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PSYCHIATRIC UNITS IN GENERAL HOSPITALS
684
Special
Articles
PSYCHIATRIC UNITS IN GENERAL HOSPITALS C. P. B. BROOK M.B. Lond., D.P.M. CONSULTANT
PSYCHIATRIST,
WARLEY
HOSPITAL,
BRENTWOOD
THE first psychiatric unit in a general hospital came into being because Thomas Guy made specific provision for 20 incurable lunatics in his hospital. It existed at Guy’s from the late 1720s to 1861, regrettably contributing nothing to the advancement of psychiatry, and it remained an isolated example until, in the years before the late war, the Middlesex Hospital became associated with St. Luke’s, and the York Clinic was founded at Guy’s Hospital. 12 But these two units treated only a small unrepresentative group of mentally ill patients, and it was not until after the war that the psychiatric units of general hospitals became well established. Usually they developed from an observation ward.3-6 In 1959 the Ministry of Health expressed the hope that the psychiatric services in general hospitals would increase, and the recommendations in the Hospital Plan bear this out. In the North East Metropolitan Region, for example, by 1975 the three existing general-hospital units will have become ten, with 900 beds. Almost a quarter of the psychiatric beds in the region will be in general hospitals. THE CASE FOR
The Ministry rejects the idea of planning more large isolated hospitalsbecause geographical isolation cuts patients off from social contacts, makes their rehabilitation difficult, discourages them from seeking early help, hinders cooperation with the community health services, and makes staff recruitment more precarious. In the past it has also aggravated the professional isolation of the psychiatrist and has emphasised the cleavage between psychiatry and the rest of medicine. In particular, there was little contact between those working in teaching hospitals and those working in mental hospitals. As a result psychiatry was neglected in the curriculum, and for lack of precise teaching a doctor outside psychiatry was seldom experienced in the diagnosis and treatment of mental diseases, and their seriousness was not always
recognised. The general-hospital unit would avoid many of these drawbacks. Patients would escape the stigma which still (though less than formerly) attaches to a mental hospital. They would also benefit from the atmosphere of therapeutic optimism, while continuity of care, day-hospital treatment, special investigation, and the treatment of concurrent physical illnesses would all be easier to arrange. THE CASE AGAINST
But this view of the disadvantages of the mental hospital and the superiority of general-hospital units has been
challenged. Because of the 1. 2.
3. 4. 5. 6. 7.
special
needs of
psychiatric patients,
Cameron, H. C. Mr. Guy’s Hospital. London, 1954. Hunter, R. A., Macalpine, I. Three Hundred Years of Oxford, 1963. Capoor, H. S., Nixon, J. W. G. Lancet, 1961, ii, 1351. Cohen, N. A., Haldane, F. P. ibid. 1962, i, 1113. Freeman, H. L. ibid. 1960, i, 218. Little, J. C. ibid. 1963, ii, 1159. Ministry of Health Hospital Building Note No. 30. H.M. Office, 1963.
Psychiatry.
Stationery
Pilkington8 would like to have only small psychiatric units in general hospitals, primarily for teaching. Barton9 conjures up a picture of lay administrators using the psychiatrist’s alleged readiness to disagree with his colleagues to dictate policy; of committees depriving the psychiatric unit of money; of staff morale being less easily maintained than in the mental hospitals. He claims that research and progress will suffer. He points to the difficulty of teaching general-trained nurses to deal with psychiatric patients, and the increased number of nurses and doctors required. Kathleen Jones 10 11 wonders whether general-hospital units, unlike the mental hospital, may not refuse to admit patients for social reasons. Keeping patients in the community may cause unwarrantable distress to the rest of the family, especially to children. Early discharge may increase (or seem to increase) violent crimes, thus leading to a public reaction. The dispersal of limited resources will increase costs and reduce efficiency. Like Barton, she fears that psychiatric units in general hospitals will suffer from competition for beds by other specialties. She is apprehensive about the increasing importance of lay administration, and fears that the administrative arrangements of a general hospital will make it difficult for a psychiatric unit to achieve the degree of autonomy which it must have if it is to run efficiently. Rehin and Martin,12 in a fair review of these advantages and disadvantages, point out two real difficulties-the special needs of psychiatric patients, and the effect of the growing number of general-hospital units on the remaining mental hospitals. Many psychiatrists are apprehensive that the general-hospital units will cream off the curable and those capable of rehabilitation, leaving the chronic patients to the mental hospitals. Faced with competition for staff from the general-hospital units, these would tend to lapse once more into custodial institutions. These criticisms of general-hospital units fall into six groups: 1. Those which have little foundation in fact, such as the perils of lay administration, increased difficulties in recruiting nurses, and less research. 