Bed numbers and acute in-patient care

I am pleased that Mat Kinton has given some views on bed numbers as a limitation to acute in-patient care (Psychiatric Bulletin, February 2007, 31, ) as it provides an opportunity to extend the debate further.

To my mind arguing that ‘improvement may be reliant upon a much more fundamental question of resources: beds for the patients’ is an unjustified oversimplification. Of course it is highly unsatisfactory when over-occupancy does occur but as Mat himself acknowledges this is not a universal experience. The 2004 survey of acute care (Sainsbury Centre for Mental Health, 2004) found a range of regional average bed occupancy rates of 91-109%. Furthermore, overall rates of admission are falling (Glover et al, 2006) and figures from the Department of Health (http://www.performance.doh.gov.uk/hospitalactivity) suggest that this is reflected in falling national bed occupancy rates (from 91.4% in 2002–2003 to 85.6% in 2005–2006).

As the situation is not homogenous, there will be places where bed numbers are unsatisfactory, and there, local action might be needed to correct shortcomings, but arguing simply for more resources for more beds detracts from the need to look in detail at what the shortcomings might be. Mat acknowledges that improvement of patient services requires a multi-agency approach; surely that includes close attention to reasons for delayed discharge, the background to admissions of uncertain purpose, process delays and cumbersome interprofessional practices and power relationships.

Glover et al (2006) highlight the influence that home treatment/crisis resolution teams can have upon bed use, and that as this is a delayed effect, the mechanism is likely to be complex. Besides (or perhaps instead of) complaining once again about inadequate resources, perhaps we should also continue to question whether those resources we have are being used as well as they might. In the case of acute psychiatric in-patient beds this might include critical reappraisal of how clearly the purpose of an admission is articulated, how readily discharge can happen when it is due, how successfully communications between in-patient and community teams support care planning, and so on. Merely highlighting bed shortages oversimplifies and detracts from more relevant but possibly more complex and challenging aspects of the very necessary agenda to improve acute in-patient care.