Whereas recent attention has been focused on developments in community-based psychiatry, in-patient mental health rehabilitation services appear to exist virtually unnoticed at present. This may be in part due to the contextual history of a major contraction of these services within the UK National Health Service (NHS) and an emphasis away from rehabilitation psychiatry over the last quarter of a century. Reference Holloway1 More recently, however, guidance has been developed by the Royal College of Psychiatrists about what type and degree of specialisation of rehabilitation services would be expected for a patient population of a certain size. Reference Wolfson, Holloway and Killaspy2 This guidance includes a definition of five categories of in-patient rehabilitation facilities: secure rehabilitation, longer-term complex care, high-dependency rehabilitation, community rehabilitation and highly specialist services. Community rehabilitation units are non-intensively staffed units focusing on activities of daily living, psychological interventions and engagement with services. High-dependency units work with individuals who are highly symptomatic, have severe comorbid conditions, significant risk histories and challenging behaviours. Longer-term complex care is for people who have high levels of disability, complex comorbidity, limited potential for change and significant risk to their own health and safety or to others.
Rehabilitation psychiatry has been described as ‘practically an evidence-free zone in modern psychiatry’ Reference Killaspy, Harden, Holloway and King3 and there are few published descriptions of in-patient rehabilitation services. Reference Macpherson and Butler4,Reference Simpson and Middleton5 A detailed survey of a local rehabilitation service was conducted across the two inner London boroughs of Camden and Islington in 2005. Reference Killaspy, Rambarran and Bledin6 However, studies reviewing the provision of in-patient rehabilitation services across neighbouring NHS trust areas have seldom been undertaken.
This study aimed to develop a better understanding of in-patient rehabilitation settings by examining a range of such settings within a defined geographical area. This consisted of the three boroughs of Birmingham, Solihull and Sandwell within the West Midlands, covering a total population of approximately 1.5 million. 7 The services were provided by two NHS mental health trusts.
Method
The study population consisted of the service users of all in-patient rehabilitation services at the time of the survey. These were defined as NHS managed and staffed non-acute units, with a stated aim of rehabilitation and providing 24-hour care from mental health nurses and a dedicated consultant psychiatrist, and later categorised as community rehabilitation units, longer-term complex care and high-dependency rehabilitation, using the definitions in Wolfson et al. Reference Wolfson, Holloway and Killaspy2 Forensic units and designated low secure units were not included.
Data were obtained using a modified version of the Resident Profile, developed by the Royal College of Psychiatrists’ Research Unit for the Mental Health Residential Care Study. Reference Lelliott, Audini, Knapp and Chisholm8 The questionnaire was supported by guidance notes to achieve better standardisation and covered demographic and residential data, psychiatric history, diagnosis, current mental health and behavioural problems, danger to self and others, physical health, personal functioning, interpersonal relationships, future placement, legal status and global rating.
The Birmingham and Solihull questionnaires were completed by the named nurse for each service user and supplemented with details from the case notes. The Sandwell questionnaires were completed by one of the investigators (C.C.) in collaboration with the senior nursing staff for the service. The data from the Birmingham and Solihull services was collected (by A.M.) between March and June 2007 and the Sandwell data in February and March 2008. The project proposal was determined by the National Research Ethics Service to be a service evaluation for which ethical committee approval was not required, and approval was obtained from the relevant clinical governance bodies in Sandwell Mental Health NHS & Social Care Trust and in Birmingham & Solihull Mental Health Trust.
Data were analysed using Statistical Package for Social Sciences 12.0.1 for Windows. Chi-squared tests were used to compare patient characteristics across the three types of unit covered by this survey.
Results
Ten services were identified with 109 service users, consisting of five community rehabilitation units (four were hospital units and one an NHS staffed and managed rehabilitation nursing home that functioned as a hospital unit, all of which fell into the community rehabilitation unit category in the Royal College of Psychiatrists’ template for rehabilitation services Reference Wolfson, Holloway and Killaspy2 ) with 44 service users (40%), three longer-term complex care services with 36 service users (33%) and two high-dependency rehabilitation units with 29 service users (27%). Ninety-eight completed questionnaires were obtained, representing 90% of all current service users. There were some questionnaires returned without a complete set of responses and this is shown accordingly in the tables. None of the service users were currently in employment and only five were married. Sixty-five were male (66%) and thirty-three female (34%). The overall mean age was 45 years: 40 in the community units, 52 in long term and 45 in high dependency, with no significant difference found across the units. In terms of ethnicity, 66 service users were White (67%), 22 Black/Black mixed (22%) and 10 in other groups (10%). Sixty-six service users had a diagnosis of schizophrenia (67%), 26 had affective (depressive and bipolar) psychoses (27%), 2 had personality disorder, 1 organic psychosis, 1 substance misuse and 1 was placed in the questionnaire's ‘other’ category.
