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Inequalities in psychiatric care in England and Wales
Sot. Sci. & Med. 1972, Vol. 6, pp. 221-227. Pergamon Press. Printed in Great Britain.
INEQUALITIES
IN PSYCHIATRIC CARE IN ENGLAND WALES
AND
ALAN MAYNARD Lecturer in Economics,
University of York
DURING the 1960’s several sets of writers analysed various aspects of the inequality of the distribution of health care facilities in England and Wales. However, they all appear to have used Hospital In-Patient Enquiry (hereinafter H.I.P.E.) data which pertained to a one in ten sample of patients discharged from non-psychiatric hospitals in England and Wales. [l] This paper is concerned with regional inequalities in the provision of psychiatric hospitals in England and Wales. Section 1 deals with the inequality in the number of beds available in 1967. Section 2 deals with inequalities in the quality of care in 1969 using Ministry data. The disparity in dates for the data is due to the differing speeds with which various types of data about the hospital services is made available. Section 3 looks at the evidence about the distribution of local authority mental health activities. Finally Section 4 offers some conclusions.
1. The provision of beds Table 1 lists the relevant data about the provision of psychiatric beds in England and Wales. TABLE 1. THE PROVISION OF PSYCHIATRIC BEDS IN
Region
Newcastle Leeds Sheffield Past Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Wessex Oxford South-Western Wales Birmingham Manchester Liverpool
Beds available
11,718 14,150 14,505 6484 16,846 11,779 13,573 26,190 8025 5881 15,849 10,762 18,955 16,939 9271
ENGLAND AND
WALES1967
Beds available per 1000 population
Beds Used
Bed Utilization*
3.802 4.419 3.153 3.845 3.889 3.594 3.989 7.796 4.117 3.166 5.184 3.972 3.740 3.717 4.120
10,835 12,631 13,199 5851 15,194 10,422 12,087 23,456 7390 5062 14,268 9863 17,297 15,524 8902
9346 89.26 93.27 9023 90.19 88.47 89.05 89.56 91.83 86.07 90.02 9164 91.25 9164 96.01
Source: Hospital Return (SH3) for the year ended 31.12.1967. Combined Regional Summary-RHB Hospitals and Teaching Hospitals. Beds used * Red utilization = x 100. Beds available 221
222
ALAN MAYNARD
From this table it is obvious that there are substantial regional inequalities in the number of psychiatric hospital beds available per 1000 population. In 1967 the range of variation for all the regions was from 3.153 beds per 1000 population in the Sheffield Region to 7.796 beds per 1000 population in the South-West Metropolitan Region-a range of 147 per cent. If we exclude the Metropolitan Regions the range is reduced to 64 per cent i.e. Sheffield (3.153) and South-West with 5.184 beds per 1000 population. The mean for beds available in 1967 in England and Wales was 4.166. In Feldstein’s study [2] of the non-psychiatric sector a significant relationship was noted between the number of beds available per 1000 population and the utilization of the bed stock in the Region. He noted that the least well endowed region, Sheffield, tended to use its bedstock less intensively than better endowed regions such as Liverpool in 1960. No such relationship seemed to exist in the psychiatric sector in 1967. A correlation analysis for the 15 regions between beds available per 1000 population and bed utilisation resulted in an insignificant correlation coefficient of -0.147. A similar analysis for the non-Metropolitan Regions gave a correlation coefficient of +0*043-again insignificant. Thus there appears to be no general relationship in the psychiatric sector between beds available per 1000 population and beds utilised in 1967. 2. The quality ofpsychiatric care Quality is a difficult concept to evaluate in any activity. In this section we look at some proxies of quality and whilst knowing their limitations, offer them as indicators of regional inequalities in the quality of psychiatric hospital care in England and Wales. (a) Mental Illness Hospitals-the quality of care in 1969. Table 2 lists six types of labour TABLE 2. LABOUR INPUTS--MENTALILLNESSHOSPITALS IN ENGLAND AND WALES 1969
Region Newcastle Leeds Sheffield East Anglian North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South-Western Wales Birmingham Manchester Liverpool Wessex England and Wales average Standard Deviation Coefficient of variation
Consultants in psychiatry
Psychologists
0.66 0.53
0.17 0.20 0.19 0.14 058 0.26 0.16 0.26 0.30 0.11 0.29 0.16 0.28 0.29 0.17 0.24 0.113 47%
0.79
0.52 0.60 0.53 0.52 0.49 1.05 044 0.73 0.62 0.53 0.53 0.53 060 0.154 26%
Instructors
0.04 0.11 0.12 0.23 0.10 0.17 0.09 0.25 0.17 0.17 0.19 0.19 0.07 0.15 0.063 42%
All Nurses
Social workers
Ward orderlies and domestics
31.6 33.6 346 27.6 29.5 30.3 32.2 28.1 39.3 32.3 33.3 31.1 31.1 31.3 32.3 31.8 2.807 9%
0.50 0.27 0.30 0.25 0.76 0.62 044 0.28 0.74 0.38 044 0.33 0.28 0.30 0.46 0.42 0.168 40%
6.8 5.0 64 3.2 4.5 5.4 5.1 45 6.5 4.8 4.7 7.3 6.4 5.6 1.153 20%
Source: “The Facilities and Services of Psychiatric Hospitals in England and Wales 1969”, Department Health and Social Security Statistical Report Series No. 10. H.M.S.O. 1970. All data is staff per 100 residents in RHB hospitals.
