Brit. J. Psychiat. (1976), 129, 418—23

Psychiatric Service for the Elderly: How Many Beds? By D. J. JOLLEY* Summary.

Reported

here

is a cohort

and TOM ARIE study

of five years'

bed usage

in the

Goodmayes Psychiatric Unit for Old People. Patients first admitted in 1970 continued to use beds, by readmission or by continuing stay, over the next four years;

subsequent

cohorts

of admissions

made

correspondingly

extended

use of

beds. Bed-usage by men appears now to have stabilized, whilst for women it is still rising. Over the first six years the bed complement was reduced by 40%, despite an increase in referrals of over 40%; this is because the Unit's style of work prevented newly admitted patients from accumulating in beds made available by deaths. It looks as if in future not only will patients who die be replaced by new female admissions but more beds will be needed for these admissions. The present bed-usage is just within the Government's recommended guidelines, and the local issues are considered in the context of national policy.

hrri@oDuc'rxoN The number of old people in England and Wales, especially the very old, has increased dramatically since the turn of the century and will continue to increase at least until the 199os. Over 25 per centof peopleaged over65 show frank psychiatric morbidity, and of persons over

of psychiatric services specifically for the elderly yields benefits in quality of care, staff satisfaction and more effective use of resources (e.g. Donovan et al (ig@ii), Robinson (1972),

8o one in five is demented

hospital in outer East London, deals with the entire referred old-age psychiatric morbidity among some 52,000 old people in a total population now of 415,000 (Arie, 1970). The

(Kay

Whitehead (ig7@), Baker (i@7@), Pitt (i@7@)). The psychiatric service for the elderly at Goodmayes Hospital, a district psychiatric

et al, i@7o).

The mental illnesses of these old people are often, indeed perhaps mostly, unrecognized by their own doctors, still less are they likely to be re ferred to psychiatrists; of those who are so re ferred about half may require admission to hospital

(Arie,

to deal with sufficient

ig@io). The

each

psychiatrist

case on its merits

beds to allow him to admit

aims of the service

are ready

availability

(with

home assessment in over 90 per cent of first referrals) and continuing responsibility wher ever appropriate. When admission to hospital is called for this can almost always occur at once and rarely is delayed beyond a matter of days. Since the inception of the service in January 1969 the unit's original complement of 350 beds (containing mostly elderly chronic residents in seven wards) has been reduced by

aiming

needs

for investi

gation, treatment, family relief, or long-stay care —¿rather than only under the pressure of a crisis. The problems of providing an effective psychiatric service for old people, and the re lated issues of staff morale pervade the entire range of services for the elderly (Arie, 1971); crowded wards, inadequate or insufficient staff, waiting lists and frank breakdown leading to ‘¿scandals'have become familiar features of the National Health Service. And yet many reports are now available which show that establishment

40 per cent,

despite

an over

40 per cent

increase

in referrals over this period. This has made it possible greatly to improve the hospital en * This study

was made

while D.J.J.

was onsecondmentby

the Manchester Area Health Authority to the Goodmayes Psychiatric 418

Unit for Old People.

D. J. JOLLEY AND TOM ARIE

vironment for the care of patients, the crowding and dismal surroundings being now largely replaced by fairly pleasant mixed-sex thirty bedded wards. In addition a small ‘¿Joint Patient Unit' was established in 1971 with the geriatri cian (Dr T. B. Dunn), where joint care is avail able for patients with ‘¿mixed' problems, patients in whom the relative importance of physical and mental components in their disorders is not clear at initial assessment, and for psychiatrically ill patients who develop intercurrent severe physical illness (Arie and Dunn, 1973). One consequence of the policy of careful assessment and energetic treatment is that those patients who remain for continuous long-stay care (i.e. over one year) in the hospital (some 10 per cent to 12 per cent of each quarterly cohort of admissions)

are

a more

deteriorated

and

de

pendent group than they used to be. The present study examines the bed usage by the Goodmayes Unit over the period i January 1970—31 December

1974.

