Psychiatric wards

Informal and formal patients

People who are experiencing severe symptoms of psychosis may spend time in hospital.

If someone agrees to be admitted to a psychiatric ward or unit, they are called a voluntary or ‘informal’ patient.

However, sometimes your relative may not accept that they are unwell and may not want to have the treatment they need. Because of this, people are sometimes compulsorily admitted to hospital under the Mental Health Act (see Mental Health Act page). People can only be admitted to hospital against their wishes if it is in the interests of their health and safety, or to protect other people.

If someone is admitted to hospital under the Mental Health Act, they are called a ‘formal’ patient. People are admitted and treated under different sections of the Act, depending on the circumstances, which is why the term ‘sectioned’ is used to describe a compulsory admission to hospital.

In 2011/12, there were 48,631 admissions or detentions made under the Mental Health Act in England (this is not necessarily the number of people who were detained under the Act as some people are sectioned more than once within a year). This figure is five per cent up on the previous year's figures.

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What to expect on admission

The National Institute for Health and Care Excellence (NICE) says when someone is admitted to a ward they should be told the name of the member of staff who is coordinating their care. They should also be told why they have been admitted.

If someone has been detained under the Mental Health Act, they should be told why this has happened, what power has been used to detain them, what that means, and how long they will be detained. They should be told about their right to appeal against that decision, about their right to complain about the care they receive and how to get independent advice (see Independent mental health advocates below).

Staff should carry out an assessment to work out the best package of treatment and support for an individual, then draw up a care plan detailing what is proposed during the stay on the ward. NICE says patients should be involved in planning and reviewing their hospital-based care and treatment. Family members should be involved, if their relative agrees.

However, in a report about the use of the Mental Health Act in 2011/12, the Care Quality Commission (responsible for both checking standards of care at hospitals in England and monitoring the use of the Mental Health Act) expressed concern about the lack of patient involvement in care planning on some psychiatric wards. This concern has also been expressed in the results of two recent independent enquiries (see Listening to people's personal experiences below).

Sometimes people are admitted to a psychiatric ward in a hospital that is far from their home. This may be because a local hospital has no available beds, or because the specialist service someone needs is not provided in their neighbourhood.

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Independent mental health advocates

Independent mental health advocates can help people detained under the Mental Health Act in England to understand their rights and what they are being told by mental health professionals, and can also, if required, speak on their behalf.

These advocates are nothing to do with the health professionals involved in treatment and care. Local independent mental health advocacy (IMHA) services are often run by voluntary organisations or charities like Rethink Mental Illness and Mind. These organisations are commissioned by local authorities to do so (from April 2013, local authorities have a legal duty to provide an IMHA service). Mental health professionals working on wards have a legal duty to tell patients how to contact the local IMHA service.

However, the report from the Care Quality Commission about the use of the Mental Health Act in 2011/12 said detained patients were not always informed of their right to see an IMHA.

One of the reasons is that staff may not know about the local IMHA service. The results of a review of IMHA services commissioned by the Department of Health and carried out by the University of Central Lancashire illustrated that some staff (and indeed patients) are not clear about the roles of different advocacy services. You can read the report (The right to be heard – review of the quality of independent mental health advocate (IMHA) services in England, published in June 2012) at the University of Central Lancashire School of Health website. 

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What to expect on a ward

The National Institute for Health and Care Excellence (NICE) says wards and psychiatric units should feel safe, should give people privacy and space, and offer separate toilets, washing facilities and sleeping accommodation for men and women.

The government has pledged to put an end to mixed sex mental health wards and all hospitals should be offering single sex wards. Statistics collected and published by the Department of Health show that a small number of NHS organisations in England are still occasionally 'breaching' this policy (and being fined for doing so). You can find out more about which NHS organisations break the policy on the NHS Choices website.

The guidance from NICE says patients should be given the chance to exercise and take part in group activities and therapies, if they want to. This could include time spent with an occupational therapist or an art therapist, for example, as well as time spent with mental health professionals offering talking therapies.

The Royal College of Psychiatrists has also published guidelines about psychiatric wards. It recommends there should not be more than 18 beds and that wards are run at an occupancy rate of 85 per cent or less – this ensures a bed is always available and helps avoid delays in admission that could be detrimental to people's mental health.

