Design

A cross sectional census day questionnaire design was employed to ensure uniformity of data.

Criteria for inclusion

For the purpose of the study the following definition of a PICU was derived: the provision of intensive multidisciplinary treatment and care by trained staff for severe or consistent disturbance exhibited by mentally disordered patients, over a time-limited period, usually within conditions of security (Pereira et al., 2001).

The definition was read out when the units were contacted to resolve inclusion.

Identification and recruitment of units

The project received MREC ethical approval. The Mental Health Act committee provided details of services in England and Wales to house detained patients. A similar list was obtained for Scotland and Northern Ireland from the Department of Health in their respective countries. Each service was individually contacted via the mental health bed manager to identify the presence of a PICU. Subsequently, each individual ward manager was contacted to finalise inclusion or not.

The survey

An eight-section questionnaire was designed by a multi-disciplinary panel of health care professionals. The questionnaire was piloted on four PICUs and one LSU after which minor changes were made to the wording and layout. The questionnaire comprised the following sections:

• Ward information

• Structure

• Facilities and policies

• Patient characteristics

• Staffing

• Operational characteristics

• Unit functioning

A full copy of the questionnaire can be obtained by contacting the authors. The data collection was carried out in 2002. To ensure a high response rate a telephone help-line was set up to assist completion of the questionnaire and the joint head of Mental Health in the Department of Health wrote letters to participants encouraging data return. Phone calls, reminder letters and personal visits to the units also took place enhancing the response rate. A response rate of 98% was achieved.

Unit characteristics

General unit information and provision

A total of 170 PICUs were identified. Of these 154 were NHS and 16 private.

Figure 1 shows that in England there were 118 NHS and 15 private PICUs. Scotland had 17 and Northern Ireland had 7 NHS units, but no private units. Wales had 12 NHS and 1 private PICU.

Figure 1.

Numbers of NHS and private PICUs in the UK

Regarding the mean number of beds, the private sector had a significantly higher number of overall beds (t = −3.55, df = 168, p = 0.000) compared to the NHS. Moreover, the private units had a higher number of male only beds (t = −3.83, df = 166, p = 0.000) compared to the NHS. There was no significant difference between the NHS and private sector regarding the number of female only beds or mixed beds. See Table 1 for details.

Table 1.

Mean number of beds

Staffing

Staffing levels are shown in Table 2. Private units had more staff working on early shifts as compared to the NHS units. Similarly, the private sector had significantly more qualified staff working in early, late and night shifts compared to the NHS. The patient:qualified staff ratio on NHS PICUs was 4 patients to each nursing staff member (4:1); for the private PICUs the patient:qualified staff ratio was 2:1. NHS units reported having more non-nursing staff; more than 1 consultant on the unit (χ² = 8.89, df = 1, p = 0.003); 26% of NHS and 12% of private units had psychologists; 49% of NHS and 37% of private units had occupational therapists; 21% of NHS and 31% of private units had social workers and 19% of NHS and 31% of private units had art therapists.

Table 2.

Nursing and other staff working on units

SHO = Senior House Officer; OT = Occupational Therapist

Provision of facilities

The results show that seclusion, time out and gym facilities were not present in a large number of PICUs (both NHS and private). These results are shown in detail in Table 3.

Table 3.

Unit facilities

Table 4.

Core interventions

ECT = Electroconvulsive Therapy

Protocols

Table 5 shows the protocols that were being used on the units. It shows that private units were significantly more likely to have referral system (χ² = 5.43, df = 1, p = 0.020), pre admission assessment (χ² = 3.90, df = 1, p = 0.023) and suicide protocols (χ² = 8.33, df = 1, p = 0.048) than NHS units.

Table 5.

Protocols

Care pathways – referral, admission and discharge

Table 6 shows that NHS units were significantly more likely to accept referrals from local mental health wards (χ² = 10.16, df = 1, p = 0.001).

Table 6.

Referral, admission and discharge

OAT = Out of Area Treatment; GBH = Grievous Bodily Harm; MHA = Mental Health Act; PD = Personality Disorder; LD = Learning Disability

Private units were significantly more likely to accept referrals from:

• Out of Area (χ² = 35.29, df = 1, p = 0.000)

• Long stay low secure (χ² = 8.74, df = 1, p = 0.003)

• Prison (χ² = 4.02, df = 1, p = 0.045)

NHS units were significantly more willing to admit informal patients (χ² = 11.01, df = 1, p = 0.001) and patients with a primary diagnosis of LD (χ² = 6.17, df = 1, p = 0.013) compared to the private units. Regarding the discharge behaviour of units, NHS units were more likely to discharge patients to local mental health wards (χ² = 10.09, df = 1, p = 0.001) and high secure facilities (χ² = 5.74, df = 1, p = 0.017) compared to their private counterparts.

Patient characteristics

The NHS PICUs were reported to be housing 1038 patients and the private PICUs 200 patients.

Demographic characteristics

Table 7 includes the basic demographic characteristics of patients in NHS and private PICUs. It shows that the majority of patients were white, male, unemployed and single irrespective of being housed in an NHS or a private facility.

Table 7.

Demographic characteristics

Reasons for admission and section status

Table 8 shows that the most common reason for admission to PICUs for both NHS and private patients was violence to others / property. Significantly more private patients were admitted to PICUs for violence to others / property and self-harm compared to NHS patients (χ² = 6.33, df = 1, p = 0.012; χ² = 5.25, df = 1, p = 0.022). A significantly greater number of NHS patients were admitted to PICUs due to crisis / relapse compared to private patients (χ² = 15.59, df = 1, p = 0.000). The majority of patients (both NHS and private) were involuntarily detained under Section 3.

Table 8.

