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. 2002 Nov 30;325(7375):1300. doi: 10.1136/bmj.325.7375.1300/b

The NHS, the private sector, and the virtual asylum

Editorial was destructive

Philip A Sugarman 1,2, Lorna Duggan 1,2, Geoff Dickens 1,2
PMCID: PMC1124757  PMID: 12458259

Editor—We were surprised by the tone of and the stigmatising language and strong opinions without cited evidence in the editorial by Poole et al on the NHS, the private sector, and the virtual asylum.1 The article sets out many undisputed facts such as the decline of the county asylums and the current inadequate provision of mental health beds under the NHS. No evidence is, however, cited to support the description of difficult to manage patients in the independent sector, poorly staffed small units, or the lack of activity or rehabilitation for patients.

What evidence there is does not support any of these claims.2,3 Paradoxically, the acknowledgement that larger independent facilities may give a higher quality of care than the NHS is also left unsupported. Further criticisms are made of NHS services and planning, again without evidence.

No mention is made at all of the rapid regionalisation of independent sector facilities, a key development in meeting patients' needs more locally. Quite how the authors perceive a lack of any policy framework or regulation to protect patients is unclear. The Care Standards Act has introduced the national minimum care standards as part of a stringent framework of policy, clinical standards, and inspection, in addition to that provided for patients by the Mental Health Act Commission.4 Under the aegis of the Independent Healthcare Association, members of both the private sector and the voluntary sector are also subject to external quality control, such as the King's Fund Health Quality Service. Interestingly, the Care Standards Act does not apply to the NHS.

Offering phrases such as private madhouse, acculturation to institutional life, and virtual asylum, Poole et al raise the possibility of the private sector being discredited in a destructive moral panic. No evidence is given as to why this has become in any way likely, except perhaps as an effect of such palpable hostility. Their piece is an example of the conflicted thinking on public-private partnership still prevalent in the state sector. This blights NHS planning for constructive partnership and needs to be addressed in the interests of patients.

Footnotes

We are employees of the St Andrew's Group of Hospitals, a registered charity providing specialist psychiatric care in Northamptonshire, Essex, and Middlesex.

References

  • 1.Poole R, Ryan T, Pearsall The NHS, the private sector, and the virtual asylum. BMJ. 2002;325:349–350. doi: 10.1136/bmj.325.7360.349. . (17 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Moss K. A comparative study of admissions to two Regional Secure Units and one independent medium secure hospital. Med Sci Law. 2000;40:216–223. doi: 10.1177/002580240004000305. [DOI] [PubMed] [Google Scholar]
  • 3.Lelliott P, Audini B, Duffett R. Survey of patients from an inner-London health authority in medium secure psychiatric care. Br J Psychiatry. 2001;178:62–66. doi: 10.1192/bjp.178.1.62. [DOI] [PubMed] [Google Scholar]
  • 4.Department of Health. Care Standards Act. London: Stationery Office; 2000. [Google Scholar]
BMJ. 2002 Nov 30;325(7375):1300.

Misconceptions are naive

John C Hughes 1

Editor—The editorial by Poole et al on the NHS, the private sector, and the virtual asylum understates and misrepresents the contribution of US independent psychiatric providers.1-1 The Department of Health figures cited provide more information than the authors report. The table shows the NHS with 34 210 (55%) inpatient psychiatric beds and the independent sector with 28 780 (45%), both of which exclude residential care units.

Poole et al complain that independent operators are disbursed, invisible, and not properly regulated. Count me among those who are delighted that these 28 780 beds are disbursed; they are mostly small establishments that respond fast to the call to provide community care on a 24 hour, 365 day basis. They are not invisible: they are shiny, clean, proud, quasi-public institutions that devote huge effort to visibility to attract inpatient and outpatient customers. They are heavily regulated by the National Care Standards Commission, the King's Fund Health Quality Service, the Mental Health Act Commission, private medical insurers, malpractice insurers, and other regulatory bodies in varied ways in which NHS hospitals are not.

Our strictest regulation comes from NHS general practitioners and specialist teams who refer to us. Each receives a confidential weekly status report, is invited to periodic care programme planning meetings, and receives a discharge summary by fax or email on the date of discharge. Our consultants have ward rounds at least three times a week as a condition of their contracts. If professional referrers are dissatisfied with the service their patients receive they have freedom of choice to select another independent unit from among 20 or more organisations that compete on the basis of quality, immediacy of response, and price. This market discipline has in fact closed more than 10 independent units in the last decade by withholding referrals—and we are all better off because of it.

The cited Department of Health statistics also show 231 000 completed consultant episodes in NHS psychiatry in 1998. That means our small, 400 bed organisation's 3600 acute admissions this year makes a contribution to public health roughly equal to 1.7% of the NHS's total provision. A census of 60 competing private establishments and 200 consultant psychiatrists in full time private practice would run this tally up to perhaps 25% of total provision in all acute care and high dependency areas of psychiatry. Half of this work is NHS funded and half self funded in cash or through private medical insurance schemes, which Poole et al don't mention.