Its main

purpose

4,9

first-ever

admission.

admissions

during

Patients the

having

six-month

index

epochs

i

January—30 June and i July—3i December of each of the five years were studied as cohorts. Their hospital residence following the index admission was mapped to 31 December 1974. The cumulative use of beds by these ten cohorts is described for the ten successive six-month epochs of 1970—74. 3. A count was made of residents in the unit on 2 January 1975. Deaths and discharges from the unit of patients admitted before i January 1970

were

obtained

from

death

and

discharge

registers for 1970—74.Together with the findings from 2 this made it possible to reconstruct the bed usage during 1970—74. 4. A few patients aged 65 and over were admitted under other consultants, and a few patients aged 6o—64were admitted into the unit for the elderly. The contribution to bed usage by these groups of patients was also studied.

was

to determine whether the present bed comple ment is likely to fall or need to be expanded. But this local issue is of more general relevance and has obvious bearing on the Government's guidelines for Services for Mental Illness Related to Old Age (DHSS, 1972).

RESULTS I. 215

admitted during (29

patients

(52

male,

to the psychiatric ‘¿970.I 19 of these

male,

90

female)

were

163

female)

were

unit for the elderly ‘¿index' admissions between

I January

and 30 June, g6 (23 male, 73 female) between i July METHOD

The study is based on routinely available hospital records and a census of residents on 2 January

1975.

i. Patients

aged

65 years

and

older

admitted

to the unit during 1970 were identified by age, sex and diagnosis (made shortly after their admission

by T.A.).

Periods

of admission

for

each case were mapped

over the years 1970—

1974.

to determine

Thus

it was

possible

the

total

bed usage both by each patient during this time and by the whole cohortover successive six month @

admitted and

patients

aged

65

years

to the unit between

31 December

Females

outnumbered

were ‘¿young-olds' (i.e. 65—74 years)

and 38 per

cent of the women. Depression was the common est diagnosis among the ‘¿young-olds',accounting for 52 per cent of the men and 48 per cent of the women; among the ‘¿old-olds'(75 years and over), 79 per cent of men and 62 per cent of women were demented. Most patients

hospital:

spent

a relatively

short

time in

63 per cent of both men and women

were resident months during

for a total of less than the five year period.

three

High bed usage was often due to repeated

epochs.

2. All

and 3! December.

males by just over 3 to I. 44 per cent of the men

1974 were

and

I January then

older

1970

identified

separately by sex. Their first admission within this five-year period was taken as the index admission. Some had had hospital stays before the index admission; for others this was their

admissions rather than to uninterrupted dence; this is so for of the 21 patients

resi with

dementia who spent more than one year in hospital. Repeated admissions emphasize the chronicity of the disability which derives from functional

disorders—particularly

states in women.

depressive

420

@

A PSYCHIATRIC

SERVICE FOR THE ELDERLY:

HOW MANY BEDS?

Demented patients are, of course, the longest beds, and the bed-days at some 5,000 bed-days per six months. Bed usage by women shows no users of beds; 77 per cent of men and 74 per cent of women admitted with this diagnosis died in such levelling-off: there has been a continuous the hospital within the five years of this study. rise to 100 beds and some 17,000 bed-days per Dementia accounted for 69 per cent of I I ‘¿310 sixmonths. bed-days used by the male cohort, and for 56 3. The number of beds in use on I January per cent of the 27,336 bed-days used by the 1970, 1971, 1972, 1973, 1974 are reconstructed. females. But thisheavy demand islargely pro Loss of patients admitted before January 1970 duced by only a few patients: the 6 longest-stay exceeded the gain of patients admitted since then men (i I @5per cent of male admissions) used in all years up to 1974 for both sexes. In 1974 therewas a verysmallgainoffemaleresidents. 5,379 bed-days, which is just under half of the total bed usage. Similarly the 15 longest-stay During the period of the study the other consultants never used more than 10 beds for women (9 per cent of female admissions) used 1,316 bed-days, or just over two-fifths of the admissions aged 65 and over; most of these total. The use of beds by the cohort falls off patientshad functionaldisorders. Conversely gradually over the five years. Yet even at the the Unit for Old People used up to 7 beds for end of this time some cases are still ‘¿active': younger patients, almost all with dementias. admissions, discharges, and deaths as well as continued residence, are still occurring. 200 E:

2. Bed

cohorts

usage

by

subsequent

has followed

a similar

index-admission

pattern

—¿ LOSS OF PATIENTS

to that of

the 1970 cases. The total usage is not, of course, confined to the six-month admission epoch nor ended by the full five years of the survey. Consideration of the number of patients left in at the end of successive six-month epochs and the bed usagewithinsuccessive six-month epochs (Fig i) confirms different patterns for the sexes.Thus, the number of male patients having theirindex admissionsincei January 1970 and remaining in hospital at the end of a six-month epoch has stabilized at less than 30

GAIN OF PATIENTS ADMITTED SINCE JAN.1970

ADMITTEDBEFOREJAN.1970

150

USE

USE

0

MALE

FEMALE

x z

20 1970 1971 1972 1973 1974 1975 I

16

Fic 2

/1/

0

12

I MALE

DISCUSSION I—

6

@

4

/

MALE

0• JJ JD 1970

JJ JD JJ JD 1971 1972 TIME

Fioi

JJ JD 1973

JJJD 1974

In this service, hospital admissions reflected the pattern of morbidity found in surveys of the elderly at home (Kay et al, 1964; Parsons, 1965), functional syndromes predominating in the ‘¿young-olds',organic in the very old. As at the time of Roth and Morrissey's studies (1952), the heaviest use of beds is by demented patients; admission to Goodmayes with a diagnosis of dementiacarrieda 75 percentchanceofevent

D. J. JOLLEY

AND

TOM

ARIE

421

ually dying in the hospital, and 6o per cent of the (60—64),who suffered in the main from organic demented women and 8o per cent of demented disorders. We have not estimated the beds used men dying in hospital are in their first admission. by other consultants for presenile dements Paranoid states now use few beds, for the more they are likely to be very few. florid symptoms usually respond to drugs. The totaldefactobed usageisthusrunning Patients with affective disorders are still heavy at about iso. The population now served is users of hospital beds: the method of following approximately 415,000 of whom 52,000 are cases through recurrent admissions emphasizes aged 65 years or more. DHSS provision would the chronicity of many of these disorders in the be 52 X (2.5 to 3) = 130 to 156 places for elderly(Post,1972),even though treatmentof persons with severe dementia; there would also the individual episode usually makes it possible be 17—33beds in a ‘¿Psycho-GeriatricAssessment Unit' (DHSS, 1970), and to our own bed to discharge the patient quite quickly. usage should be added 2 of the 4 beds in the Although 63 per cent of cases admitted during a yearspentlessthan a total ofthreemonths in JointPatientUnit sharedwith thegeriatrician hospitals in that year and the followingfour which (Arie and Dunn, 1973) are being used years, there is continuing use of beds throughout equally by each. In addition a proportion the fiveyears.The Nottingham case register (undefined but small) of the ‘¿05beds per 1,000' drew attention to similarly extended contact by for general adult psychiatry would be available elderly patients (DHSS, 197 ia). It is important to the elderly. Thus the present bed usage by patients admitted to the service since the begin to take this into account in planning bed re quirements, which cannot reasonably be as ning of 197015 within the DHSS suggested norms but there is very little room for manoeuvre; sessed on less than five years' experience. Indeed, moreover, although for men the bed usage for women even this length of observation may appears to have stabilized, for women it is still evidently be insufficient. rising. The beds originally occupied by ‘¿gradu The Goodmayes unit deals with all psychiatric ates' (long-stay patients who have grown old problems in the elderly in a defined population in the hospital) were the unit's initial ‘¿working —¿â€˜functional' and ‘¿organic' alike; its bed capital'. The fact that female ‘¿gains'are now complement thus cuts across the Government's exceeding ‘¿losses' of graduates means that this guidelines for beds: beds for functional disorders source of ‘¿capital'has run out, and the total in the elderly are included (though not specified) within the general psychiatric provision of 0@5 number of beds is likely to have to be increased unless the criteria for admission are changed. beds per 1,000 total population (DHSS, 1971b), Maintenance of the present service would re while provision for dements is specified sep arately in Servicesfor Mental illness Related to Old quire more beds—but how are they to be found? Certainly not by putting up again the excess Age (DHSS, 1972); in addition further beds are beds which have been taken down: new facilities proposed for ‘¿Psycho-GeriatricAssessment Units' will be needed. (DHSS, 1970). The evidence on which these ‘¿norms'are based has not been publicly stated; it seems CONCLUSION likely that HM(7I)97 took note of reports For the country as a whole it would thus be from generalhospitalunits(Silverman,1961; Baker, 1969),while HM(72)71 issaid to be prudent to observe trends for a while longer based on ‘¿an estimate of the average number of before accepting the DHSS guidelines; and in demented old people in psychiatric hospitals this connection, for reasons argued elsewhere (Arie, 1974), we feel that too much hope should at thepresenttime'(DHSS, 1972). The current bed usage by the cohorts studied notbe heldoutthatexpansionofDay Care will help to greatly diminish the number of in Is 130. In addition, up to rn beds were being used by other consultants in their management patient beds which are needed. ofpeopleadmittedin oldage,and theunithad It cannot be too strongly emphasized that at times used up to 7 beds for younger patients the number of beds used can be a very mislead