2. Those which foresee a public reaction against real or fancied criminal acts by ex-patients, and the occasional piece of antisocial activity by patients. This can be forestalled by educating the public. 3. Some mental hospitals have given a non-specific therapy by providing a social milieu in the hospital.13 Jones 11 doubts whether this therapeutic community can be reproduced in a general-hospital unit. Mental hospitals should (although not all do) provide halls, playing-fields, libraries, occupational and social therapy departments, and industrial therapy units. In a general-hospital unit, these should also be provided, and they will make heavy demands on precious space. There is a changing pattern of needs, some of which are now relatively oversupplied in the mental hospital, which suggest that plans for a unit should not be too rigid and should be easily modified. 4. Changes brought about by the increasing number of general-hospital units need further investigation and research -e.g., the effect of community care on the family. One pilot study showed that families were given more relief by a hospitalcentred service than by a community-care service. But families whose burdens were heavy were equally relieved by both. 14 8. 9. 10. 11. 12. 13. 14.
Pilkington, F. Lancet, 1961, i, 828. Barton, R. in Trends in the Mental Health Services. Oxford, 1963. Jones, K., Sidebotham, R. Mental Hospitals at Work. London, 1962. Jones, K. in Trends in the Mental Health Services. Rehin, G. F., Martin, F. M. Planning (P.E.P.), 1963, 29, no. 468. Clarke, D. H. in Trends in the Mental Health Service. Grad, J., Sainsbury, P. Lancet, 1963, i, 544.
685 5. It will be less economical to treat patients in generalhospital units. If the units are to succeed, and if long-term patients are to be properly looked after, more money must be found, and more staff recruited. The shortage of doctors is already becoming critical. 6. Account must be taken of regional differences, geographical and demographical, and of existing services. WHAT SORT OF GENERAL-HOSPITAL
UNIT ?>
Because of local variations, different types of generalhospital units will be needed. I would suggest that six
different patterns could emerge. 1. No
Units
Psychiatric
In areas, such
as Croydon and York, where there already community psychiatric service based on a mental hospital, a general-hospital unit would be unnecessary and
is
a
wasteful. 2.
Psychiatric
Beds in General Wards
Such a scheme, which is still operating, was described three years ago by myself and Stafford-Clark. 15 We pictured these units as an interim measure, but the arrangement could be permanently available at general hospitals which are not going to have psychiatric units. The beds could be used for investigating outpatients or for giving a short course of electroconvulsion therapy. 3.
Teaching-hospital Units
In 1963 the psychological medicine committee of the Royal College of Physicians of London recommended that all teaching hospitals should have an inpatient unit of 80 beds within the curtilage of the hospital. These units would, of course, not care for any long-stay, or even
medium-stay, patients. 4.
General-hospital
Unit with
Parent Mental
Hospital short-stay and medium-stay patients. Long-stay patients would be transferred to the parent mental hospital, and could thus a
This type of unit3 could deal with
remain under the care of the same consultant. The two hospitals would interchange medical and nursing staff. This unit would almost certainly be the commonest type. 60 beds (35 female, 25 male) and 20-30 day patients would be a minimum desirable size, assuming that a separate geriatric unit would deal with most elderly patients. For a 60-bed unit I would tentatively suggest the following arrangements: Medical
staff.-1 half-time consultant, 1 full-time senior registrars, and 2 senior house-officers, with the half-timers spending the rest of their sessions at the parent mental hospital. This may seem an overgenerous staffing, but the doctors will have outpatient clinics to run, and patients in the general wards, and will have to cope with emergencies. Nursing staff.-1 assistant matron, 7 trained nurses, 8 pupil nurses from the mental hospital, 6 pupil nurses from the general hospital, 6 assistant nurses, and 4 part-time nurses for the day-hospital unit. Ancillary staff.-1 psychiatric social worker, and I seconded from the local authority, 1 full-time and 1 or 2 part-time occupational therapists. An artisan (a carpenter or metal worker) would be in charge of the industrial therapy unit under the supervision of the mental hospital’s industrial therapy officer. Psychological assessments would be made by one of the parent hospital’s psychologists. registrar,
2 half-time
Facilities.-A comprehensive rehabilitation unit, on which day patients could be based, and which could also be used by patients from the general wards. This unit could be housed in prefabricated buildings (for the sake of cost and flexibility). It 15.
