The virtual institution: cross-sectional length of stay in general adult and forensic psychiatry beds

Abstract

BackgroundLength of stay in psychiatric hospitals interests health service planners, economists and clinicians. At a systems level it is preferable to study general adult and forensic psychiatric beds together since these are likely to be inter-dependent. We examined whether patients were placed according to specialist need or according to their cross-sectional length of stay.MethodsA one night census of all registered mental nursing home (RMNH) beds was carried out for a defined catchment area of 1.2 m population in north London in November 1999. This included all public sector psychiatric hospital beds, independent sector and forensic beds in and outside the catchment area. Cross-sectional length of stay was defined as time since the date of admission from the community. Log rank (Mantel-Cox) Chi squared was used to test for differences between groups and hierarchical logistic regression for statistical modelling.ResultsThere were 1,085 occupied psychiatric beds. Cross-sectional LOS was greater than 365 days in 43.5%. Forensic beds had longer cross-sectional LOS than general beds. LOS increased with the level of therapeutic security from open through low, medium and high secure. Cross-sectional LOS was shorter for open hospital beds than community RMNH beds, shorter for informal patients than those detained under civil mental health law, and longest for forensic detentions. Longest cross-sectional LOS were for patients placed in RMNHs in the community, 10.7% of whom were ‘forensic’ as were 25.4% of low secure patients. Designated length of stay (acute, rehab/medium term and long term) was also associated with increasing cross-sectional LOS. In regression analysis only three variables contributed to a model of cross-sectional LOS, commissioning status (general or forensic), designated length of stay and designated level of therapeutic security.ConclusionsStudying cross-sectional LOS for whole systems (all psychiatric beds) is essential for operational health service management. At the time of this survey ‘forensic’ status was the main way of accessing long term high dependency places. This has been an organic development over time, a response to patient needs rather than the outcome of any specific policy or plan.

A mixed-methods study exploring the characteristics and needs of long-stay patients in high and medium secure settings in England: implications for service organisation

“…A recent study, 34 based on a 1-night census of a catchment area of a 1.2 million population in North London in 1999, found a median LoS of 79 days in non-forensic beds, whereas for forensic settings this figure was 1367 days. Of general psychiatric patients, 23.4% stayed for > 1 year and 17.9% stayed for > 5 years, whereas the corresponding figures for forensic patients were 81.2% and 39.1%, respectively.…”

“…12,26,28,29,33,34,37,[39][40][41][42]57,74, Eleven countries were represented: the UK (n = 22 12,26,28,29,33,34,37,39-42,77-80, 82,84,86,87,89,92,97 ), the USA (n = 4 90,94,96,99 ), Ireland (n = 2 81,98 ), Germany [n = 2 93 (one of which was personal communication: Dönisch-Seidel, Ministerium für Gesundheit, Emanzipation, Pflege und Alter des Landes Nordrhein-Westfalen, 2013)], Croatia (n = 2 57,88 ), Australia (n = 1 85 ), Malaysia (n = 1 83 ), New Zealand (n = 1 95 ), Norway (n = 1 91 ), the Netherlands (n = 1 74 ) and Sweden (n = 1 76 ). The studies from the UK had samples drawn from high secure (n = 5 29,33,78,84,89 ), medium secure (n = 14 26,37,[39][40][41][42]77,79,80,82,86,87,92,97 ) and mixed secure (n = 3 12,28,34 ) settings. The Norwegian study was based in a 'maximum' secure setting.…”

“…These were published between 1987 and 2015 with samples covering the period from 1972 to 2011. Five countries were represented: the UK (n = 12 12,26,28,33,34,[39][40][41][42]82,92,97 ), Germany (n = 1 93 ), the USA (n = 1 99 ), Malaysia (n = 1 83 ) and Ireland (n = 1 98 ). Thirteen studies supplied LoS as a mean value; only five provided medians, which are arguably a better measure of central dispersion for a variable that commonly has a non-normal ('skewed') distribution.…”

Ethical issues of long-term forensic psychiatric care

“…Firstly, not surprisingly, LoS in forensic psychiatric settings far exceeds that in general psychiatric services, though only few studies have compared these two settings directly. A recent study [10], based on a one-night census of a catchment area of a 1.2 million population in North London in 1999, found a median length of stay of 79 days in non-forensic beds whereas, for forensic settings, this figure was 1367 days. In total, 23.4% of general psychiatric patients stayed for more than one year, and 17.9% for more than 5 years, whereas the corresponding figures for forensic patients were 81.2 and 39.1%, respectively.…”

Long-Term Forensic Mental Health Services: An Exploratory Comparison of 18 European Countries

“…Though a rapid reduction of beds in psychiatric hospitals generally has been witnessed internationally, there has been a significant increase in demand for forensic services (Hodgins, Müller-Isberner, & Allaire, 2006;JansmanHart, Seto, Crocker, Nicholls, & Cote, 2011;Priebe et al, 2005Priebe et al, , 2008. While the length of stay (LoS) in forensic inpatient mental health services has fallen, at least in some countries, and recovery principles have been applied to MDOs (Sugarman & Oakley, 2012), a number of patients still experience lengthy stays in forensic services, potentially at inappropriately high levels of security (Shah, Waldron, Boast, Coid, & Ullrich, 2011;Sharma, Dunn, O'Toole, & Kennedy, 2015;Shaw, Davies, & Morey, 2001). This is of concern for two reasons; firstly, lowvolume inpatient forensic services are cost and resource intensive, and secondly, the quality of life in these restrictive environments may be poor (Joint Commissioning Panel for Mental Health, 2013;Vorstenbosch, Bouman, Braun, & Bulten, 2014).…”