A PSYCHIATRIC SERVICE FOR THE ELDERLY: HOW MANY BEDS?

422

ing guide to the number of beds needed—for decisions to admit depend on the number of beds have

available: a service zero admissions!

system accommodates, resources,

but

that has no beds, In other words,

will the

in a fashion, to available

at a cost—and

one

must

con

stantly remind oneself of this effect, otherwise a series of damaging ‘¿self-fulfillingprophesies' will result, in which inadequate provision is made to appear adequate. To assess the number of beds needed one must look at the quality

of the service as well as at the

REFERENCES ARni,

T.

(,g7o)

The

first year

of the Goodmayes

Psych

iatric Service for Old People. Lancet, ii, 1179—82. —¿

(ig7i)

Morale

and

the

planning

of

psychogeriatric

services. British Medical ,Journal, iii, 166—70. —¿

(1974)

Day

Care

in

geriatric

psychiatry.

Gerontologia

Clinica, 17, 31—9. —¿

&

DUNN,

T.

(i@7@)

A

do-it-yourself

psychiatric

geriatric joint patient unit. Lancet, ii, 1313—16. —¿

(1976)

Thoughts

on

rationing

and

responsibility.

Proceedings of Symposiwn on ‘¿Brain Failure in the Elderly', jersey, 1975. Age and Ageing. In Press. BAKER, A. A. (1969)

Psychiatric

unit

in a general

hospital.

Lancet, i, 1090—2.

number of beds it uses. Nor should it be assumed by planners that beds occupied by ‘¿graduates' C00FER, M. H. (1975) Rationing Medical Care. London: Croom-Heim. are all rightly to be regarded as potential beds for new admissions—some are likely to be DHSS (‘97°)XHS Psycho-Geriatric Assessment Units. —¿

occupied

service is thus always bound

to be only a relative

figure—'appropriate' to what scope of care? and appropriate in relation to what scope of provision of local authority and of other National Health Service resources? A low of beds might

well be sufficient

—¿

elective admission for early treatment, for relief for relatives, or for investigation; it all depends what aims a service sets itself and what level and

(1971a)

psychogeriatrics?

The

1969.

Lancet,

795—6.

London: HMSO.

Nottingham

Statistical

i,

Psychiatric

Report,

Case

Register,

Series No.

I962@-

13. London:

HMSO. —¿

(1971b)

Hospital

Services

for

the

Mentally

Ill.