Brook, C.
P.
B., Stafford-Clark, D. ibid. 1961, i, 1159.
would have a shop, a canteen, and cafeteria, occupational and industrial therapy workshops (including a patients’ kitchen), and a small recreation hall. Selection of patients.-If the general hospital is unable to admit all patients, then priority should be given to patients most likely to benefit from being in a general unit-e.g., those with psychosomatic disorders and concurrent physical illnesses, those requiring special investigation, and those transferred from the other wards (particularly those with confusional states and puerperal psychoses). There should be a small intensivetreatment unit for attempted suicides. The next degree of priority should be given to patients who live near the unit (who will be more easily discharged early to continue on a day basis) and those who refuse inpatient treatment in a mental hospital. 5. A
Psychiatric Service
Centred
on
the General
Hospital
Littlehas proposed that the psychiatric team should be centred on the general hospital, giving most of its time to acute patients, rather less time to the middle-stay patients conveniently housed nearby, and still less time to the true chronic " unrecoverables ". The middle-stay unit would include an industrial-therapy organisation and a day centre for long-term patients. The mental hospital would be at the periphery, " providing frankly custodial care for 500 patients ", and would be staffed by a resident doctor of clinical assistant grade and general practitioners, while the main psychiatric team would make visits. This scheme would focus attention and care on patients most likely to benefit, and would bring back medium-stay patients into the town, easing their resettlement in the community. Its day hospital would allow some chronic patients to be discharged from the mental hospital. Timewasting journeys by doctors between mental hospital and general hospital would be greatly reduced. But the scheme has dangers. The mental hospital would become an institution, and those going into it would be regarded as beyond hope. This might engender an attitude of therapeutic despair, and nurse recruitment would be difficult. Custodial care, where necessary, should be provided in small units and not in 500-bed institutions housed in converted mental hospitals. The unit with a parent mental hospital seems a more promising
pattern. 6.
General-hospital Unit accepting all Types of Patients
Admittedly this unit would face additional problems, particularly those imposed by a large number of patients with varied needs. The unit must have a rehabilitation unit (offering occupational, social, and industrial therapy). The local authority must have adequate services for the elderly, and, except where admission was needed on psychiatric grounds, elderly patients should be cared for in a geriatric unit under the charge of a geriatrician. Indeed, this type of unit could exist only in a district hospital or in b a balanced hospital community. FURTHER PROBLEMS
The formation of these units will raise many the
questions.
Adrrainistration.-Blending psychiatric unit into a general will but to evade them by difficulties; many hospital present setting up, as Cohen and Haldane suggest,4 an autonomous unit, is to render nugatory many of the very reasons which brought the psychiatric unit into existence. Nursing staff.-Should there by a permanent staff of nurses for the psychiatric unit, with a possibility of student general nurses being temporarily attached ? Whatever advantages this system may have, there will be little chance for exchange of ideas between the general and psychiatric nurses, and pro-
686
psychiatric units will release beds in the mental hospitals for
fessional isolation might cause mutual suspicion. One solution would be a permanent nucleus of senior nurses, with junior nurses drawn from the parent mental hospital, and student general nurses seconded to the unit for three months. This system has worked well at the York Clinic of Guy’s Hospital. I would suggest that the senior nursing officer of the unit should be of assistant-matron rank, and should be jointly appointed by the general hospital and parent mental hospital, but answerable to the matron of the general hospital only. At least one of the senior tutors in the school should be mentally trained.
other purposes. When this time does come, it may be worth examining the possibility of the mental hospital acting as a rehabilitation centre for all types of medium-stay and long-stay patients. For geographical and structural reasons the numbers of suitable hospitals will be small.
The more general-hospital units there are, the greater will be the demands on them. Are the numbers of beds in these units going to be adequate ? This is only one example of the changing patterns of needs that must, if possible, be anticipated by research. Research, too, will be needed to assess the effect of the psychiatric units on the general hospital, on the mental hospital, on the course of the patients treated in psychiatric units, and on the families of these patients. Will, for example, the findings of Grad and Sainsbury 14 hold on a national scale, or will regional variations throw up different patterns of response ? A flexible approach will be needed to respond to the new needs that new units will expose and even create.
