Sixty Second Interiew with Mat Kinton
The Mental Health Act Commission is charged with safeguarding the interests of all people detained under the Mental Health Act 1983. Last week they released a report covering their work in the financial years 2003/04 to 2004/05 during which time they have continued to visit all psychiatric facilities that detain patients and have met with patients in private. Here Mat Kinton speaks to Amy Taylor about the commission’s concerns.
Your report found that there was evidence that inpatient mental health services are losing staff and resources to community services despite the pressure on in patient beds remaining high. Why are community services being favoured and what needs to happen to address this?
The relative neglect of some inpatient services is perhaps an unintentional consequence of resources and staff gravitating towards community services which are seen as more exciting and cutting-edge. We should be very wary of this, and remember that the project of closing the asylums was instigated by the awfulness of so-called ‘back-wards’, where long-stay inpatients were abandoned to a second class service. The polarization of hospital and community services could reintroduce such a two-tier system. There certainly have been enormous developments in community services over the last two decades, but as a result inpatient admission is sometimes seen as a failure of community-based, alternative treatment. I think that this view is dangerous. We need to re-emphasise that hospital admission is a necessary part of many psychiatric patients’ care and that providing inpatient care is a skilled and extremely valuable role within health services. We should beware of unfair pay differences between community and hospital staff. Hospital and community care must be viewed as interlaced but equally vital aspects of a functional mental health service.
You also found that over half of mental health wards were full or had more patients than beds. What is the impact of this on the care people receive?
Too often commissioners arrive on a ward to find services operating at permanent crisis-level. We have visited wards where patients are so often being moved around within the hospital, and between the hospital and their home, that they are unable to unpack their belongings or know from one day to the next where they will spend that night. It can mean that too much staff time is spent on the bureaucracy of bed-management, and little time with patients. Intense pressure for beds may distort the threshold at which it is considered safe to let a patient bed out for the night. Many patients on overcrowded wards also complain that their environment is noisy, chaotic and even frightening.
The report warns that patients subject to compulsion could end up on failing wards because they would not be able to choose their treatment under new market-based systems of funding. Does this concern you?
In theory, ‘contestability’ in a market-based system should lead to failing services having to improve or close because of a lack of patients choosing to accept such services. For psychiatric inpatient services, this is bound to be distorted by the fact that a considerable proportion of psychiatric inpatients are admitted to services under legal compulsion and therefore denied the choice of rejecting a particular hospital placement. At best, this may simply mean that it is not possible for psychiatric services to implement contestability based around psychiatric patient choice, especially in some services, such as secure units, where a majority of patients are detained. At worst, it could mean that otherwise unacceptable services are maintained through compulsory admissions, with investment in and attention to mental health services diverted towards areas of health care that are more open to the pressures of the marketplace. Either way, detained patients would be disadvantaged, so this is a big concern.
Are mental health in-patient services particularly vulnerable to cuts as NHS trusts face financial crises?
Where services cater for stigmatized populations or conditions they are clearly more likely to be in the firing line for cuts. From a public relations perspective, it may be easier to be seen to curtail psychiatric services rather than, for example, reducing oncology or paediatric services or endangering performance subject to targets. Even within mental health services, inpatient services are expensive and not necessarily popular or valued by the communities that they serve, so that psychiatric wards can be closed under the (sometimes disingenuous) claim that community services will fill in any gap in provision.
Are all the problems due to a lack of resources or could some of them be solved by existing services performing differently?
It is difficult to argue that mental health services are necessarily under-resourced, as money intended for the improvement of mental health services hasn’t always ended up being spent wisely or appropriately. The National Director for Mental Health has stated that some primary care trusts have not given sufficient priority to mental health, and have even diverted additional resources intended for mental health development to other services. The use of existing resources within mental health services is also part of the problem, in that services relying on expensive out-of-area beds or agency staff are to some extent creating their own difficulties. There needs to be careful consideration of whether current and proposed service commissioning arrangements provide sufficient expertise and overview for efficient mental health provision.
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