Well-trained staff should treat patients with respect and dignity and spend time creating a relationship with them. Wards should have access to outdoor areas and there should be structured programmes of therapeutic activities seven days a week to aid recovery, including therapies recommended by NICE – cognitive behaviour therapy for psychosis, for example. Patients and their family members should be given information about treatment and involved in decisions about care and care planning. Patients should also be encouraged to improve their physical health – through a healthy diet and exercise, for example.

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Listening to people's personal experiences

In order to prepare the annual report about the use of the Mental Health Act, the Care Quality Commission employs Mental Health Act Commissioners to visit psychiatric wards and talk to patients and staff.

The Care Quality Commission's report about 2011/12 says that some mental health wards visited during the year were overcrowded; that patients were sometimes accommodated in temporary beds and makeshift rooms; that people weren't always given enough privacy or space.

On some wards, there was a long waiting list for psychological therapies and few activities, particularly at weekends.

Many wards visited during the year were locked. The Care Quality Commission says 'control and containment were sometimes prioritised over treatment and support of individuals'. Voluntary patients, for example, had sometimes been detained under 'blanket rules', and may not have been told of their rights to leave a ward.

Two independent enquiries that reported in consecutive years (2011 and 2012) have illustrated that guidelines from NICE and the Royal College of Psychiatrists are not always being followed on psychiatric wards.

Mental health charity Mind asked people to tell them about their personal experiences when they had been in crisis. The subsequent report – Listening to experience, an independent inquiry into acute and crisis mental health care – was published at the end of 2011 and called for improvements in crisis services, including psychiatric wards: people surveyed had commonly reported dirty wards, stressed and over-worked staff who were not respectful towards patients and boredom on the ward because of lack of activities.

At the end of 2012, the Schizophrenia Commission, set up by charity Rethink Mental Illness, published its report after hearing 'evidence' from people who have a diagnosis of schizophrenia, their family members and mental health professionals. The report says many wards have become 'frightening places where the overwhelmed nurses are unable to provide basic care and support,' where 'medication is prioritised at the expense of psychological interventions.'

People who gave evidence to the Schizophrenia Commission talked about 'stress and chaos on wards', 'boredom', 'lack of activity' and 'lack of staff-patient engagement'. The Commission heard about wards that were 'furnished bleakly'. The report concluded that people who spend time in hospital often do not want to do so again – so when they relapse, they end up being sectioned because they are reluctant to be admitted as a voluntary patient. Recruiting staff can be problematic because mental health professionals may also be reluctant to spend time on wards. Download the Schizophrenia Commission's report: The abandoned illness

The Schizophrenia Commission called for reform: it said commissioners and providers of mental health services must ask whether the service they are buying or providing passes the 'friends and family test' – 'if you had a relative who was experiencing psychosis, would you want them treated here?'

Star Wards is a programme designed by people with experience of being a patient on mental health wards. The programme includes scores of ideas for activities on wards. Star Wards has created Wardipedia, an online resource that includes 1,000 examples of good practice from wards across the UK, with many low cost activities: psychiatric wards that have adopted the Star Wards programme have shown that patients are more satisfied and less bored, and that staff morale is higher.

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Friends and family test

From April 2013, NHS trusts and foundation trusts will routinely ask patients (shortly after discharge) whether they would recommend hospital wards and A&E departments to their friends and family members, if they needed similar care or treatment. If people say they would not recommend a ward or casualty department, they will be asked why not. The idea of the national scheme launched by the government is that NHS trusts can use the results to improve services, and NHS commissioning organisations can use the results to inform their spending decisions.

Later in the year, the 'friends and family test' will be introduced for women who use maternity services and eventually anyone who uses any NHS service will be able to comment via the test.

The results of the friends and family tests will be publicly available on NHS Choices from July 2013 onwards. You can find out more at the NHS Choices website

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Safety on the ward

People who are admitted to hospital are very unwell. A patient may have been admitted because he or she is considered to be at risk of harming themselves or other people. When someone is admitted to hospital, staff will carry out a risk assessment to work out how likely he or she is to become disturbed or violent (towards themselves or to other people).

If members of staff think someone could become disturbed or violent, that patient should be offered the chance to say what they do and what they don’t want to happen in that situation. A record of what the patient has said should be included in their care plan.

The National Institute for Health and Care Excellence (NICE) guideline Violence: managing disturbed/violent behaviour details what staff should do in a violent situation, and what methods staff can use to calm people down. This could sometimes involve ‘rapid tranquillisation’, the use of medication to sedate someone. Different medicines can be used for rapid tranquillisation of people with psychosis, including antipsychotic medication or lorazepam, a type of medicine called a benzodiazepine.