Special types of patients.-I believe it is possible for the large comprehensive unit to make provision for psychopaths, but the special needs (and special problems) of psychopaths and security patients make their admission to a general hospital undesirable.
’
Role of the parent mental hospital.-How can the mental hospital be prevented from reverting to a custodial institution ? By acting (I would suggest) as parent to a general-hospital unit, sending out in rotation its medical, nursing, and ancillary staff, and providing special facilities for medium-stay and long-stay patients. It will be some years before general-hospital
qualify for a grant, proposals must be approved by the appropriate Health Department. Examples of what is in mind are: (i) additional rooms for consultation, ancillary help, examination, storage, &c.; (ii) enlargement of existing roomsfor similar purposes; (iii) division of existing rooms to make more, but smaller
EXPENDITURE ON N.H.S. PRACTICE PREMISES The Minister’s Letter A LETTER from Mr. Anthony Barber, Minister of Health, Dr. James Cameron, chairman of the General Medical Services Committee, sets out the conclusions which have emerged from discussions on general practitioners’ expenditure on their practice premises. Mr. Barber to
units available; of toilet, wash basin, water supply, heating, installation (iv) lighting, ventilation, &c. " The work must be a genuine improvement of what exists, not the provision of new premises whether by new building or rebuilding. Acquisition of land will not qualify. Grant will be one-third of the approved cost. It would be necessary to make the following general conditions: (1) Minor improvements costing less than, say, E100 will not qualify, nor repairs and maintenance expenditure accepted as such for tax purposes; nor moveable
says: " There are two separate elements in this expenditurefirst, the money the doctor has to find to build or buy practice premises and, secondly, the running expenses, including interest on any loans raised for building or purchase. We are agreed that the latter cost ought to be reflected in remuneration, but we differ as to whether current net remuneration as recommended by the Review Body includes a return on the capital the doctor has invested in the practice. I am sure that the best course is the one which you have adopted of putting the matter to the Review Body, but we are agreed that fairer distribution is anyway desirable and we are engaged on the factual enquiries necessary to establish the basis for a scheme for this purpose. " As regards initial provision of premises, I have explained that I think that the extension of interest-free loans would be unfair as between the doctor who incurs capital expenditure in the future and the doctor who has incurred it in the past, and I consider that they should be confined to those fields in which it is desired to encourage one form of practice rather than another (cf. group practice loans). For the Exchequer to take over capital liabilities generally would raise far-reaching questions relating to the method of provision of general medical services, but there are of course already arrangements whereby doctors can work in publicly-owned premises, paying a suitable rent. We are agreed that there may be scope for greater use of such arrangements and we are looking further into the statutory powers of the various public authorities who might provide premises in this way and the question whether any extension of these powers is required. " However, I see no reason why Exchequer grants should not be made for the improvement of premises and we have agreed the following main principles of a scheme for this purpose: Basis of Scheme for Improvement Grants Grants for the improvement of practice premises will be available to doctors providing unrestricted general medical services with National Health Service lists (average lists if in partnership) of 500 or more (350 or more in rural areas). To "
equipment. (2) The improvements must be for the purpose of National Health Service practice. (3) There must be reasonable security of tenure and some safeguard to prevent grants being used for improvements designed to enable the owners of the premises to sell them at a higher price. (4) The project must be reasonable in relation to the circumstances of the practice and the existing state of the building. " We shall proceed to fill in the details of a scheme on these lines. This is bound to take a little time but we are getting on with it as rapidly as we can. There remains the problem of the raising of capital. In the ordinary way, doctors should be able to get the capital they need from ordinary commercial sources, but there may be the odd case in which the security offered is unattractive to the ordinary lender for reasons which carry less weight with the ’
"
Government, and in which it would therefore be reasonable for the Government to guarantee a loan. Examples of the sort of cases we have in mind are: (a) purpose-built surgeries which have no other practical use;
,