of
Inequalities in Psychiatric Care in England and Wales
223
input in psychiatric hospitals: consultants in psychiatry, psychologists, instructors, all nurses, social workers and ward orderlies and domestics. The range of variation between the least well-endowed and the best endowed areas are quite substantial. (i) For consultants in psychiatry the range including (excluding) the Metropolitan Regions was 044 (044) in the South-West to l-05 (1.05) in the Oxford Region i.e. 138 per cent. (ii) For psychologists the range including (excluding) the Metropolitan Regions was 0.11 (0.11) in the South-West to O-58 (O-30) in the N.W. Metropolitan Region (Oxford Region) i.e. 427 per cent (172 per cent). (iii) For instructors the range including (excluding) the Metropolitan Region was O-04 (O-04) in the Newcastle Region to 0.25 (O-25) in the South-West Region i.e. 525 per cent. (iv) For all nurses (i.e. both qualified and unqualified) the range including (excluding) the Metropolitan Regions was 27.6 (27.6) in East Anglia to 39.3 (39.3) in Oxford i.e. 42 per cent. (v) For social workers the range including (excluding) the Metropolitan areas was O-25 (O-25) in East Anglia to O-76 (0.74) in the N.W. Metropolitan Region (Oxford Region). i.e. 204 per cent (196 per cent). (vi) For social workers, ward orderlies and domestics the range including (excluding) the Metropolitan areas was 3-2 (3.2) in the East Anglian Region to 7.3 (7.3) in the Liverpool Region, i.e. 128 per cent. These measures of variation are crude. An alternative in the form of the coefficient of variation is shown in the bottom line of Table 2. This relative measure shows that the variation is greatest amongst psychologists, instructors and social workers, i.e. it substantiates the previous measures. Thus in the mental illness hospitals of England and Wales there are substantial variations in labour input which must affect the quality of hospital care. Two extreme cases stand out on these indices. Firstly, East Anglia is poorly endowed ranking lowest on categories 4, 5 and 6, third lowest on category 1 and second lowest oncategory2,with no dataon instructors. Oxford, on the other hand, is generally well endowed [3] being best endowed in categories 1 and 4 and second best endowed in 2,5 and 6. Again there was no data about instructors. A substantial number of correlation calculations were carried out on this data and the results are shown in Table 3. A plausible hypothesis about the quality of care might be that regions that were badly endowed with one labour input might be compensated with a larger supply of another labour input i.e. there might be an inverse relationship between one input and another between the regions. The correlation matrix gives us substantial grounds for refuting this hypothesis. All the negative coefficients are insignificant. The few correlations which are significant seem to indicate that there is a positive relationship between the relevant variables e.g. the correlation coefficient of consultants and nurses is O-78 which indicates that those areas which are well endowed with consultants are also well endowed with nurses. Our conclusion about mental illness hospitals is that there are substantial inequalities and that there is no evidence to show that regions that are badly endowed in one sphere are compensated by better endowments in other spheres. (b) Hospitals for the mentally handicapped-the quality of care in 1969. Table 4 lists the same six categories of labour input that were dealt with in the previous sub-section. The ranges of variation between the worst endowed and the best endowed regions are again substantial. (i) For consultants in psychiatry the range including (excluding) the Metropolitan areas was O-11 (O-11) in the South-West to O-49 (O-49) in East Anglia i.e. 345 per cent.