After rapid tranquillisation, patients should be told why they were sedated, and families should be involved in reviewing what happened with staff on the ward, unless the individual who is unwell does not want family members to be involved.

Other procedures may be used to calm people down or to ensure the safety of all patients. These include seclusion and manual restraint. If members of staff are concerned about the safety of an individual – including the possibility of them trying to take their own life – they may instigate ‘special observation’. This means providing extra care and attention to an individual patient for a period of time. It may involve staff checking on an individual regularly, or a member of staff staying continuously with a patient.

The NICE guideline was produced in 2005 and is currently being updated. The updated guideline is due to be published in 2014. 

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Discharge planning

Staff on the ward should start planning for discharge early on to make sure someone continues to receive the treatment and support they need when they leave hospital. This will probably involve transferring the responsibility of providing care to community-based mental health team. Or, if someone is discharged from the care of specialist mental health services, their GP then becomes their first point of contact if they become unwell again.

Discharge plans should be drawn up in collaboration with the individual and his or her family, unless the person who is unwell objects to the involvement of family members.

Staff working on wards should liaise regularly with local councils and other organisations so they can also help organise accommodation, benefits and other support.

People should only be discharged from hospital when appropriate support in the community has been organised. The Care Quality Commission found that in some parts of England in 2011/12, patients may have been discharged from hospital too soon because of pressure to free up beds.

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The role of the Care Quality Commission

The Care Quality Commission (CQC) checks all hospitals in England to make sure they are meeting standards set by government. You can find out how well a mental health hospital meets quality and safety standards, and read the results of the latest checks by visiting the Care Quality Commission website. You can also submit feedback about individual hospitals or units.

The CQC also has a legal duty to monitor the use of the Mental Health Act in England.

It appoints Mental Health Act Commissioners to visit psychiatric wards to interview patients and staff to find out if the Act is being used correctly. The findings of these visits are included in an annual report presented to parliament. The report highlights examples of good practice as well as concerns. You can download a copy of the Mental Health Act 2012/13 annual report from the CQC'S website.

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Alternatives to psychiatric wards

People with experience of mental health problems, their families and mental health professionals have all expressed concerns about the effectiveness of psychiatric wards.

Research has shown that people with mental health problems and their families feel the stigma associated with admission can be even greater than that associated with a diagnosis of mental ill health. Research has also shown that being admitted to a psychiatric hospital, although life-saving in some cases, can sometimes be an unpleasant and sometimes traumatising experience (see Post traumatic stress disorder and psychosis page).

Community-based home treatment/crisis resolution teams are an alternative to admission to hospital (see Mental health services page). However, there has been some concern that these teams are over-stretched and under-resourced and do not always offer appropriate levels of support: the report of the Schizophrenia Commission at the end of 2012 expressed concerns of this nature.

In recent years, there have also been a small number of new residential services developed as alternatives to traditional psychiatric wards. Some are run by NHS organisations, and some are provided by private and voluntary organisations. Crisis houses, for example, are mostly run by voluntary organisations, offering safe places for people who need 24-hour care for a short period of time. In some places, there are women-only crisis houses.

Recovery houses can also offer an alternative to hospital, or they can be a 'half-way house', offering support to someone who has been discharged from a mental health ward before he or she settles back in the community. Assessment units sometimes offer people a safe place to stay for a set number of days while their mental health is assessed and professionals work out the best way of offering them support.

Your relative’s GP or the mental health professionals working with your relative should be able to tell you whether there are any alternatives to psychiatric wards available in your area.

 

 


This page was updated 16 March 2013 (NICE name change incorporated 3 April 2013)
Links last updated: 29 August 2014
Next links check due: December 2014


Resources

Star Wards

This is an initiative led by people who have been admitted to inpatient wards. It promotes hundreds of ideas for joint activities for patients and staff. Star Wards has created Wardipedia, an online resource that includes 1,000 examples of good practice from wards across the UK, with low cost ideas for improving patients' experience on the ward.


Accreditation for Inpatient Mental Health Services

(AIMS) is an initiative from the Royal College of Psychiatrists that seeks to improve psychiatric wards and units. To achieve AIMS, wards have to meet high standards. The process for getting accreditation helps wards and units identify problems and make change.


Guidance from the National Institute for Health and Clinical Excellence (NICE) about what to expect on a ward is set out in its guideline Violence: managing disturbed/violent behaviour.


Resources

Mental Health Act 2012/13

The annual report from the Care Quality Commission.