Pressure On Beds: A Side Effect of Systemic Dislocation

(“All parts of the system should identify with the primary organisational task”)

In working with patients with mental health problems, chronic risk is much harder to manage than acute risk, the appropriate responses to which are well-known, well-worn and even rewarding at times. Immediate risk requires direct, linear action. On the other hand, chronic risk, which clinical staff often drift into the habit of watching with a kind of worried complacency (sometimes called passive surveillance), needs a more sustained and systemic approach. The former seems to generate excitement and galvanise collective action whereas the latter is the dull ache which staff either feel impotent to do anything about or magically believe will eventually just go away. What is always there becomes a familiar feature on the clinical or cognitive landscape, problematic, maybe, but an important contributor to homeostasis and its comforts.

Pressure on psychiatric beds is that chronic feature of clinical life, energetically addressed on the day by bed managers when patients needing a bed are stacking up in police cells or A+E, but mostly viewed by staff as something which has always been there, which you have to get used to and which is largely felt to be the consequence of reactionary and ill-informed government policy.

The facts of it are clear and undisputed. In London, bed occupancy (the number of people who are nominally allocated to a particular ward) averages over 100% and in some areas is as high as 140%. This perhaps strange statistic is possible because new patients will frequently be given the bed of someone who is away from hospital on official short-term leave or, quite often, unilaterally taken unauthorised leave; or perhaps in a general hospital having tests or treatment for a physical problem.

Although occupancy is supposed to be around 85%, there is in fact a covert law in operation which says that an acute psychiatric ward will always be full, however dynamic services in the rest of the community are, with either a little or a lot over, depending on demography, morbidity and similar powerful currents. The second law of acute beds is a version of the better-known Broadmoor Law which says that at any one time a third of the patients don’t need to be there –the problem is knowing which third. A derivative of this is that a proportion of patients on any acute ward are being under-treated and a similar proportion over-treated, without staff knowing quite which category a patient belongs to.

In London the number of beds per 1000 of the population has fallen by 37%. Detentions under the Mental Health Act have gone up around 7% in the same time (though this may be partly an artefact of the fashion for using a shorter, 28-day section to admit someone to hospital followed by a longer 6-month section soon afterwards for treatment).