224
ALAN MAYNARD
TABLE 3. Correlation
Consultants Psychologists Instructors Nurses Social workers Ward orderlies and domestics
(1) (2) (3) (4) (5) (6)
Matrix-Mental
(1)
(2)
-
0.21 -
Illness Hospitals in England and Wales 1969 (3)
-0.20 0.33 -
(4) 0.78 -0.06 -0.03 -
(s) 0.49 0.59 0.07 0.33 -
(6) 0.45 - 0.06 - 0.18 0.66 0.26 -
(ii) For psychologists the range including (excluding) the Metropolitan areas was O*Ol (O-01) in Sheffield to 0.23 (O-23) in the South-West Metropolitan and Oxford Regions i.e. 2300 per cent. (iii) For instructors the range including (excluding) the Metropolitan areas was 044 (044) in the Liverpool Region to 1.82 (1.52) in the South-West Metropolitan Region (Newcastle Region) i.e. 313 per cent (245 per cent). (iv) For nurses the range including (excluding) the Metropolitan areas was 23.16 (23.29) in the South-East Metropolitan Region (Birmingham Region) to 41~51(41~51)in the Liverpool Region, i.e. 79 per cent (78 per cent). (v) For social workers the range including (excluding) the Metropolitan areas was 0.04 (0.04) in East Anglia to 0.39 (O-39) in the Oxford Region i.e. 875 per cent. (vi) For ward orderlies and domestics the range including (excluding) the Metropolitan areas was 3.28 (3.28) in Newcastle to 9.43 (9.43) in Liverpool i.e. 187 per cent. Once again the variation ranges are substantial with category (ii) showing the greatest variation for any input in the psychiatric hospital service. As with the mental illness data further calculations have been carried out on the mentally handicapped data. The final line of Table 4 shows the coefficient of variation. This measure is greatest for psychologists and social workers and thus substantiate our conclusion that the greatest variations are present in these input categories. We repeated the exercise done on the mental illness data to produce Table 5, a correlation matrix for hospitals for the mentally handicapped in England and Wales in 1969. This table shows little evidence to support the hypothesis that areas badly endowed with one input are compensated with good endowments of other inputs. Few of the correlation coefficients are significant. The most significant value was obtained for a correlation of nurses and ward orderlies (O-71) which seems to indicate that those areas which are well endowed with nurses are well endowed with orderlies-the Liverpool Region is the extreme example of this. Our conclusions about the hospital’s facilities for the mentally handicapped is that they are unequally distributed amongst the regions and that there is little evidence to suggest that the poorly endowed regions are compensated in any way. 3. Local authority activities Psychiatric care outside the hospital system was the preserve of the Local Authorities in 1969. This section looks at two aspects of such care. Firstly we look at expenditure per 1000 population on training centres and secondly we look at the cost per attendance at such
Inequalities in Psychiatric Care in England and Wales
225
TABLE 4. LABOURMPUTS-HOSPITALS FOR THE MENTALLY HANDICAPPED IN ENGLANDAND Wm
Region
Consultants in psychiatry
Newcastle Leeds Sheffield East Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South-Western Wales Birmingham Manchester Liverpool wessex England and Wales average Standard Deviation CoetBcient of variation
0.29 @22 0.24 o-49 0.17 0.27 0.19 0.20 0.38 0.11 0.22 0.32 O-15 0.29 0.19 0.25 0.096 36%
Psychologists
0.09 0.03 0.01 @20 o-14 0.14 005 0.23 0.23 0.05 0.08 0.10 0.08 0.11 o-073 64%
Instructors and teachers 1.52 l-18 0.77 0.63 0.89 0.88 0.72 1.82 l-09 1.41 l-06 1.48 l-10 044 1.85 l-12 0.423 37%
All nurses
Social workers
29.06 24.23 26.86 2664 24.26 25.83 23.16 25.11 30.91 23.82 28.90 23.29 26.15 41.51 25.97 27.04 4.58 17%
0.11 0.08 0.04 o-07 0.14 005 0.21 0.39 0.07 O-09 0.16 0.05 0.11 0.12 @094 75%
1969
Ward orderlies and domestics 3.28 4.96 4.81 3.94 4.87 3.38 3.74 6.14 4.03 4.22 7.16 3.83 4.10 9.43 3.91 4.79 1.65 34%
Source: “The Facilities and Services of Psychiatric Hospitals in England and Wales 1969”, Department Health and Social Security Statistical Report Series No. 10. H.M.S.O. 1970. All data is staff per 100 residents in RHB hospitals.
of
TABLE 5. Correlation
Consultants Psychologists Instructors Nurses Social Workers Ward orderlies and domestics
(1) ::; (4) (5) (6)
matrix-mentally
(1)
(2)
-
0.52 -
handicapped Wales 1969 (31
-0.32 0.16 -
(4) 0.32 0.33 -0.41 -
hospitals in England and
(5) 0.33 0.64 0.27 0.52 -
(61 -0.07 0.03 -0.29 0.71 0.01 -
training centres. The data is for 1969, and will be dealt with again with other local health services in a forthcoming paper [4]. Table 6 enumerates the variations in expenditure per 1000 population on local authority mental health training centres in the year 1968-69. The largest variation in expenditure is to be found in the county boroughs (496 per cent), followed by the Welsh counties (250 per cent), the English counties (211 per cent) and the London Boroughs (73 per cent). There is no ready explanation of these variations but they further substantiate the view that there are significant regional disparities in the quantity and quality of mental care available in England and Wales.