(b) improvements to practice premises, not excluding those qualifying for the new grants; the (c) purchase of shares in partnership premises. We would not of course guarantee loans which were beyond the likely resources of the borrower to repay, and enquiries into credit worthiness would be necessary. The machinery for this, and the other details of a scheme for Exchequer guarantees,
Special
Articles
PSYCHIATRIC UNITS IN GENERAL HOSPITALS C. P. B. BROOK M.B. Lond., D.P.M. CONSULTANT
PSYCHIATRIST,
WARLEY
HOSPITAL,
BRENTWOOD
THE first psychiatric unit in a general hospital came into being because Thomas Guy made specific provision for 20 incurable lunatics in his hospital. It existed at Guy’s from the late 1720s to 1861, regrettably contributing nothing to the advancement of psychiatry, and it remained an isolated example until, in the years before the late war, the Middlesex Hospital became associated with St. Luke’s, and the York Clinic was founded at Guy’s Hospital. 12 But these two units treated only a small unrepresentative group of mentally ill patients, and it was not until after the war that the psychiatric units of general hospitals became well established. Usually they developed from an observation ward.3-6 In 1959 the Ministry of Health expressed the hope that the psychiatric services in general hospitals would increase, and the recommendations in the Hospital Plan bear this out. In the North East Metropolitan Region, for example, by 1975 the three existing general-hospital units will have become ten, with 900 beds. Almost a quarter of the psychiatric beds in the region will be in general hospitals. THE CASE FOR
The Ministry rejects the idea of planning more large isolated hospitalsbecause geographical isolation cuts patients off from social contacts, makes their rehabilitation difficult, discourages them from seeking early help, hinders cooperation with the community health services, and makes staff recruitment more precarious. In the past it has also aggravated the professional isolation of the psychiatrist and has emphasised the cleavage between psychiatry and the rest of medicine. In particular, there was little contact between those working in teaching hospitals and those working in mental hospitals. As a result psychiatry was neglected in the curriculum, and for lack of precise teaching a doctor outside psychiatry was seldom experienced in the diagnosis and treatment of mental diseases, and their seriousness was not always
recognised. The general-hospital unit would avoid many of these drawbacks. Patients would escape the stigma which still (though less than formerly) attaches to a mental hospital. They would also benefit from the atmosphere of therapeutic optimism, while continuity of care, day-hospital treatment, special investigation, and the treatment of concurrent physical illnesses would all be easier to arrange. THE CASE AGAINST
But this view of the disadvantages of the mental hospital and the superiority of general-hospital units has been
challenged. Because of the 1. 2.
3. 4. 5. 6. 7.
special
needs of
psychiatric patients,
Cameron, H. C. Mr. Guy’s Hospital. London, 1954. Hunter, R. A., Macalpine, I. Three Hundred Years of Oxford, 1963. Capoor, H. S., Nixon, J. W. G. Lancet, 1961, ii, 1351. Cohen, N. A., Haldane, F. P. ibid. 1962, i, 1113. Freeman, H. L. ibid. 1960, i, 218. Little, J. C. ibid. 1963, ii, 1159. Ministry of Health Hospital Building Note No. 30. H.M. Office, 1963.
Psychiatry.
Stationery
Pilkington8 would like to have only small psychiatric units in general hospitals, primarily for teaching. Barton9 conjures up a picture of lay administrators using the psychiatrist’s alleged readiness to disagree with his colleagues to dictate policy; of committees depriving the psychiatric unit of money; of staff morale being less easily maintained than in the mental hospitals. He claims that research and progress will suffer. He points to the difficulty of teaching general-trained nurses to deal with psychiatric patients, and the increased number of nurses and doctors required. Kathleen Jones 10 11 wonders whether general-hospital units, unlike the mental hospital, may not refuse to admit patients for social reasons. Keeping patients in the community may cause unwarrantable distress to the rest of the family, especially to children. Early discharge may increase (or seem to increase) violent crimes, thus leading to a public reaction. The dispersal of limited resources will increase costs and reduce efficiency. Like Barton, she fears that psychiatric units in general hospitals will suffer from competition for beds by other specialties. She is apprehensive about the increasing importance of lay administration, and fears that the administrative arrangements of a general hospital will make it difficult for a psychiatric unit to achieve the degree of autonomy which it must have if it is to run efficiently. Rehin and Martin,12 in a fair review of these advantages and disadvantages, point out two real difficulties-the special needs of psychiatric patients, and the effect of the growing number of general-hospital units on the remaining mental hospitals. Many psychiatrists are apprehensive that the general-hospital units will cream off the curable and those capable of rehabilitation, leaving the chronic patients to the mental hospitals. Faced with competition for staff from the general-hospital units, these would tend to lapse once more into custodial institutions. These criticisms of general-hospital units fall into six groups: 1. Those which have little foundation in fact, such as the perils of lay administration, increased difficulties in recruiting nurses, and less research. 