Reason for admission and section status

Clinical issues

Table 9 shows that 58% of NHS patients and 51% of private patients had schizophrenia, schizotypal and delusional disorders as their primary diagnosis. A higher number of private patients had personality disorders as their primary diagnosis compared to the NHS patients (χ² = 6.57, df = 1, p = 0.010). A high majority of both NHS and private patients had at least one complex need, most often substance misuse. One fourth of both the NHS and private patients were defined as delayed discharged and more than 50% patients had at least one mental health admission in the last year. NHS patients had significantly more previous PICU stays compared to the private patients (χ² = 6.38, df = 1, p = 0.011) but significantly more private patients had forensic history and were on 1–1 observation compared to NHS patients (χ² = 12.97, df = 1, p = 0.000; χ² = 13.42, df = 1, p = 0.000).

Table 9.

Clinical issues

1 CN = Have at least 1 complex need

Unit characteristics

It is clear from the results that private PICUs had more qualified staff available for each patient, as the patient:staff ratio was 2:1, almost twice the NHS patient:staff ratio. This is an interesting finding but does it mean that the level of care provided in private units is better than in NHS units? A possible explanation of this high patient:staff ratio on private PICUs could be the challenging nature of the majority of patients admitted to private units, which may necessitate employing more staff to cater for this difficult group of patients.

Although in some respects the two sectors did not appear to differ significantly it is important here to highlight the finding that both did not seem to be working according to the National Standards (DoH, 2002). Less than 50% of units (both NHS and private) had psychologists, occupational therapists, social workers and art therapists. This number seems very low considering the fact that multidisciplinary team working is at the heart of PICU provision. Psychologists, occupational therapists and social workers form the core services provided on PICUs as recommended by the National Standards (DoH, 2002). This area needs some serious consideration as it compromises the effectiveness and quality of service provided in the PICUs.

NHS units had fewer gym facilities or OT/activity areas compared to the private units. This seems surprising when we take into account the fact that NHS units reported having more occupational therapists compared to the private sector. The provision of an OT/activity area in a PICU is essential as the provision of therapeutic activity shares an equal status with safety and security (DoH, 2002). It seems important to provide the occupational therapists with proper facilities where they can discharge their duties in a professional and therapeutic manner within the NHS PICUs.

Seclusion facilities were available in 52% of NHS and 37% of private PICUs. This corroborates the findings of a survey conducted to determine whether the physical environment of PICUs and low secure units are in line with the National Minimum Standards (DoH, 2002) where almost 50% of units reportedly did not have seclusion facilities (Pereira et al., Reference Pereira, Chaudhry, Pietromartire, Dale and Halliwell2005).

NHS PICUs also seem to lag behind their private counterparts with respect to having written protocols about the referral systems, pre-admission assessment and management of suicide attempt on ward protocols. Only 58% of NHS units reported having pre-admission assessment protocols, which does not seem to be satisfactory and could affect good practice. Having these protocols could improve the communication and evaluation processes imperative to the smooth running of the unit.

Private PICUs reported being more willing to accept referrals from out of area and other trusts, which may be due to lack of local facilities available, contributing towards moving patients to out of area private units (Coid, Reference Coid1991a). This appears to go against the standards outlined for people with severe mental illness, which state that service users should be placed as close to home as possible (DoH, 1999). Another possible explanation for high out of area referrals could be that the private PICUs have been established in areas where there was a lack of NHS PICU facilities. The private sector profited by spotting this gap in services and opening these units provided them with a lucrative business/marketing opportunity (Coid, Reference Coid1991b).

Sixty-two percent of NHS PICUs were willing to accept informal patients and 37% of NHS PICUs were willing to accept patients with a primary diagnosis of learning disabilities (LD), which seems a striking figure when compared to the National Standards. It is noteworthy that admission of voluntary or informal patients to these units appears to go against the nature and principles of PICUs and undoubtedly raises important ethical and legal issues related to deprivation of liberty (Laidlaw & Buckle, Reference Laidlaw and Buckle2005). According to the National Standards (DoH, 2002) admission criteria for PICUs, patients have to be detained under an appropriate assessment / treatment section of the mental health act. Moreover, it excluded patients with a primary diagnosis of LD. PICUs are not designed to cater for the needs of this client group and clearly the acceptance of these patients highlights bad practice in the NHS and needs to be addressed. The acceptance of patients with a primary diagnosis of LD might well be against the units’ operational policy as the majority of NHS PICUs (57%) reported accepting patients against their operational policy, demonstrating bad practice.

Patient characteristics

The basic demographic profiles of NHS and private patients were similar. Interestingly, there was a significant difference between the NHS and private units in terms of the average length of stay of patients (21 days v 138 days). This could be due to a number of reasons, possibly including the type of patients being admitted in private facilities. In our sample, a high number of patients admitted to private PICUs tended to have a diagnosis of personality disorders, forensic history and violence and self harm being the reason for admission, which may have resulted in these patients being more challenging and therefore contributing to a longer duration of stay. In addition, more private patients were on 1–1 observation, which could also be explained in terms of the challenging nature of the patient group. Coid (Reference Coid1991a,b) commented that ‘difficult to place’ patients displaying ‘challenging behaviour’ are passed from one service to another and many end up in private care as local NHS services may not be able to appropriately cater for the needs of this complex and difficult patient group. Similarly, Poole et al. (2002) voiced their concern at the displacement of patients to the private sector due to an absence of appropriate NHS provision. Another reason for a longer duration of stay in private facilities could be inefficient monitoring systems in place to bring the patients back to their respective catchment area (Coid, Reference Coid1991a).

Another interesting finding is that private patients tended to have more medication comparatively as 30% patients were receiving more than 2 anti-psychotics. Could this finding be explained in the light of the complex needs and challenging behaviour of the patients? This factor needs to be further investigated in more detail.