226
ALAN MAYNARD TABLE 6. EXPENDITURE* ON LOYAL AUTHORITY TRAINING CENTRES (MENTAL HEALTH)
(a) County boroughs
(b) London boroughs
(c) English counties
(d) Welsh counties
Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation
E264.45 E85.55 E510-55 496 % E215.60 E88-65 f37360 73% E258.45 f130.00 f405.20 211% E285.10 E132.55 E464.85 250%
(Hastings) (Boone) (Westminster) (Barking) (Suffolk East) (Sussex East) (Radnor) (Angelsey)
Source: “Local Health Service Statistics 1968-69.” Institute of Municipal Treasurers and Accountants 1970. * Expenditure per 1000 population.
It is interesting to note the relative “efficiency” of the authorities in providing these mental health training places. Table 7 indicates that once again there are regional variations with the county boroughs having the greatest variation (326 per cent) and the Welsh counties the least variation and on average the highest costs [5].
TABLE 7. MENTALHEALTHTRAININGCE
(a) County boroughs
(b) London boroughs
(c) English counties
(d) Welsh counties
-osTPERA'ITENDANCE
Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation
El.47 D65 E2.77 326 % El.73 El.07 f3-27 205% El-71 El-12 E3.15 181% D-02 El.46
(Leeds) (Merthyr Tydfll) (Baling) (Sutton) (Northampton) (Rutland*) (Montgomery)
Source: “Local Health Service Statistics 1968-69.” Institute of Municipal Treasurers and Accountants 1970. l After Rutland, the highest was Westmorland at E2-55.
Inequalities in Psychiatric Care in England and Wales
227
4. Some conclusions This paper has analysed various facets of psychiatric care in England and Wales and found evidence of substantial regional variations in the quantity and quality of care available. This section attempts to point out the relevance of these findings for policy. I$ ently there has been considerable criticism of our system d mental health care [6] and Y t ere is some reason to view the psychiatric sector of the hospital service as “a forgotten land”. This “forgetfulness” is no doubt caused by factors such as the “unspectacular” aspects of such medicine (compared with e.g. transplants) and the feeling that to talk of such things is not pleasant and should be avoided (a hangover from previous generations). The problems facing the policy makers are two-fold. Firstly given the acceptance of an objective of equality, efforts will have to be made to reduce the inequalities of the present system. To do this will require considerable resources, which, given the nature of the problem, cannot be obtained by a “market solution” and thus will have to be met by the taxpayer [7]. The second problem is that many people in mental hospitals could be discharged if society had the facilities to care for them outside the confines of the hospital. Unofficial estimates put the number of such patients in some areas as high as 30 per cent. To reduce the number in care by 30 per cent in e.g. the South West would contribute substantially to improving the quality of care for those remaining in the hospitals [8]. But to discharge such a large percentage would put a significant burden on the local authorities. For the local authorities to meet this problem more resources would have to be found from the taxpayer. The problems then are complex. The critical need is to define the objectives of the psychiatric services and then attempt to meet these objectives. At present the psychiatric services are a confused jungle of inequality and relative inefficiency due to society’s failure to look at the problem as a whole, define its objectives and then take measures to obtain the objectives. It is possible that the problems cannot be solved but they can be alleviated by lucid thinking and adventurous policy making. REFERENCES 1. See for example
(a) FORSYTH,and LOGAN, R. F. L. The Demund for Medical Cure, NutBeld Prov. Hospital Trust 1960. (b) FIZLD~ZIN,M. S. Hospital Bed Scarcity: An Analysis of the Effects of Inter-Regional Differences, Economica 1965. (c) COOPER,M. H. and CULYER,A. J. An Economic Assessment of Some Aspects of the N.H.S., in Health Services Financing, British Medical Association 1970. 2. FELDSTEIN,M. S. op. cit. 3. As it is for non-psychiatric hospital care-see COOPER, M. H. and CULYER,A. J. op. cit. Disparities in Expenditure and Costs (forthcoming). 4. The Local Health Services-Regional 5. As in most other services! e.g. The Report of the Farleigh Committee of Inquiry H.M.S.O. 7.4.71. 76: See the present author’s The Distribution of Health Resources for a further discussion of this point. 8. It might not, of course, reduce inequalities.
