Expert answers from
- Informal and formal patients
- Before admission
- What to expect on admission
- Assessments and planning care
- What to expect on a ward
- Safety on the ward
- Discharge planning
- Alternatives to psychiatric wards
- The Care Quality Commission
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 can be 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 2013-2014, the Mental Health Act was used 53,176 times in England to detain patients in hospital for longer than 72 hour (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, and 30 per cent higher than a decade before (2003-2004).
NICE (the National Institute for Health and Care Excellence) recommends that when someone is very unwell, other options should be explored before admission to hospital. Treatment at home by a crisis resolution/home treatment team should be the first option (NICE 2014 guideline about psychosis* and schizophrenia). NICE recommends everyone who is unwell should be assessed by members of these teams; that crisis resolution/home treatment teams ‘gate-keep’ beds in psychiatric wards; and that people are not admitted to hospital unless the outcome of an assessment is that home treatment is not appropriate. NICE also says mental health professionals should consider crisis houses and day treatment in a hospital or special unit rather than admit to a psychiatric ward. See 'Alternatives to psychiatric wards' below.
*Psychosis and Schizophrenia in adults, NICE Guideline on Treatment and Management, updated edition 2014, uses the term 'psychosis' to describe the symptoms of psychosis experienced by people who have a diagnosis of schizophrenia, schizoaffective disorder, schizophreniform disorder or delusional disorder. Recommendations for supporting people who are having psychotic-like experiences that are distressing are also included. The guidance does not include recommendations about treatment for people who experience psychosis as a symptom of bipolar disorder, psychotic depression, dementia or Parkinson's disease. These recommendations are contained in other NICE guidance.
The National Institute for Health and Care Excellence (NICE) says if admission to hospital is unavoidable, someone should be admitted to a ward that is suitable for their age, gender and ‘level of vulnerability.’
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. The Care Quality Commission, responsible for monitoring the use of the Mental Health Act, has expressed concern about 'the increasing number of patients being detained far away from home’ during 2013-2014.
When someone is admitted to a ward they should be given information about the hospital and the ward, about the treatments, activities and services that are available, about ward rules, visiting hours and meal times. Patients should be given enough time to ask questions, shown around the ward and introduced to the health professionals who work there, including the person who will be co-ordinating their care. You can find out more about what should happen when your relative is admitted (and during his or her stay in hospital) by reading the NICE guideline called ‘Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services'.
Some people are very distressed, or unable to think clearly when they are admitted to a ward. Therefore, information about what happens on the ward and introductions to new people and places, can be difficult to take in. The information should be repeated or conveyed over a period of time so that it can be understood and remembered by the person new to the ward. Wards often have ‘welcome packs’ or written information and patient notice boards that repeat the same information.
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 and how long they will be detained. They should be told about their rights, including their right to appeal against that decision, and their right to access independent advice.
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. They can also, if required, speak on patients’ behalf.
These advocates are nothing to do with the health professionals involved in treatment and care. Local independent mental health advocacy (IMHA) services are commissioned and paid for by local authorities but are mainly run by voluntary organisations or charities like Rethink Mental Illness and Mind. Local authorities have a legal duty to provide an IMHA service and mental health professionals working on psychiatrics wards have a legal duty to tell patients how to contact the local service.
NICE says health professionals should meet with a patient within two hours of admission to carry out an assessment and plan what treatment and support will be offered during the time spent in hospital. NICE-recommended treatments should be available, including cognitive behaviour therapy for psychosis. A care plan detailing proposed treatment should then be prepared.
Patients should be involved in planning their hospital-based care and treatment. Family members should be involved, if their relative agrees. However, some patients are not prepared or able to fully participate in this process when they are first admitted. Therefore, sometimes care plans may be initially formulated by ward staff until patients start to recover.
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.
While on the ward, NICE says patients should be offered meetings with their consultant (eg a psychiatrist) for at least 20 minutes each week and a specialist mental health pharmacist to discuss any medication that is prescribed, including the pros and cons of taking it.