2. Those which foresee a public reaction against real or fancied criminal acts by ex-patients, and the occasional piece of antisocial activity by patients. This can be forestalled by educating the public. 3. Some mental hospitals have given a non-specific therapy by providing a social milieu in the hospital.13 Jones 11 doubts whether this therapeutic community can be reproduced in a general-hospital unit. Mental hospitals should (although not all do) provide halls, playing-fields, libraries, occupational and social therapy departments, and industrial therapy units. In a general-hospital unit, these should also be provided, and they will make heavy demands on precious space. There is a changing pattern of needs, some of which are now relatively oversupplied in the mental hospital, which suggest that plans for a unit should not be too rigid and should be easily modified. 4. Changes brought about by the increasing number of general-hospital units need further investigation and research -e.g., the effect of community care on the family. One pilot study showed that families were given more relief by a hospitalcentred service than by a community-care service. But families whose burdens were heavy were equally relieved by both. 14 8. 9. 10. 11. 12. 13. 14.
Pilkington, F. Lancet, 1961, i, 828. Barton, R. in Trends in the Mental Health Services. Oxford, 1963. Jones, K., Sidebotham, R. Mental Hospitals at Work. London, 1962. Jones, K. in Trends in the Mental Health Services. Rehin, G. F., Martin, F. M. Planning (P.E.P.), 1963, 29, no. 468. Clarke, D. H. in Trends in the Mental Health Service. Grad, J., Sainsbury, P. Lancet, 1963, i, 544.
685 5. It will be less economical to treat patients in generalhospital units. If the units are to succeed, and if long-term patients are to be properly looked after, more money must be found, and more staff recruited. The shortage of doctors is already becoming critical. 6. Account must be taken of regional differences, geographical and demographical, and of existing services. WHAT SORT OF GENERAL-HOSPITAL
UNIT ?>
Because of local variations, different types of generalhospital units will be needed. I would suggest that six
different patterns could emerge. 1. No
Units
Psychiatric
In areas, such
as Croydon and York, where there already community psychiatric service based on a mental hospital, a general-hospital unit would be unnecessary and
is
a
wasteful. 2.
Psychiatric
Beds in General Wards
Such a scheme, which is still operating, was described three years ago by myself and Stafford-Clark. 15 We pictured these units as an interim measure, but the arrangement could be permanently available at general hospitals which are not going to have psychiatric units. The beds could be used for investigating outpatients or for giving a short course of electroconvulsion therapy. 3.
Teaching-hospital Units
In 1963 the psychological medicine committee of the Royal College of Physicians of London recommended that all teaching hospitals should have an inpatient unit of 80 beds within the curtilage of the hospital. These units would, of course, not care for any long-stay, or even
medium-stay, patients. 4.
General-hospital
Unit with
Parent Mental
Hospital short-stay and medium-stay patients. Long-stay patients would be transferred to the parent mental hospital, and could thus a
This type of unit3 could deal with
remain under the care of the same consultant. The two hospitals would interchange medical and nursing staff. This unit would almost certainly be the commonest type. 60 beds (35 female, 25 male) and 20-30 day patients would be a minimum desirable size, assuming that a separate geriatric unit would deal with most elderly patients. For a 60-bed unit I would tentatively suggest the following arrangements: Medical
staff.-1 half-time consultant, 1 full-time senior registrars, and 2 senior house-officers, with the half-timers spending the rest of their sessions at the parent mental hospital. This may seem an overgenerous staffing, but the doctors will have outpatient clinics to run, and patients in the general wards, and will have to cope with emergencies. Nursing staff.-1 assistant matron, 7 trained nurses, 8 pupil nurses from the mental hospital, 6 pupil nurses from the general hospital, 6 assistant nurses, and 4 part-time nurses for the day-hospital unit. Ancillary staff.-1 psychiatric social worker, and I seconded from the local authority, 1 full-time and 1 or 2 part-time occupational therapists. An artisan (a carpenter or metal worker) would be in charge of the industrial therapy unit under the supervision of the mental hospital’s industrial therapy officer. Psychological assessments would be made by one of the parent hospital’s psychologists. registrar,
2 half-time
Facilities.-A comprehensive rehabilitation unit, on which day patients could be based, and which could also be used by patients from the general wards. This unit could be housed in prefabricated buildings (for the sake of cost and flexibility). It 15.
