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Violence, substance abuse and chronic staff shortages - two major reports launched last week paint a dismal picture of life on an acute psychiatric ward.

A study of 300 in-patient wards and 50 NHS trusts across England by charity the Sainsbury Centre for Mental Health finds a general over-reliance on agency staff.

Nearly half of wards lack a lead consultant psychiatrist while 13 per cent do not have a ward manager or senior nurse. And almost a quarter of ward managers say their wards are unfit for use.

An audit of 265 mental health and disability wards by the Royal College of Psychiatrists, released by the Healthcare Commission, reveals high levels of violence, fuelled by substance misuse, inadequate staffing and boredom.

A spokesperson for the Sainsbury Centre says the priority for government over recent years has been to develop community-based services. While this is to be welcomed, he argues, it has left acute care behind.

One of the most telling statistics from the Sainsbury report is the fact that a quarter of wards have lost staff members to a community service over the past year.

According to the spokesperson staffing shortages are at the heart of the problems facing acute wards, a view backed by Mental Health Nurses Association professional officer Brian Rogers.

He believes staff have been attracted by the increasingly sophisticated care being offered by community-based services and feels in-patient care suffers from a perceived lack of status as a result. "They do not feel as valued, that they have the same sort of control over what happens in their environment as community staff."

These issues lead to recruitment problems and the increasing reliance on agency staff, who are not around long enough to build up a therapeutic relationship with patients. They will also be less likely to cope in the potentially explosive situations arising on acute wards, argues Rogers.

Of course, if staff levels are low, nurses will have less time to spend with individual patients.

"There's a lack of meaningful therapeutic activity for patients on the wards and that can lead to people getting tense, bored and irritated," says Simon Lawton-Smith, senior policy adviser on mental health for the King's Fund.

The lack of activity is compounded by the growing number of patients with complex needs, principally stemming from drug and alcohol misuse, he says.

Lawton-Smith argues that the issues facing acute wards have been clear for many years - it is time to look at what works. But he warns against any temptation to believe that introducing compulsory community-based treatment, as suggested in the latest draft Mental Health Bill, will take pressure off acute wards.

International evidence suggests that as more people are treated in the community the number of in-patient beds is reduced. But the people who require those beds are the most ill and will make a proportionately higher demand on resources, he says.

Also, community treatment orders, being a statutory requirement, will inevitably draw resources away from other areas, he adds.
According to Rethink spokesperson Paul Corry the only way to solve the problems facing acute care is to restructure mental health services. Corry talks about reclaiming the original meaning of the word "asylum" as a non-hospital crisis centre people could use for a few days at a time. Rethink has developed two such centres, staffed by nurses, in conjunction with a helpline.
"The solution lies outside hospital in better preventive care," he says.

For some nothing less than a complete overhaul of the mental health system can provide a solution.

Mental Health Foundation chief executive Andrew McCulloch believes a greater range of different treatments and preventive measures, including crisis intervention and therapeutic communities, should be introduced. All the acute centres that are unfit for use and where patients sit around waiting for something to happen should eventually be closed down, he argues.

"It's not about knocking staff," he says. The model of in-patient care is wrong and must be overhauled. "Trying to take an incremental approach doesn't work."

• Sainsbury report at www.scmh.org.uk and Healthcare Commission audit from www.healthcarecommission.org.uk