Inpatient Care [61]

Acute inpatient care is a core and integral component of the National Service Framework for Mental Health to which all the NSF standards are relevant. Improving adult acute inpatient care and its connections and integration with the other key elements of the whole system of care in its local context
is a priority NSF implementation target.

This adult acute inpatient guidance augments existing National Plan and NSF guidance and is a supplement to the Mental Health Policy Implementation Guide. In conjunction with this core acute care guidance supplementary guidance psychiatric intensive care is being issued. Further related guidance on acute care education and training and on substance misuse is being prepared and should be available later this year.

Acute inpatient care should already be a designated high priority by any definition prioritising the needs of people with serious mental illness. It is usually only when people are most seriously ill that they are admitted to an acute care ward. Inpatient provision is still the single element on which we spend the greatest proportion of the adult mental health budget and employ the greatest number of staff.

This guidance is based on user and carer feedback, expert professional opinion and good practice. The good practice examples cited are tangible illustrations of what can be achieved by staff with a real sense of purpose and a passion for developing acute care inpatient services which can match the best of provision in any other inpatient or residential care setting. There are far more examples of such good work than can be cited here, the National Institute for Mental Health in England web site for this guidance will allow regular good practice updates to be produced.

However, too often acute inpatient services are not working to anyone’s satisfaction. A range of reports and surveys and the reported experience of service users and staff have clearly and consistently demonstrated a high level of criticism and dissatisfaction with current provision. These shortcomings and concerns are acknowledged and detailed in section 3 of the guidance. It is clear that the physical, psychological and therapeutic environment of care must all be attended to.

To date existing inpatient practice and service delivery arrangements have not received the same focussed attention or policy guidance as the development of the newer community based elements of the acute care system (Crisis Resolution, Assertive Outreach, Respite and Early Intervention services).

In part, this is because it has been necessary to focus on getting effective alternatives to admission established. This major investment in the development of alternatives to admission now creates a very real opportunity to reduce pressure on inpatient wards and to attend in more meaningful ways to the necessary reshaping of inpatient services in a whole systems context. In addition £30 million capital has already been made available for investment in significantly improving the physical environment of acute wards.

The document will serve as a guide to stimulate local action. This guidance aims to encourage and assist a reorganisation of inpatient services for people who are acutely ill which adequately reflects the value base that underpins all current mental health policy. Values need to be translated into appropriate practice, structure and relationships that promote humane and therapeutic inpatient care in the overall context of continuing service improvement.

The key target areas are:

• To define the purpose and place of adult inpatient care in the context of the National Mental Health Policy whole systems approach.
• To establish effective means of service co-ordination of acute services to provide a safe, structured and therapeutic inpatient experience.
• To develop effective service user centred decision-making processes and ward arrangements. To address the need to enhance the role, status, training, support and career development of inpatient staff.
• To direct clinical leadership and management attention and expertise on the organisation and management of inpatient services.
• To ensure adequate clinical and support inputs to inpatient wards and to maximise the time spent by staff therapeutically engaged with service users.
• To promote ways in which future provision can project a more positive and socially inclusive view of mental health.

This guidance is addressed to all involved in acute mental health care; it is inclusive of all adult acute inpatient wards and should be relevant and useful to all who use, work in or commission these services.

Implementation will require the creation of stronger partnerships and dialogue between staff, service users and carers, between inpatient and community mental health services and between mental health services and the community served. The focus is not on presenting any idealised picture of inpatient services for those planning new facilities but of recognising the need to deal with the pressures and shortcomings of existing overburdened inpatient wards.

Key to this work will be the establishment of local Acute Care Forums in each Trust to:

• Identify the strengths and weaknesses of current local arrangements.
• To stimulate appropriate action.
• To sustain a momentum of change.

In order to resolve the current lack of research evidence and detailed data on inpatient service operation and use, these Acute Care Forums need to collaborate to undertake a service mapping exercise to identify benchmarks and good practice standards that can provide reliable evidence on which to build continuous service improvement and carry inpatient services positively into the future. This work will be carried out with the support of the National Institute for Mental Health in England’s Regional Development Centres who will establish ongoing service improvement and practice development networks explicitly for acute care services.