Brook, C.
P.
B., Stafford-Clark, D. ibid. 1961, i, 1159.
would have a shop, a canteen, and cafeteria, occupational and industrial therapy workshops (including a patients’ kitchen), and a small recreation hall. Selection of patients.-If the general hospital is unable to admit all patients, then priority should be given to patients most likely to benefit from being in a general unit-e.g., those with psychosomatic disorders and concurrent physical illnesses, those requiring special investigation, and those transferred from the other wards (particularly those with confusional states and puerperal psychoses). There should be a small intensivetreatment unit for attempted suicides. The next degree of priority should be given to patients who live near the unit (who will be more easily discharged early to continue on a day basis) and those who refuse inpatient treatment in a mental hospital. 5. A
Psychiatric Service
Centred
on
the General
Hospital
Littlehas proposed that the psychiatric team should be centred on the general hospital, giving most of its time to acute patients, rather less time to the middle-stay patients conveniently housed nearby, and still less time to the true chronic " unrecoverables ". The middle-stay unit would include an industrial-therapy organisation and a day centre for long-term patients. The mental hospital would be at the periphery, " providing frankly custodial care for 500 patients ", and would be staffed by a resident doctor of clinical assistant grade and general practitioners, while the main psychiatric team would make visits. This scheme would focus attention and care on patients most likely to benefit, and would bring back medium-stay patients into the town, easing their resettlement in the community. Its day hospital would allow some chronic patients to be discharged from the mental hospital. Timewasting journeys by doctors between mental hospital and general hospital would be greatly reduced. But the scheme has dangers. The mental hospital would become an institution, and those going into it would be regarded as beyond hope. This might engender an attitude of therapeutic despair, and nurse recruitment would be difficult. Custodial care, where necessary, should be provided in small units and not in 500-bed institutions housed in converted mental hospitals. The unit with a parent mental hospital seems a more promising
pattern. 6.
General-hospital Unit accepting all Types of Patients
Admittedly this unit would face additional problems, particularly those imposed by a large number of patients with varied needs. The unit must have a rehabilitation unit (offering occupational, social, and industrial therapy). The local authority must have adequate services for the elderly, and, except where admission was needed on psychiatric grounds, elderly patients should be cared for in a geriatric unit under the charge of a geriatrician. Indeed, this type of unit could exist only in a district hospital or in b a balanced hospital community. FURTHER PROBLEMS
The formation of these units will raise many the
questions.
Adrrainistration.-Blending psychiatric unit into a general will but to evade them by difficulties; many hospital present setting up, as Cohen and Haldane suggest,4 an autonomous unit, is to render nugatory many of the very reasons which brought the psychiatric unit into existence. Nursing staff.-Should there by a permanent staff of nurses for the psychiatric unit, with a possibility of student general nurses being temporarily attached ? Whatever advantages this system may have, there will be little chance for exchange of ideas between the general and psychiatric nurses, and pro-
686
psychiatric units will release beds in the mental hospitals for
fessional isolation might cause mutual suspicion. One solution would be a permanent nucleus of senior nurses, with junior nurses drawn from the parent mental hospital, and student general nurses seconded to the unit for three months. This system has worked well at the York Clinic of Guy’s Hospital. I would suggest that the senior nursing officer of the unit should be of assistant-matron rank, and should be jointly appointed by the general hospital and parent mental hospital, but answerable to the matron of the general hospital only. At least one of the senior tutors in the school should be mentally trained.
other purposes. When this time does come, it may be worth examining the possibility of the mental hospital acting as a rehabilitation centre for all types of medium-stay and long-stay patients. For geographical and structural reasons the numbers of suitable hospitals will be small.
The more general-hospital units there are, the greater will be the demands on them. Are the numbers of beds in these units going to be adequate ? This is only one example of the changing patterns of needs that must, if possible, be anticipated by research. Research, too, will be needed to assess the effect of the psychiatric units on the general hospital, on the mental hospital, on the course of the patients treated in psychiatric units, and on the families of these patients. Will, for example, the findings of Grad and Sainsbury 14 hold on a national scale, or will regional variations throw up different patterns of response ? A flexible approach will be needed to respond to the new needs that new units will expose and even create.
