The chaotic, violent world of our mental health wards

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Do not be deceived by the studiedly neutral tone of today's report from the Sainsbury Centre on the state of Britain's psychiatric wards. The scandal it reveals is evident in the subtitle: this is the first national survey of acute in-patient mental health wards anyone has thought to carry out. That it has taken until 2005 for an official, systematic investigation of how our neediest and most vulnerable citizens are being cared for is bad enough. Standards of care for heart patients, cancer patients and surgical patients have been studied for more than a decade, but mental patients, as ever, come last in the queue.

Do not be deceived by the studiedly neutral tone of today's report from the Sainsbury Centre on the state of Britain's psychiatric wards. The scandal it reveals is evident in the subtitle: this is the first national survey of acute in-patient mental health wards anyone has thought to carry out. That it has taken until 2005 for an official, systematic investigation of how our neediest and most vulnerable citizens are being cared for is bad enough. Standards of care for heart patients, cancer patients and surgical patients have been studied for more than a decade, but mental patients, as ever, come last in the queue.

The report is full of dry statistics: these will provide a useful benchmark for future audits which can check what progress, if any, is made in coming years. But what the report fails to convey is the feel, the taste, the bedlam of most psychiatric wards. They are noisy, frightening places, with people out of control, in varying states of distress and with too few staff to cope. Most patients are forcibly admitted under section, heavily drugged to enable them to cope, and then left to fend for themselves. The average admission is for three weeks - not the two or three days common for physical illnesses - and boredom is a key problem.

There is nothing to do on most wards except watch TV or smoke cannabis. Many patients indulge in the latter to wile away the days; there is drug dealing and, inevitably, violence. The wards are crowded, unpleasant, and in varying states of disrepair. More than one in five managers in the Sainsbury Centre survey said their ward environment did not promote positive mental health care. The Healthcare Commission survey found more than one in three patients had experienced threatening behaviour - mostly from other patients.

How can such places provide the therapeutic care patients need? Admission to hospital is too often damaging rather than healing. Treatment is mostly with heavy doses of powerful sedative drugs - few wards have the resources to offer psychological treatments - which patients are reluctant to take once discharged. Hence they fall ill, are readmitted and the cycle begins again.

No part of the mental health system can function effectively unless all parts do so. The modern emphasis on caring for acutely ill mental patients at home, where possible, is welcome as it avoids the damaging effects of admission to hospital and the stigma that comes with it. Drugs can be given and patients monitored at home just as well as in hospital, given sufficient staff, with visits up to three times a day to those in crisis. But the effect has been to suck staff and resources away from the in-patient wards to fund the new community teams. The wards thus remain neglected, with the fewest staff and least resources. At the same time, rather than reducing hospital referrals as hoped, the community teams have mopped up the less severe cases while passing on the most severe for admission. The result is the hospitals have become filled with sicker, more distressed and more acutely ill patients - the ones they should have - but at a time when they are losing staff and resources.

The NHS has had billions in extra cash in recent years, and although the service to patients is slowly getting better, mental health is not keeping pace. Management tables published last year by the Healthcare Commission showed that a third of mental health trusts had one star or less, indicating poor performance. The number allocated zero stars had risen over the previous year from three to seven. Sir Ian Kennedy, the chairman of the commission, said he had marked the mental health system as a priority for remedial action. The new Health Secretary, Patricia Hewitt, must now do so, too.

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