Psychiatric wards

• Informal and formal patients
• What to expect on admission
• What to expect on a ward
• The role of the Care Quality Commission
• Safety on the ward
• Discharge planning
• Alternatives to 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 2010/11, there were 45,248 admissions or detentions made under the Mental Health Act.

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What to expect on admission

The National Institute for Health and Clinical 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 they have 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.

Independent Mental Health Advocates help people detained under the Mental Health Act in England to understand their rights. These advocates are nothing to do with the health professionals involved in treatment and care. They can help people understand what they are being told by mental health professionals, and represent their views.

At the moment, NHS primary care trusts have a legal duty to provide an Independent Mental Health Advocate (IMHA) service. The changes spelled out in the government's Health and Social Care Bill mean local authorities will in future become responsible for commissioning this service (primary care trusts are to be abolished in 2013).

However, a report from the Care Quality Commission (see below) about the use of the Mental Health Act in 2010/11 expressed concern about access to the IMHA service. Monitoring the Mental Health Act in 2010/11 (published December 2011) is based on information collected during visits to psychiatric wards and discussions with more than 4,700 patients. Patient had regular access to IMHAs on only 65 per cent of wards visited during the year, though advocates would come if requested to 85 per cent of them. What's more, staff didn't always know about the IMHA service and therefore patients (and their 'nearest relative' – see Mental Health Act page) were not always told about the service, even though staff have a legal duty to inform them.

When people are admitted to hospital, staff should carry out an assessment to work out the best package of treatment and care for an individual, then draw up a care plan detailing what is proposed during the stay on the ward. The National Institute for Health and Clinical Excellence (NICE) also says patients should be involved in planning and reviewing their hospital-based care and treatment. Family members should be involved, if their relative agrees.

The Care Quality Commission's report about the use of the Mental Health Act in 2010/11 also stresses that patients should be involved in decisions about their care and treatment.

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What to expect on a ward

The National Institute for Health and Clinical 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: since April 2011, hospitals have been 'fined' for every day a patient is kept on a mixed sex ward.

The Care Quality Commission annual report (2010/11) about the Mental Health Act 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 and space.

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 Care Quality Commission reports that in 2010/11, 90 per cent of patients detained under the Mental Health Act who were interviewed said there were activities available on the ward, though many patients said there weren't enough activities at the weekend.

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The role of the Care Quality Commission

The Care Quality Commission 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 essential standards of quality and safety 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 on this website.

The Care Quality Commission (CQC) also has a legal duty to monitor the use of the Mental Health Act in England.

The CQC appoints ‘Mental Health Act Commissioners’ and they visit every psychiatric ward where patients are detained. They interview formal patients and staff to find out if the Mental Health Act is being used correctly. The findings of these visits are included in an annual report presented to parliament. The report for 2010/11 was published in December 2011. You can download a copy of Monitoring the Mental Health Act in 2010/2011 from the CQC's website.

The report highlights some ongoing concerns – about staffing levels on mental health wards, for examples – and includes information about deaths of patients who had been detained under the Mental Health Act. 

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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 Clinical 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.

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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 a community mental health team, or other sort of community-based team. 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.

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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 be an unpleasant and sometimes traumatising experience (see Post traumatic stress disorder and psychosis page).

Community-based home treatment/crisis resolution teams have been developed as an alternative to admission to hospital.

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 the NHS, and some are provided by private and voluntary organisations. One of the better known type of alternatives are crisis houses and these are mostly run by voluntary organisations, offering safe places for people who need 24-hour care. In some places, there are women’s only crisis houses. Crisis houses are also called recovery houses and these are being developed in many places.

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

The mental health charity Mind recently asked people to tell them about their experiences and views on psychiatric wards, crisis houses and community-based home treatment/crisis resolution teams. Mind commissioned an independent panel to review the information collected and make recommendations for the future. The report – Listening to experience, an independent inquiry into acute and crisis mental health care – was published at the end of 2011. You can download it from the Mind website. The report calls for improvements in crisis services, including 'treating people with humanity' and making sure people have access to help when they need it.