Special types of patients.-I believe it is possible for the large comprehensive unit to make provision for psychopaths, but the special needs (and special problems) of psychopaths and security patients make their admission to a general hospital undesirable.
’
Role of the parent mental hospital.-How can the mental hospital be prevented from reverting to a custodial institution ? By acting (I would suggest) as parent to a general-hospital unit, sending out in rotation its medical, nursing, and ancillary staff, and providing special facilities for medium-stay and long-stay patients. It will be some years before general-hospital
qualify for a grant, proposals must be approved by the appropriate Health Department. Examples of what is in mind are: (i) additional rooms for consultation, ancillary help, examination, storage, &c.; (ii) enlargement of existing roomsfor similar purposes; (iii) division of existing rooms to make more, but smaller
EXPENDITURE ON N.H.S. PRACTICE PREMISES The Minister’s Letter A LETTER from Mr. Anthony Barber, Minister of Health, Dr. James Cameron, chairman of the General Medical Services Committee, sets out the conclusions which have emerged from discussions on general practitioners’ expenditure on their practice premises. Mr. Barber to
units available; of toilet, wash basin, water supply, heating, installation (iv) lighting, ventilation, &c. " The work must be a genuine improvement of what exists, not the provision of new premises whether by new building or rebuilding. Acquisition of land will not qualify. Grant will be one-third of the approved cost. It would be necessary to make the following general conditions: (1) Minor improvements costing less than, say, E100 will not qualify, nor repairs and maintenance expenditure accepted as such for tax purposes; nor moveable
says: " There are two separate elements in this expenditurefirst, the money the doctor has to find to build or buy practice premises and, secondly, the running expenses, including interest on any loans raised for building or purchase. We are agreed that the latter cost ought to be reflected in remuneration, but we differ as to whether current net remuneration as recommended by the Review Body includes a return on the capital the doctor has invested in the practice. I am sure that the best course is the one which you have adopted of putting the matter to the Review Body, but we are agreed that fairer distribution is anyway desirable and we are engaged on the factual enquiries necessary to establish the basis for a scheme for this purpose. " As regards initial provision of premises, I have explained that I think that the extension of interest-free loans would be unfair as between the doctor who incurs capital expenditure in the future and the doctor who has incurred it in the past, and I consider that they should be confined to those fields in which it is desired to encourage one form of practice rather than another (cf. group practice loans). For the Exchequer to take over capital liabilities generally would raise far-reaching questions relating to the method of provision of general medical services, but there are of course already arrangements whereby doctors can work in publicly-owned premises, paying a suitable rent. We are agreed that there may be scope for greater use of such arrangements and we are looking further into the statutory powers of the various public authorities who might provide premises in this way and the question whether any extension of these powers is required. " However, I see no reason why Exchequer grants should not be made for the improvement of premises and we have agreed the following main principles of a scheme for this purpose: Basis of Scheme for Improvement Grants Grants for the improvement of practice premises will be available to doctors providing unrestricted general medical services with National Health Service lists (average lists if in partnership) of 500 or more (350 or more in rural areas). To "
equipment. (2) The improvements must be for the purpose of National Health Service practice. (3) There must be reasonable security of tenure and some safeguard to prevent grants being used for improvements designed to enable the owners of the premises to sell them at a higher price. (4) The project must be reasonable in relation to the circumstances of the practice and the existing state of the building. " We shall proceed to fill in the details of a scheme on these lines. This is bound to take a little time but we are getting on with it as rapidly as we can. There remains the problem of the raising of capital. In the ordinary way, doctors should be able to get the capital they need from ordinary commercial sources, but there may be the odd case in which the security offered is unattractive to the ordinary lender for reasons which carry less weight with the ’
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Government, and in which it would therefore be reasonable for the Government to guarantee a loan. Examples of the sort of cases we have in mind are: (a) purpose-built surgeries which have no other practical use;
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(b) improvements to practice premises, not excluding those qualifying for the new grants; the (c) purchase of shares in partnership premises. We would not of course guarantee loans which were beyond the likely resources of the borrower to repay, and enquiries into credit worthiness would be necessary. The machinery for this, and the other details of a scheme for Exchequer guarantees,