INEQUALITIES
IN PSYCHIATRIC CARE IN ENGLAND WALES
AND
ALAN MAYNARD Lecturer in Economics,
University of York
DURING the 1960’s several sets of writers analysed various aspects of the inequality of the distribution of health care facilities in England and Wales. However, they all appear to have used Hospital In-Patient Enquiry (hereinafter H.I.P.E.) data which pertained to a one in ten sample of patients discharged from non-psychiatric hospitals in England and Wales. [l] This paper is concerned with regional inequalities in the provision of psychiatric hospitals in England and Wales. Section 1 deals with the inequality in the number of beds available in 1967. Section 2 deals with inequalities in the quality of care in 1969 using Ministry data. The disparity in dates for the data is due to the differing speeds with which various types of data about the hospital services is made available. Section 3 looks at the evidence about the distribution of local authority mental health activities. Finally Section 4 offers some conclusions.
1. The provision of beds Table 1 lists the relevant data about the provision of psychiatric beds in England and Wales. TABLE 1. THE PROVISION OF PSYCHIATRIC BEDS IN
Region
Newcastle Leeds Sheffield Past Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Wessex Oxford South-Western Wales Birmingham Manchester Liverpool
Beds available
11,718 14,150 14,505 6484 16,846 11,779 13,573 26,190 8025 5881 15,849 10,762 18,955 16,939 9271
ENGLAND AND
WALES1967
Beds available per 1000 population
Beds Used
Bed Utilization*
3.802 4.419 3.153 3.845 3.889 3.594 3.989 7.796 4.117 3.166 5.184 3.972 3.740 3.717 4.120
10,835 12,631 13,199 5851 15,194 10,422 12,087 23,456 7390 5062 14,268 9863 17,297 15,524 8902
9346 89.26 93.27 9023 90.19 88.47 89.05 89.56 91.83 86.07 90.02 9164 91.25 9164 96.01
Source: Hospital Return (SH3) for the year ended 31.12.1967. Combined Regional Summary-RHB Hospitals and Teaching Hospitals. Beds used * Red utilization = x 100. Beds available 221
222
ALAN MAYNARD
From this table it is obvious that there are substantial regional inequalities in the number of psychiatric hospital beds available per 1000 population. In 1967 the range of variation for all the regions was from 3.153 beds per 1000 population in the Sheffield Region to 7.796 beds per 1000 population in the South-West Metropolitan Region-a range of 147 per cent. If we exclude the Metropolitan Regions the range is reduced to 64 per cent i.e. Sheffield (3.153) and South-West with 5.184 beds per 1000 population. The mean for beds available in 1967 in England and Wales was 4.166. In Feldstein’s study [2] of the non-psychiatric sector a significant relationship was noted between the number of beds available per 1000 population and the utilization of the bed stock in the Region. He noted that the least well endowed region, Sheffield, tended to use its bedstock less intensively than better endowed regions such as Liverpool in 1960. No such relationship seemed to exist in the psychiatric sector in 1967. A correlation analysis for the 15 regions between beds available per 1000 population and bed utilisation resulted in an insignificant correlation coefficient of -0.147. A similar analysis for the non-Metropolitan Regions gave a correlation coefficient of +0*043-again insignificant. Thus there appears to be no general relationship in the psychiatric sector between beds available per 1000 population and beds utilised in 1967. 2. The quality ofpsychiatric care Quality is a difficult concept to evaluate in any activity. In this section we look at some proxies of quality and whilst knowing their limitations, offer them as indicators of regional inequalities in the quality of psychiatric hospital care in England and Wales. (a) Mental Illness Hospitals-the quality of care in 1969. Table 2 lists six types of labour TABLE 2. LABOUR INPUTS--MENTALILLNESSHOSPITALS IN ENGLAND AND WALES 1969
Region Newcastle Leeds Sheffield East Anglian North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South-Western Wales Birmingham Manchester Liverpool Wessex England and Wales average Standard Deviation Coefficient of variation
Consultants in psychiatry
Psychologists
0.66 0.53
0.17 0.20 0.19 0.14 058 0.26 0.16 0.26 0.30 0.11 0.29 0.16 0.28 0.29 0.17 0.24 0.113 47%
0.79
0.52 0.60 0.53 0.52 0.49 1.05 044 0.73 0.62 0.53 0.53 0.53 060 0.154 26%
Instructors
0.04 0.11 0.12 0.23 0.10 0.17 0.09 0.25 0.17 0.17 0.19 0.19 0.07 0.15 0.063 42%
All Nurses
Social workers
Ward orderlies and domestics
31.6 33.6 346 27.6 29.5 30.3 32.2 28.1 39.3 32.3 33.3 31.1 31.1 31.3 32.3 31.8 2.807 9%
0.50 0.27 0.30 0.25 0.76 0.62 044 0.28 0.74 0.38 044 0.33 0.28 0.30 0.46 0.42 0.168 40%
6.8 5.0 64 3.2 4.5 5.4 5.1 45 6.5 4.8 4.7 7.3 6.4 5.6 1.153 20%
Source: “The Facilities and Services of Psychiatric Hospitals in England and Wales 1969”, Department Health and Social Security Statistical Report Series No. 10. H.M.S.O. 1970. All data is staff per 100 residents in RHB hospitals.