There should be a choice of foods and a family area within the hospital where children can visit. Patients should have access to a phone, and to the internet, and be able to join in a wide variety of activities, including creative and leisure activities and exercise, seven days a week, during the day and evening.
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.
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 aggressive or violent (towards themselves or to other people).
The National Institute for Health and Care Excellence (NICE) has issued guidance that describes what health professionals should do if patients behave in an aggressive or violent way.
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 and write their wishes down in an ‘advance decision’ or ‘advance statement’.
The NICE 2015 guideline ‘Violence and aggression: short term management in mental health and community settings’ details the methods that staff can use to keep people safe until they are more relaxed and calm. They may use:
• observation: this means a health professional will constantly supervise a patient. How long, and how closely a patient is supervised will depend on their risk of becoming violent. If the risk is very high, more than one member of the ward team will observe a patient.
• manual restraint: this means health professionals will hold a patient in a way that prevents them from hurting themselves or another person. Patients should be held for as short a time as possible.
• mechanical restraint – such as handcuffs – should only be used in a high-secure psychiatric hospital to stop or prevent extreme violence or injury.
• an injection of medication to sedate (called rapid tranquilisation). NICE recommends health professionals use either lorazepam on its own, or haloperidol combined with promethazine.
• seclusion: this means taking a patient to a room away from everyone else. The room may be locked. Patients should be secluded for as little time as possible and there should be toilet and washing facilities within the room. The Department of Health says seclusion can only be used for people detained under the Mental Health Act (Positive and Proactive care: reducing the need for restrictive interventions, 2014).
If any of these ‘restrictive interventions’ are used, the patient should be given the opportunity to talk about what happened with a member of the ward team and an advocate or family member. If patients have witnessed the use of restrictive interventions, they should also be offered the chance to discuss what happened.
‘Safewards’ is a guide designed to help ward staff increase safety without using restrictive interventions. Much of the Safewards package, developed by Professor Len Bowers at the Institute of Psychiatry, Psychology & Neuroscience, King’s College London, focuses on improving relationships between staff and patients. Research has shown that Safewards practical initiatives – like a display of positive messages about the ward from discharged patients and making time to talk – can cut down on aggressive and violent behaviour and the need to control it. The use of Safewards is recommended by the Department of Health. Find out more at www.safewards.net.
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 may involve transferring the responsibility of providing care to community-based mental health 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.
Staff working on wards should liaise with local councils and other relevant organisations regarding accommodation, benefits and other support.
NICE says patients should be given at least two days notice before they leave hospital. When discharged, they should be given a 24 hour number to call in case they need help.
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 many people 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).
Crisis houses offer safe and homely places for people who need 24-hour care and support for a short period of time. In some places, there are women-only crisis houses. A crisis house is small unlocked unit, usually in a converted house, designed to be like a home rather than a hospital. They are staffed around the clock by mental health professionals and are run by NHS organisations or voluntary sector organisations. The majority of crisis houses work closely with crisis resolution/home treatment teams. Research has shown that people much prefer crisis houses to wards.
Recovery houses can also sometimes offer an alternative to hospital, or they can be a 'half-way house' after discharge, offering support to someone who has left a mental health ward before he or she settles back in the community. Recovery houses are also mostly run by voluntary organisations such as Rethink.
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.
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 and prepares an annual report that is presented to parliament. The report highlights examples of good practice as well as concerns. You can download a copy of the Monitoring the Mental Health Act in 2013-14, Care Quality Commission (August 2015) at the CQC website.
In order to prepare the annual report, the CQC employs Mental Health Act Commissioners who visit psychiatric wards and talk to patients and staff.
The Care Quality Commission's report about the use of the Act in 2013-14 raises concerns about:
• patients not being routinely involved discussions about their treatment
• lack of beds
• the use of restrictive practices, particularly seclusion and long term segregation
• the disproportionately large number of black and ethnic minority people who were detained under the Act
• detained patients not always being informed of their right to see an independent mental health advocate.
This page was last updated 30 September 2015
Links updated 6 July 2016
Safewards: a guide designed to help ward staff increase safety without using restrictive interventions.
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.
(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.