A total of 75 (77%) service users had come from another psychiatric ward before entering the in-patient rehabilitation units, with 44 of these from acute in-patient wards. Out of the other 23 service users, 2 in the high-dependency services had come from prison, 3 in the longer-stay complex services had come from residential care and 1 from their family home. In the community services, 8 had come from their own home and 9 from supported accommodation or residential care. The median length of stay at the time of the survey was 38 months (range 0-143): 14 months (0-80) in community services, 75 months (8-130) in longer-term care and 38 months (6-143) in high-dependency services This difference between the three service types was significant (Kruskal-Wallis χ2 = 41.00, P<0.0001). Further descriptive data are shown in Table 1, with comparison between the three types of unit.
Table 1 Clinical details
| All, n (%) (n=98) |
Community, n (%) (n=41) |
Long term, n (%) (n=30) |
High dependency n (%) (n=27) |
χ2 | P | |
|---|---|---|---|---|---|---|
| Service history | ||||||
| On another hospital ward prior to entry | 75 (77) | 24 (59) | 26 (87) | 25 (93) | 12.99 | 0.002 |
| First contact <1 year ago | 3 (3) | 3 (7) | 0 (0) | 0 (0) | – | NS |
| First contact 410 years ago | 71/95 (75) | 24 (59) | 24/28 (86) | 23/26 (89) | 10.08 | 0.0006 |
| No admissions | 3 (3) | 0 (0) | 2 (7) | 1 (4) | – | NS |
| 5 or more admissions | 64/96 (67) | 26/40 (65) | 21 (70) | 18 (67) | – | NS |
| >5 years in hospital in lifetime | 68 (69) | 18 (44) | 25 (83) | 25 (93) | 22.13 | <0.0001 |
| <3/12 in hospital in lifetnime | 5 (5) | 4 (10) | 1 (3) | 0 (0) | – | NS |
| Current community team | ||||||
| Assertive outreach | 24 (25) | 9 (22) | 8 (27) | 7 (26) | ||
| CMHT/early intervention | 29 (30) | 22 (54) | 6 (20) | 1 (4) | ||
| None | 45 (46) | 10 (24) | 16 (53) | 19 (70) | 23.27 | <0.0001 |
| Diagnosis | ||||||
| Schizophrenia | 66/97 (68) | 29 (71) | 23 (77) | 14/26 (54) | ||
| Affective psychosis | 26/97 (27) | 8 (19) | 6 (20) | 12/29 (41) | ||
| Other | 5/97 (5) | 4 (10) | 1 (3) | 0 (0) | 9.3 | 0.05 |
| Mental status | ||||||
| Moderate/severe problems in at least one symptom domain | 75 (77) | 30 (73) | 22 (73) | 23 (85) | – | NS |
| Moderate/severe alcohol/drug problems | 14 (14) | 8 (20) | 2 (7) | 4 (15) | – | NS |
| Physical health | ||||||
| No physical health problem | 39 (40) | 14 (34) | 7 (23) | 18 (67) | 12.08 | 0.002 |
| Moderate/severe health problem | 35 (36) | 12 (29) | 17 (57) | 6 (22) | 18.62 | 0.01 |
| Currently detained under Mental Health Act | 42/97 (43) | 10 (24) | 10 (33) | 22/26 (85) | 25.26 | <0.0001 |
CMHT, community mental health team; NS, not significant.
Table 2 shows the results for current social functioning and risk behaviours. Moderate/severe problems in social functioning were found in 88% and significant differences emerged between units in social functioning and history of violence, although not for risk behaviours displayed over the preceding month.
