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In-patient units

How many places? Although it was originally hoped that a well-resourced provision of community care would greatly reduce the need for in-patient care, it is now recognized that every psychiatric service requires an in-patient unit capable of providing prompt treatment for some acutely ill patients. The number of beds for patients acute psychiatric required is difficult to determine exactly since it depends on:

•  The willingness of families to care for acutely ill relatives;

•  The availability psychiatric nurses and other community staff to provide crisis services and 24-hour intensive care in the home;

•  Facilities for treatment of acute psychiatric disorder outside hospital, such as well-staffed hostels;

•  Facilities for early discharge of patients from hospital after the acute phase of the disorder; these facilities resemble those under the previous two points above, although it is generally easier to discharge early than to avoid admission.

It has been proposed that a reasonable balance between in-patient and community care can usually be achieved with the number of hospital places, provided that the other facilities mentioned above are in place. The figure of 100 places for acute hospital care per 250000 total population includes the requirements for both acute disorders and acute exacerbations of chronic disorders in people up to 65 years of age; for patients over this age, the figure excludes dementia. Special provision is required for patients who require intensive nursing during episodes of disturbed behavior, and for those who may be dangerous to others (some provision for the latter may be provided in a secure unit serving a wider area). See Szmuckler and Holloway for a review of the needs for beds and other resources in general psychiatry.

When community care was introduced, it was expected that the need for in-patient facilities would be greatly reduced. Experience in England and Wales has not confirmed this expectation: for example, compulsory admissions increased by over 50% between 1990 and 1995 and ward occupancy rose to almost 100%. These increases arose because of inadequate provision of the alternatives to admission for patients who do not need the whole range of services provided in an admission ward, or to speed discharge when the need for full services is at an end.

The design of acute in-patient units - In their design, in patient units for acutely ill patients should strike a balance between the patients' needs for privacy and the staff's requirement to observe them. There is a need for secure areas for the most disturbed patients, areas where patients can be alone, and areas where they can interact with others. There should be provisions for occupational therapy, the practice of domestic skills, and recreation. Outdoor space is desirable.

The siting of acute in-patient units - In-patient care for acute psychiatric disorders is generally provided as part of a general hospital complex. This siting reduces stigma and provides easy access to general medical services when required. The disadvantages of such siting include the difficulties of providing adequate space for occupational activities and of creating an informal environment suitable for psychiatric care in a hospital designed primarily for the different needs of physically ill patients. Some of these problems can be overcome if the psychiatric unit occupies a separate building within the general hospital complex.

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