of
Inequalities in Psychiatric Care in England and Wales
223
input in psychiatric hospitals: consultants in psychiatry, psychologists, instructors, all nurses, social workers and ward orderlies and domestics. The range of variation between the least well-endowed and the best endowed areas are quite substantial. (i) For consultants in psychiatry the range including (excluding) the Metropolitan Regions was 044 (044) in the South-West to l-05 (1.05) in the Oxford Region i.e. 138 per cent. (ii) For psychologists the range including (excluding) the Metropolitan Regions was 0.11 (0.11) in the South-West to O-58 (O-30) in the N.W. Metropolitan Region (Oxford Region) i.e. 427 per cent (172 per cent). (iii) For instructors the range including (excluding) the Metropolitan Region was O-04 (O-04) in the Newcastle Region to 0.25 (O-25) in the South-West Region i.e. 525 per cent. (iv) For all nurses (i.e. both qualified and unqualified) the range including (excluding) the Metropolitan Regions was 27.6 (27.6) in East Anglia to 39.3 (39.3) in Oxford i.e. 42 per cent. (v) For social workers the range including (excluding) the Metropolitan areas was O-25 (O-25) in East Anglia to O-76 (0.74) in the N.W. Metropolitan Region (Oxford Region). i.e. 204 per cent (196 per cent). (vi) For social workers, ward orderlies and domestics the range including (excluding) the Metropolitan areas was 3-2 (3.2) in the East Anglian Region to 7.3 (7.3) in the Liverpool Region, i.e. 128 per cent. These measures of variation are crude. An alternative in the form of the coefficient of variation is shown in the bottom line of Table 2. This relative measure shows that the variation is greatest amongst psychologists, instructors and social workers, i.e. it substantiates the previous measures. Thus in the mental illness hospitals of England and Wales there are substantial variations in labour input which must affect the quality of hospital care. Two extreme cases stand out on these indices. Firstly, East Anglia is poorly endowed ranking lowest on categories 4, 5 and 6, third lowest on category 1 and second lowest oncategory2,with no dataon instructors. Oxford, on the other hand, is generally well endowed [3] being best endowed in categories 1 and 4 and second best endowed in 2,5 and 6. Again there was no data about instructors. A substantial number of correlation calculations were carried out on this data and the results are shown in Table 3. A plausible hypothesis about the quality of care might be that regions that were badly endowed with one labour input might be compensated with a larger supply of another labour input i.e. there might be an inverse relationship between one input and another between the regions. The correlation matrix gives us substantial grounds for refuting this hypothesis. All the negative coefficients are insignificant. The few correlations which are significant seem to indicate that there is a positive relationship between the relevant variables e.g. the correlation coefficient of consultants and nurses is O-78 which indicates that those areas which are well endowed with consultants are also well endowed with nurses. Our conclusion about mental illness hospitals is that there are substantial inequalities and that there is no evidence to show that regions that are badly endowed in one sphere are compensated by better endowments in other spheres. (b) Hospitals for the mentally handicapped-the quality of care in 1969. Table 4 lists the same six categories of labour input that were dealt with in the previous sub-section. The ranges of variation between the worst endowed and the best endowed regions are again substantial. (i) For consultants in psychiatry the range including (excluding) the Metropolitan areas was O-11 (O-11) in the South-West to O-49 (O-49) in East Anglia i.e. 345 per cent.