Table 2 Social functioning and risk behaviours
| All, n (%) (n=98) |
Community, n (%) (n=41) |
Long term, n (%) (n=30) |
High dependency n (%) (n=27) |
χ2 | P | |
|---|---|---|---|---|---|---|
| Social functioning | ||||||
| Moderate/severe problems in at least one domain | 84/96 (88) | 31/40 (78) | 27/29 (93) | 26 (96) | 6.4 | 0.041 |
| Little or no social interaction | 17/97 (18) | 1/40 (3) | 7 (23) | 9 (33) | 11.6 | 0.003 |
| Global rating of severe or overwhelming inability to lead ordinary life | 41/96 (43) | 10 (24) | 17/29 (59) | 14/26 (54) | 9.94 | 0.007 |
| Risk behaviour | ||||||
| Serious history of violence/dangerousness | 48/97 (50) | 13 (32) | 13 (43) | 22/26 (85) | 18.47 | <0.0001 |
| Moderate/severe aggression or disruptiveness in previous month | 38 (39) | 16 (39) | 12 (40) | 10 (37) | – | NS |
| Moderate/severe risk of self-harm in previous month | 11 (11) | 4 (10) | 3 (10) | 4 (15) | – | NS |
| Moderate/severe risk of non-deliberate harm in previous month | 40 (41) | 15 (37) | 13 (43) | 12 (44) | – | NS |
NS, not significant.
Table 3 shows the views of staff about suitability, placement issues and risks regarding discharge to less supervised settings. Nineteen (19%) had been transferred unsuccessfully to another placement at some point and returned to the service, with no significant difference in this between the service types. Out of the 47 service users who were considered inappropriately placed in their current unit, for 20 this was because of no suitable move-on accommodation (12 because none was available and 8 because a suitable one had no vacancies) and for 9 because of lack of funding for an available place.
Table 3 Placement appropriateness and discharge planning
| All, n (%) (n = 98) |
Community, n (%) (n = 41) |
Long term, n (%) (n = 30) |
High dependency n (%) (n = 27) |
χ2 | P | |
|---|---|---|---|---|---|---|
| Moderate/severe risk if discharged to independent setting | ||||||
| Violence | 56/97 (58) | 16 (39) | 16 (53) | 24/26 (92) | 18.89 | <0.0001 |
| Self-harm | 41/97 (42) | 16 (39) | 10 (33) | 15/26 (58) | – | NS |
| Unintentional harm | 60/96 (63) | 21 (51) | 17/29 (59) | 21/26 (81) | 7.84 | 0.02 |
| Anticipated problems if discharged to less dependent setting | ||||||
| Mild/moderate problems requiring attention | 89/95 (94) | 36/40 (90) | 28 (93) | 25/25 (100) | – | NS |
| Severe/very severe problems | 43/95 (45) | 9/40 (23) | 18 (60) | 16/25 (64) | 14.54 | 0.001 |
| Placement | ||||||
| Appropriately placed in current service | 50/97 (52) | 19 (46) | 12 (40) | 19/26 (73) | ||
| Different in-patient setting appropriate | 18/97 (19) | 4 (10) | 8 (27) | 6/26 (23) | ||
| Supported community setting appropriate | 24/97 (25) | 15 (37) | 8 (27) | 1/26 (4) | ||
| Independent setting appropriate | 5/97 (5) | 3 (7) | 2 (7) | 0 (0) | 15.19 | 0.019 |
NS, not significant.
Discussion
This study has limitations in that there was a difference in data collection periods and procedure between services where collection of one data-set commenced 11 months after the rest and involved one of the investigators rather than being left with key informant nursing staff to complete. The investigation schedule was an adaptation of an older questionnaire and not a standardised instrument. Out-of-area in-patient and low secure placements were not considered and consequently it was not possible to analyse their care pathways in relation to the local rehabilitation services.
The service user group surveyed here was characterised by significant use of in-patient services over a long period, active psychiatric symptoms, poor social functioning and unsuitability for independent living, despite interventions over a prolonged period of time. Substantial numbers had recent aggression and problems anticipated by staff if discharged to less dependent settings. The survey also demonstrated the well-documented high rate of moderate or severe physical health problems in this group of service users. Reference Connolly and Kelly9 Overall, the range of in-patient rehabilitation units in this survey managed high levels of risk and disability. They also provided the opportunity for service users to move on to less supported settings but with limited availability of suitable facilities creating obstacles to this end.
