoped to outgrow-that of chronic custodial institutions. The results of our inquiry suggest that if the trend continues, the word " perhaps " may be deleted, so far as this mental hospital is concerned. They also illustrate that, when a choice in mental treatment is available, the patient, his relatives, and his doctor often prefer the smaller and certainly no more attractive general-hospital unit. While it may be too early to argue from this particular study to the general impact of such units on mental hospitals, there is enough evidence to suggest that planning authorities should give serious consideration to the effects these units may have on the mental hospital and its staff. These new units can no longer be seen as one of those extensions of the National Health Service which are designed to meet a hitherto unsatisfied demand (e.g., cardiac surgery or neurosurgery) for they now compete directly with the mental hospital. Small as their bed numbers may be, they are in many respects providing an alternative service and are thus making a major contribution to the running down of the mental
hospital. At first these units were mainly attached to. teaching hospitals and the staff had no formal link with the local mental hospital. Besides the mental-hospital psychiatrist, there was now a new type of specialist, the general-hospital psychiatrist. The independence of the units may have contributed to the enthusiasm that pervaded them, to the rapid turnover of beds, and to the urgent development of comprehensive outpatient and day-hospital services for which, geographically, they were well suited. The debit side is partly reflected in the insecurity of those working exclusively in mental hospitals which have been exposed to this type of competition, who are now fully aware of the changing nature of their
institutions. There seems to be a good case for staffing new psychiatric units in general hospitals with doctors and nurses from the neighbouring mental hospital. This does not mean that the new units should be administered by the mental hospital, which, in spite of its much larger number of beds, may be treating fewer patients than the generalhospital unit. Full integration with the parent general hospital would not only ease the running down of the large mental hospital but would shift the accent from bed state to work done. But what of the mental hospital ? It is generally agreed be too large. Garratt et al. (1958) have shown that many people could leave the mental hospital if they had somewhere else to go and that the elaborate structure of the institution is not necessary for the majority of its inmates, while others have shown that it may indeed be harmful. When the Mental Health Act, 1959, came into force, it was expected that local authorities would shoulder much of the responsibility for aftercare, and that there would be an adequate number of hostels for patients not requiring the full resources of the mental hospital. Unfortunately these have not been forthcoming in anything like the number required. Yet many patients in mental hospitals could be adequately cared for in such
to
647
hostels. They should preferably be small (about 20 beds) and as such could eventually become a useful accessor) in the conduct of general practice, enabling the genera: practitioner to admit his own patients directly or tc receive patients from either the mental or general hospital, As they would probably be near the patient’s home, this arrangement would promote a more intimate atmosphere and keep the patient close to his relatives and general cultural background. The patient would also be attended by his own doctor, who is familiar with his previous history. An indirect advantage would be the provision of an outlet for those senior nurses from the mental hospital who may not wish to transfer to the general hospital and who often have a special liking for their long-stay
patients. As these hostels would be substituting for mentalhospital beds, local authorities may, understandably, be reluctant to subsidise the running down of the mental hospital. This highlights one of the weaknesses of the Mental Health Act, 1959, in that two of the most important functions in mental health-namely, prophylaxis and aftercare-are specifically delegated to local authorities which lack the resources to fulfil them. These functions are far removed from the traditional field of public health and cannot be separated from the hospital service. It is difficult to understand why they were ever handed over to the local authority, for it merely frees the Health Service from the responsibility of treating patients once they have left the institution. There are still patients who will require long-term residential treatment and are therefore unsuitable for the short-stay general-hospital unit. These include psychopathic personalities, uncooperative alcoholics and drugaddicts, and security risks. There are also the younger schizophrenic patients who through many years of institutionalisation cannot lead an independent life in the community or in the sheltered conditions of the hostel. All these form only a small proportion of the total mental-hospital population which is rapidly becoming geriatric (see table vi) and therefore do not justify the preservation of the mental hospital in its present formwhich, in any case, caters rather ineffectively for their special needs. The general-hospital unit also has formidable problems. Its development, particularly in the teaching hospital, has been hampered by financial stringency; for, in most instances, boards of governors have had to find the money from their own limited budget. Any expansion could take place only after competing with other more entrenched departments of the hospital. The Minister may say that he would view with favour the extension of general-hospital psychiatric services, but until he sets aside special grants for capital expenditure, establishments, and maintenance, these units will be unable to develop to their full potential. Even where a board of governors finds the money from its own budget, it is not always desirable that a new department should siphon off capital to which other departments feel they have a prior claim. This could destroy the goodwill on which the very future of the new department depends. In any case, as has been shown, a generalhospital unit does much of the work of a mental hospital and should be given the financial support to continue with and expand this work. The above suggestions still leave much unsolved. As has already been stated, this study applies to a densely
populated urban area only. It remains to be seen what the impact of a general-hospital unit will be in a rural or semirural area. A factual study reveals information which would otherwise not have been suspected, and there is no adequate substitute for the patient assembly of facts. The time has probably come to experiment. SUMMARY
1. The
psychiatric
impact units
mental working in
on a
hospital by independent its catchment
area
is
described. 2. Suggestions are made for the smoother run-down of the mental hospital and for the integration of its staff into the general-hospital unit. 3. The
problems arising from the delegation to the local authority of prophylaxis and aftercare of mental illness are
discussed.
4. Suggestions are made for improved financial provisions for general-hospital psychiatric units. to thank the Medical Superintendent of Hollymoor the Medical Director of the Uffculme Clinic, and the Board of Governors of the United Birmingham Hospitals for permission to use their statistics and extract the relevant data.
We wish
Hospital,
REFERENCES
Baker, A. A. (1958) Lancet, ii, 253. Carse, J., Panton, N. E., Watt, A. (1958) ibid. i, 39. Clark, D. H. (1958) ibid. i, 805. Garratt, F. N., Lowe, C. R., McKeown, T. (1958) ibid. i, 682. Jones, K., Sidebotham, R. (1962) Mental Hospitals at Work. London. Kidd, H. B. (1961) Lancet, ii, 703. Little, J. C. (1963) ibid. ii, 1159. P.E.P. (1963) Psychiatric Services in 1975. Political and Economic Planning, Queen Anne’s Gate, London, W.1. Tooth, G. C., Brooke, E. M. (1961) Lancet, 1, 710.
Public Health Poisoned Food
Gainsborough Urban District Council has been warned by its medical officer of health, Dr. William Ward,’ that food may be contaminated by price tags stuck into it. Unless the food is to be cooked later, he advises people not to buy it. Infectious Diseases in England and Wales
*
Not 1.
including late
returns.
Times, March 15, 1965.