224
ALAN MAYNARD
TABLE 3. Correlation
Consultants Psychologists Instructors Nurses Social workers Ward orderlies and domestics
(1) (2) (3) (4) (5) (6)
Matrix-Mental
(1)
(2)
-
0.21 -
Illness Hospitals in England and Wales 1969 (3)
-0.20 0.33 -
(4) 0.78 -0.06 -0.03 -
(s) 0.49 0.59 0.07 0.33 -
(6) 0.45 - 0.06 - 0.18 0.66 0.26 -
(ii) For psychologists the range including (excluding) the Metropolitan areas was O*Ol (O-01) in Sheffield to 0.23 (O-23) in the South-West Metropolitan and Oxford Regions i.e. 2300 per cent. (iii) For instructors the range including (excluding) the Metropolitan areas was 044 (044) in the Liverpool Region to 1.82 (1.52) in the South-West Metropolitan Region (Newcastle Region) i.e. 313 per cent (245 per cent). (iv) For nurses the range including (excluding) the Metropolitan areas was 23.16 (23.29) in the South-East Metropolitan Region (Birmingham Region) to 41~51(41~51)in the Liverpool Region, i.e. 79 per cent (78 per cent). (v) For social workers the range including (excluding) the Metropolitan areas was 0.04 (0.04) in East Anglia to 0.39 (O-39) in the Oxford Region i.e. 875 per cent. (vi) For ward orderlies and domestics the range including (excluding) the Metropolitan areas was 3.28 (3.28) in Newcastle to 9.43 (9.43) in Liverpool i.e. 187 per cent. Once again the variation ranges are substantial with category (ii) showing the greatest variation for any input in the psychiatric hospital service. As with the mental illness data further calculations have been carried out on the mentally handicapped data. The final line of Table 4 shows the coefficient of variation. This measure is greatest for psychologists and social workers and thus substantiate our conclusion that the greatest variations are present in these input categories. We repeated the exercise done on the mental illness data to produce Table 5, a correlation matrix for hospitals for the mentally handicapped in England and Wales in 1969. This table shows little evidence to support the hypothesis that areas badly endowed with one input are compensated with good endowments of other inputs. Few of the correlation coefficients are significant. The most significant value was obtained for a correlation of nurses and ward orderlies (O-71) which seems to indicate that those areas which are well endowed with nurses are well endowed with orderlies-the Liverpool Region is the extreme example of this. Our conclusions about the hospital’s facilities for the mentally handicapped is that they are unequally distributed amongst the regions and that there is little evidence to suggest that the poorly endowed regions are compensated in any way. 3. Local authority activities Psychiatric care outside the hospital system was the preserve of the Local Authorities in 1969. This section looks at two aspects of such care. Firstly we look at expenditure per 1000 population on training centres and secondly we look at the cost per attendance at such
Inequalities in Psychiatric Care in England and Wales
225
TABLE 4. LABOURMPUTS-HOSPITALS FOR THE MENTALLY HANDICAPPED IN ENGLANDAND Wm
Region
Consultants in psychiatry
Newcastle Leeds Sheffield East Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South-Western Wales Birmingham Manchester Liverpool wessex England and Wales average Standard Deviation CoetBcient of variation
0.29 @22 0.24 o-49 0.17 0.27 0.19 0.20 0.38 0.11 0.22 0.32 O-15 0.29 0.19 0.25 0.096 36%
Psychologists
0.09 0.03 0.01 @20 o-14 0.14 005 0.23 0.23 0.05 0.08 0.10 0.08 0.11 o-073 64%
Instructors and teachers 1.52 l-18 0.77 0.63 0.89 0.88 0.72 1.82 l-09 1.41 l-06 1.48 l-10 044 1.85 l-12 0.423 37%
All nurses
Social workers
29.06 24.23 26.86 2664 24.26 25.83 23.16 25.11 30.91 23.82 28.90 23.29 26.15 41.51 25.97 27.04 4.58 17%
0.11 0.08 0.04 o-07 0.14 005 0.21 0.39 0.07 O-09 0.16 0.05 0.11 0.12 @094 75%
1969
Ward orderlies and domestics 3.28 4.96 4.81 3.94 4.87 3.38 3.74 6.14 4.03 4.22 7.16 3.83 4.10 9.43 3.91 4.79 1.65 34%
Source: “The Facilities and Services of Psychiatric Hospitals in England and Wales 1969”, Department Health and Social Security Statistical Report Series No. 10. H.M.S.O. 1970. All data is staff per 100 residents in RHB hospitals.
of
TABLE 5. Correlation
Consultants Psychologists Instructors Nurses Social Workers Ward orderlies and domestics
(1) ::; (4) (5) (6)
matrix-mentally
(1)
(2)
-
0.52 -
handicapped Wales 1969 (31
-0.32 0.16 -
(4) 0.32 0.33 -0.41 -
hospitals in England and
(5) 0.33 0.64 0.27 0.52 -
(61 -0.07 0.03 -0.29 0.71 0.01 -
training centres. The data is for 1969, and will be dealt with again with other local health services in a forthcoming paper [4]. Table 6 enumerates the variations in expenditure per 1000 population on local authority mental health training centres in the year 1968-69. The largest variation in expenditure is to be found in the county boroughs (496 per cent), followed by the Welsh counties (250 per cent), the English counties (211 per cent) and the London Boroughs (73 per cent). There is no ready explanation of these variations but they further substantiate the view that there are significant regional disparities in the quantity and quality of mental care available in England and Wales.