Circular

HM(7I)97. London: HMSO. —¿

(1972)

Services

Circular

for

Mental

HM(72)71,

DoNovAR,j.

illness

London:

Related

to

Old

Age.

HMSO.

F. WILLIAMS, I. E. I. & WILSON, T. S. (i@7,)

A fully integrated psychogeriatric service. In Recent Developmentsin Psychogeriatrics(ed. D. W. K. Kay and A. Walk.) British journal of Psychiatry cation No. 6. Ashford, Kent: Headley

for an

effective crisis service, or even for a long-stay care service, while not giving opportunities for

Why

Circular HM(7o)II.

by ‘¿graduates' for a long time yet; and

we are only now beginning to obtain estimates of the likely size of the forthcoming generation of graduates (Mann and Cree, ‘¿975). The ‘¿appropriate' number of beds for a

number

(1974)

HAwKS,

D.

(1975)

Community

Care.

Official Bros.

British

Publi

Journal

of

Psychiatry, 127, 276—85. KAY, D.W.K., BEAMISM,P. & Roi@ss, M. (1964) Old age mental

disorders

in

Newcastle

upon

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British

Journal of Psychiatry, 110, 146—58. —¿

BERGMANN,

K.,

FOSTER,

E.

M.,

McKacunnt,

A.

A.

&

Rom, M. (@o) Mental illness and hospital usage in quality of care it is willing or able to offer. the elderly. Comprehensive Psychiatry, 1,26—35. When there are too few beds to give any ‘¿elbow MAMn, S. & CREE, W. (1975) The ‘¿newlong-stay' in room' for facultative as well as emergency mental hospitals. British Journal of Hospital Medicine, 14 admission, then not only does quality of care 56—63. @

suffer,

but

with

it staff

morale.

The

need

to

operate a ‘¿rationing'of services which is defined by no publicly agreed criteria is dispiriting for staff, and makes for poor rapport between a service, its colleagues outside the hospital and its clients. Local assessment of what is feasible (rather than just what is desirable) is necessary, and the conclusions should be publicly announced; in this way the ‘¿rationing'of medi cal care (Cooper, 1975; Owen, 1975, Arie, 1976) could be more objectively conducted according to known criteria rather than merely negotiated ad hoc between individual clinician and mcli vidual client.

OWEN,

DAvm,

MP.

in House

of Commons,

quoted

in British Medical Journal, ii, 356. PARSONS,

P. L.

(i@6@)

Mental

health

of Swansea's

old

folk.

British Journal of Preventive and Social Medicine, 14,56-

63. Prrr,

B. (,@7@) Psychogeriatrics. Livingstone.

POST, F. (1972)

The management

London:

and nature

Churchill of depressive

illness in late-life: a follow-through study. British Journal of Psychiatry, 121, 393—404. ROBINSON, R. A. (1972) Organising a psychogeriatric

service.In TheElderlyMind.British Hospitaljournal/ Hospital

Rom,

International,

22-4.

M. & MORRISSEY, j. D. (1952) Problems in the

diagnosis

and

classification

of mental

age. Journal of Mental Science, 98, 66.

disorder

in old

D. J. JOLLEY SILVERMAN,

M.

(i96i)

A comprehensive

department

AND of

psychological medicine. British Medical Journal, ii,

TOM WmIir.@r),

ARIE

423 j.

A. (I974)

Psychiatric

Disorders

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London: Harvey Miller and Medcalf.

698—701.

D. J. Jolley, B.Sc., M.B., M.R.C.Psych.,Consultant Psychiatrist, University Hospital of South Manchester; Hon. Lecturer in Psychiatry, Manchester University Tom Arie, M.A., B.M., M.R.C.Psych.,F.F.C.M., Consultant Psychiatrist, Goodmayes Hospital, Ilford; Hon. Senior Lecturer in Psychiatry, University College Hospital Medical School Detailed

@

tabulations

of the bed usage data may be obtained

(Received 24 November

revised 9 March 1976)

from either author,

as may reprints.