Some significant differences emerged between the units. Those in community units had less extensive service histories. Those in high-dependency services were more likely to be considered appropriately placed, reflecting the high risk of challenging behaviours that made less intensive settings untenable, and less likely to have an identified community team, which would have the effect of slowing referral out of the units. The individuals in high-dependency services were also more likely to have an affective psychosis, perhaps reflecting a group who are poorly engaged or whose condition is treatment resistant and who would not comply with open settings and could only be safely managed in a closed environment. The individuals in complex needs services were more likely to have severe physical health problems.
The overall findings were similar to another recent comparable survey Reference Killaspy, Rambarran and Bledin6 in terms of gender balance, ethnicity, age and comorbid substance misuse but there were fewer diagnosed with schizophrenia or schizoaffective disorder and more admitted from a community setting, possibly reflecting the higher morbidity of the inner-city London context of that service. Comparing long-term in-patient with short-term in-patient groups showed older age, longer contact with services and poorer social functioning in both studies. In our study more of the long-term in-patient group were detained but lengths of stay were lower, perhaps reflecting fewer patients who had come from long-stay mental hospital wards.
The findings support the principle that different types of rehabilitation services are required. In particular, provision is clearly warranted for those with more marked, challenging or risk behaviours, many of whom continue to be detained under the Mental Health Act 1983. The large number of service users remaining in these services due to their risk potential if discharged highlighted the need for comprehensive risk assessment to facilitate therapeutic risk-taking as part of the process of rehabilitation.
The findings indicated two areas of unmet needs in users of rehabilitation services. The first was difficulties moving on when considered no longer appropriate for their current environment. The most common reason given for this was a lack of suitable move-on accommodation, a more frequent reason than unavailable funding. This highlighted the serious lack of a range of appropriate residential settings being readily available, particularly relevant for the long-stay service user group. Similar results relating to the problems accessing appropriate move-on accommodation have been found among long-stay patients in acute admission wards. Reference Commander and Rooprai10 It appears that rehabilitation and acute services are attempting to access the same limited resources.
The greatest need was for supported residential settings reflecting less intensive needs, particularly for the community-unit service users. However, there was also a substantial requirement for ongoing intensive in-patient settings in the long-term service user group. Those in the high-dependency settings were the most likely to be considered appropriately placed, probably because this setting most clearly provided for the management of their enduring risk behaviours. Additionally, nearly half had no community team involvement, highlighting the risk of disconnection from community services, particularly for those in high-dependency services. This may result in longer than necessary stays since community care coordinators have a vital role in moving on, especially when moving from in-patient to supported or independent settings.
The second area of poorly met need was the availability of appropriate services for high levels of disability. This can be seen in the fact that a quarter were service users of assertive outreach teams, indicating that even the most highly resourced and intensive of community services for severe and enduring mental illness was still insufficient to maintain a substantial minority of such service users without residential services. Some service users were simply too disabled to be supported in the community. This may be related to the decline in rehabilitation services that took place in order to create assertive outreach teams in particular, with a corresponding focus away from reducing disability to management of risk Reference Holloway1,Reference Mountain, Killaspy and Holloway11 and loss of close links with residential care services.
Commissioning strategies need to take account of a ‘total system’ approach in order to facilitate service users being able to move through the various types and stages of rehabilitation necessary to gain an increased degree of independence. Reference Macpherson, Shepherd and Edwards12 It has also been recommended that commissioners need to look towards developing specialised services nearer to home for service users, which could provide better care at a lower cost. Reference Ryan, Hatfield, Sharma, Simpson and McIntyre13,14 Knowledge of the required types of rehabilitation in-patient services, and the corresponding size of population likely to need each type, Reference Wolfson, Holloway and Killaspy2 is of critical importance to the collaborative working of commissioners and providers. Whereas only the very largest NHS trusts will be able to provide rehabilitation in-patient facilities up to the full complement of services advocated, Reference Wolfson, Holloway and Killaspy2 smaller NHS trusts will need to orchestrate effective working between commissioners and providers in order to be able to access a similar range of services locally. Groups of neighbouring commissioners will increasingly need to work collaboratively in order to develop more local and specialised rehabilitation services.
Acknowledgements
We would like to thank the nursing staff of the ten rehabilitation services who provided invaluable assistance with data collection for this study.
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