Everyone wants the debate to continue so that all psychiatric providers—public, voluntary sector, and independent—can best serve patients. But readers need to be informed with hard facts on all sectors. Please avoid perpetuating misconceptions.

References

  • 1-1.Poole R, Ryan T, Pearsall The NHS, the private sector, and the virtual asylum. BMJ. 2002;325:349–350. doi: 10.1136/bmj.325.7360.349. . (17 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Nov 30;325(7375):1300.

No lessons have been learnt

Leila B Cooke 1,2, Peter Carpenter 1,2

Editor—The editorial by Poole et al on the NHS, the private sector, and the virtual asylum must have struck a chord with many psychiatrists.2-1 The move from institutional to community care has occurred later in services for people with learning disability, but the same mistakes are being repeated.

Around Bristol the large hospitals for people with learning disability have been closed. Only 12 admission beds for a population of 1 million remain, and 40 rehabilitation beds are earmarked for closure over the next year. The loss of over 1200 NHS beds has been replaced with over 1200 beds in private residential care or nursing homes.

For over 10 years social services have been seen as the main commissioners of care for people with learning disability, and, with the new partnership boards, are to commission residential health care. We still see no evidence of them having the knowledge, strategic vision, will, or staff to ensure that the private sector overall provides a comprehensive local service that can deal with a wide range of challenges and needs in an individual manner. No provision has been planned for the longer term care of detained patients, patients who require forensic psychiatry, or patients who require rehabilitation by skilled staff.

The private sector is subject to market forces and therefore can be responsive to service needs, but it needs good leadership to develop high quality entrepreneurial services. The new private system is open to strong external inspection to maintain good basic care and a healthy environment, but in learning disability, as in mental health, little good supervision is taking place of the quality of clinical care provided for individual patients.

The local disaggregation into five primary care trusts and their partnership boards has now apparently made it impossible to plan jointly the provision of new expensive tertiary or quaternary services. The commissioning costs are divided, and each is faced with funding expensive emergency placements without the resources to plan a less expensive service proactively. These emergency placements have cost as much as £750 000 a year. When longer term skilled placements are needed, people still go outside the area, where they are less supervised by the local team and little incentive exists for the provider to rehabilitate them.

Until we can obtain good commissioning and good placement supervision along with an effective mechanism to plan together, patients and their families will continue to suffer and money will be wasted.

References

  • 2-1.Poole R, Ryan T, Pearsall The NHS, the private sector, and the virtual asylum. BMJ. 2002;325:349–350. doi: 10.1136/bmj.325.7360.349. . (17 August.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Nov 30;325(7375):1300.

Authors' reply

Rob Poole 1,2,3, Tony Ryan 1,2,3, Alison Pearsall 1,2,3

Editor—It is unfortunate that we have provoked a defensive reaction in two large private sector providers, St Andrew's and their business partners Cygnet. Our editorial is not an attack on the private sector. On the contrary, the private sector has fortunately provided extra bed capacity in the absence of appropriate NHS provision for long stay mentally ill patients.

Hughes describes the full range of his company's services, much as he did in a recent Sunday Times article.3-1 His few comments that are pertinent are unsustainable. Shiny, clean, proud, quasi-public institutions exist, but many more small nursing homes are tucked away in redundant hotel buildings or close to commercial areas outside towns. He celebrates dispersal, but the provision of long term care far from home was a key failing of county asylums. It isolates patients and militates against rehabilitation to less institutional settings. Our experience of visiting many patients across the full spectrum of private care does not support his complacency about the effectiveness or appropriateness of the regulatory systems.

The St Andrew's correspondents object to the rhetorical nature of the paper, but this is the function of an editorial. In defending themselves against perceived attack they cite evidence relating to medium secure units, which represent only a small part of long term provision. Long stay patients placed outside their area have attracted little research attention, although the flaws in the system of care are widely recognised. Information about these patients is difficult to access. Systematic research is needed urgently. This must be focused on patients, not institutions, to establish better systems of long term care, straddling private and public provision.

Who, we wonder, are we accused of stigmatising? Private madhouse is accepted historical terminology. Acculturation to institutional life is the outcome of rehabilitation when it occurs without integration with the next stage of care. Virtual asylum alludes to “county asylum.” Institutional psychiatric care far from home is as known as “asylum.” The term may be uncomfortable but is neither stigmatising nor unfair.

It is disheartening, although hardly surprising, to learn that similar problems exist in learning disability services. Even high quality institutions cannot overcome the inevitable failings of ad hoc whole systems of care. Variations in quality of care exacerbate rather than cause these problems. Such variations exist both in and across the NHS and the private sector.

Footnotes

We are seeking funding to research the care of long stay mentally ill patients placed outside their area.

References

  • 3-1. Hughes J. Private sector can help NHS care better for mentally ill: the Enterprise Network. Sunday Times 2002;14 July:business section.

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