30

Psychiatric BedsTHE Ministry of Health’s announcement,l in 1961,

that the number of beds for psychiatric patients wouldbe reduced by nearly half (from 3-4 to 1-8 per 1000

population) by the mid-1970s was received with somemisgiving in psychiatric circles. The statistical basisof this rundown policy was the projection of a down-ward trend observed in the numbers of resident psychia-tric patients between 1954 and 1959, as revealed by thecohort studies of Dr. G. C. TOOTH and Miss EILEENBROOKE.2 Yet, when it was published, the Tooth-Brookeprojection was criticised as being unrealistic and

statistically unsound. Despite these criticisms, however,a recently published census,3 carried out by MissBROOKE for the Ministry in 1963, of all patients in

psychiatric hospitals and units shows that the pre-dictions were substantially correct, and that the rundownforecast was, in fact, being maintained at the time of thecensus. Even so, not all psychiatrists will concede thatthe present rate can or should be maintained, and thevery fact that the Ministry policy has remained a con-troversial issue is enough to justify a census. The

present census is the first full survey of patients inpsychiatric beds to be published in Britain, and, as such,it will be a valuable reference for future planning. It isto be hoped that the exercise will be repeated at intervals-perhaps every five years.

Given a tolerant and sympathetic public, changes inthe patterns of admission, discharge, and readmissioncan be as effective as therapeutic advances in determin-ing future bed requirements, but there can be no suddenadministrative revolution in psychiatry-the size of thelong-stay population will see to that. Long-stay patients(those resident in hospital for two years or more) accountfor two-thirds of the total beds, and many of them havebeen in institutions too long to benefit from intensivepsychiatric treatment. Since their care is often custodialrather than therapeutic, their presence in hospital,though unavoidable, to some extent frustrates the

implementation of measures (early treatment, main-tenance of contact with family and community, after-care, and active rehabilitation) designed to limit the

build-up of the future long-stay population. In 1963there were 90,000 long-stay patients in psychiatrichospitals and units-20,000 fewer than in 1954. The

Ministry’s critics believe that this rate of rundown

imposes too great a burden on the community (althoughhow much of this reduction resulted from deaths andhow much from discharge is not revealed by the census).In practical terms, however, it means that 20,000 bedshave been released for the active practice of preventivepsychiatry, which, barring dramatic and unforeseen

improvements in treatment, is the only hopeful way ofpreventing patients in the early stages of mental illnessfrom entering the long-stay population-from whichthey may all too soon become irretrievable.As the problem of the long-stay patients slowly

1. Ministry of Health Circular H.M.(61)25. 1961.2. Tooth, G. C., Brooke, E. M. Lancet, 1961, i, 710.3. Brooke, E. M. Census of Patients in Psychiatric Beds 1963. H.M.

Stationery Office, 1967.

diminishes, another is rapidly taking its place-that is,the growing number of elderly patients. Between 1954and 1963 the number of patients aged 65 and over roseby 6300 (from 45,400 to 51,700), and almost half thewomen patients are now 65 or more. Is this increasemade up merely of existing long-stay patients who aregrowing older, or are more patients being admitted whoare already senile ? In a census in the Leeds area GOREand his colleagues 4 found that some 60% of this groupwere long-stay patients but that the other 40% had beenadmitted over the age of 65. Slowly the number ofpatients who are feeble and senile is increasing, and agedpatients are being admitted to hospitals where conditionsare unsuitable and nursing staff inadequate for physicalnursing. Moreover, this trend is likely to continueunless additional accommodation for the aged, bothhospital and local authority, is provided elsewhere. Theproblem of looking after old people affects all sectorsof the health and welfare services, but it would be a pityif efforts to increase the efficiency of mental hospitalsand the efficacy of psychiatric treatment were to bethwarted by demands arising from the lack of adequatefacilities for general geriatric care.The census reveals considerable regional variation-

in provision of beds, percentage bed occupancy, dis-tribution of the various mental disorders, proportions ofinformal and detained patients, and so on-and althoughsome of these variations can probably be explained bydifferences in geography and social conditions, othersmay be related more to standards of clinical practice.These findings are certainly worth deeper study. Westill know too little of how our mental hospitals are beingused, and planning would be more accurate if regionalboards would take another long hard look at the figures

. for their own areas, to discover how and why they

; differ from the national picture.

Record Order

IN 1965 the Tunbridge committee on hospital medicalrecords reported 5 to the Central Health ServicesCouncil. Its terms of reference were limited to the

problems of standardisation, though, in the event, thecommittee also looked ahead at the possibilities of data-processing and record-linkage. At the time we wel-comed the report as an authoritative guide to a reason-able middle path of partial standardisation. The

Ministry memorandum 6 accompanying the reporturged that eleven standard forms be taken into use byApril, 1966, or at the latest by March, 1968. Whilstthere was a considerable warmth of support for this

very necessary principle of standardisation, manypeople felt that there were some real points of difficultywhich ought first to be settled and that this proposedintroduction of the forms on a broad front was too

4. Gore, C. P., Jones, K., Taylor, W., Ward, B. Lancet, 1964, ii, 457.5. The Standardisation of Hospital Medical Records. Report of the Sub-

committee of the Standing Medical Advisory Committee of theCentral Health Services Council. H.M. Stationery Office, 1965. See

Lancet, 1965, ii, 675.6. Ministry of Health Memorandum H.M.(65)71.