226
ALAN MAYNARD TABLE 6. EXPENDITURE* ON LOYAL AUTHORITY TRAINING CENTRES (MENTAL HEALTH)
(a) County boroughs
(b) London boroughs
(c) English counties
(d) Welsh counties
Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation
E264.45 E85.55 E510-55 496 % E215.60 E88-65 f37360 73% E258.45 f130.00 f405.20 211% E285.10 E132.55 E464.85 250%
(Hastings) (Boone) (Westminster) (Barking) (Suffolk East) (Sussex East) (Radnor) (Angelsey)
Source: “Local Health Service Statistics 1968-69.” Institute of Municipal Treasurers and Accountants 1970. * Expenditure per 1000 population.
It is interesting to note the relative “efficiency” of the authorities in providing these mental health training places. Table 7 indicates that once again there are regional variations with the county boroughs having the greatest variation (326 per cent) and the Welsh counties the least variation and on average the highest costs [5].
TABLE 7. MENTALHEALTHTRAININGCE
(a) County boroughs
(b) London boroughs
(c) English counties
(d) Welsh counties
-osTPERA'ITENDANCE
Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation Average Lowest Highest % Variation
El.47 D65 E2.77 326 % El.73 El.07 f3-27 205% El-71 El-12 E3.15 181% D-02 El.46
(Leeds) (Merthyr Tydfll) (Baling) (Sutton) (Northampton) (Rutland*) (Montgomery)
Source: “Local Health Service Statistics 1968-69.” Institute of Municipal Treasurers and Accountants 1970. l After Rutland, the highest was Westmorland at E2-55.
Inequalities in Psychiatric Care in England and Wales
227
4. Some conclusions This paper has analysed various facets of psychiatric care in England and Wales and found evidence of substantial regional variations in the quantity and quality of care available. This section attempts to point out the relevance of these findings for policy. I$ ently there has been considerable criticism of our system d mental health care [6] and Y t ere is some reason to view the psychiatric sector of the hospital service as “a forgotten land”. This “forgetfulness” is no doubt caused by factors such as the “unspectacular” aspects of such medicine (compared with e.g. transplants) and the feeling that to talk of such things is not pleasant and should be avoided (a hangover from previous generations). The problems facing the policy makers are two-fold. Firstly given the acceptance of an objective of equality, efforts will have to be made to reduce the inequalities of the present system. To do this will require considerable resources, which, given the nature of the problem, cannot be obtained by a “market solution” and thus will have to be met by the taxpayer [7]. The second problem is that many people in mental hospitals could be discharged if society had the facilities to care for them outside the confines of the hospital. Unofficial estimates put the number of such patients in some areas as high as 30 per cent. To reduce the number in care by 30 per cent in e.g. the South West would contribute substantially to improving the quality of care for those remaining in the hospitals [8]. But to discharge such a large percentage would put a significant burden on the local authorities. For the local authorities to meet this problem more resources would have to be found from the taxpayer. The problems then are complex. The critical need is to define the objectives of the psychiatric services and then attempt to meet these objectives. At present the psychiatric services are a confused jungle of inequality and relative inefficiency due to society’s failure to look at the problem as a whole, define its objectives and then take measures to obtain the objectives. It is possible that the problems cannot be solved but they can be alleviated by lucid thinking and adventurous policy making. REFERENCES 1. See for example
(a) FORSYTH,and LOGAN, R. F. L. The Demund for Medical Cure, NutBeld Prov. Hospital Trust 1960. (b) FIZLD~ZIN,M. S. Hospital Bed Scarcity: An Analysis of the Effects of Inter-Regional Differences, Economica 1965. (c) COOPER,M. H. and CULYER,A. J. An Economic Assessment of Some Aspects of the N.H.S., in Health Services Financing, British Medical Association 1970. 2. FELDSTEIN,M. S. op. cit. 3. As it is for non-psychiatric hospital care-see COOPER, M. H. and CULYER,A. J. op. cit. Disparities in Expenditure and Costs (forthcoming). 4. The Local Health Services-Regional 5. As in most other services! e.g. The Report of the Farleigh Committee of Inquiry H.M.S.O. 7.4.71. 76: See the present author’s The Distribution of Health Resources for a further discussion of this point. 8. It might not, of course, reduce inequalities.