Mental Handicap Hospital Research Articles

A Tale of Two Inquiries: Sans Everything and Ely

AbstractThe government acknowledged scandalously poor care of long‐stay patients in National Health Service (NHS) hospitals in 1969. This followed the Ely Hospital inquiry, which emerged in the aftermath of revelations of abuse at seven hospitals described in Barbara Robb's book Sans Everything: A Case to Answer (1967). Allegations in Sans Everything and at Ely were similar. However, the inquiry committees which investigated, ‘disproved’ those in Sans Everything and upheld those at Ely. The Ely inquiry became pivotal to NHS policy reform for long‐stay mental illness and mental handicap hospitals, and for giving patients and their families a greater voice if they had concerns about inadequacies. This paper explains the relationship between Sans Everything and ‘Ely’ and analyses the impact of Robb's work—her high‐profile press campaign, networking, and determination to achieve improvement—which triggered revelations at Ely and elsewhere, and helped shape the course and constructive outcome of the Ely inquiry.

SERVICE CONTACT: CHANGES OVER FIVE YEARS IN A TOTAL POPULATION SAMPLE

The impact of a new community based service (NIMROD) on generic service contact was assessed for people living in different residential settings: supported accommodation in ordinary housing; mental handicap hospitals, and private family homes. 1 Results over five years indicated considerable variability in patterns of generic service usage and provided evidence of a limited impact of NIMROD on the frequency and type of services used. While receipt of NIMROD may have effected an increase in service usage for some people living in family homes, findings also indicated an opposite effect for those who moved into supported accommodation. Doctors and dentists were used by a consistently high proportion of people over time. The most marked change in service usage during the study was an increase in the use of chiropody services by hospital residents. The central role played by General Practitioners in community based care is discussed and the importance of examining client need in conjunction with extent of service usage is highlighted.

Mental Handicap Hospital: Issues of Primary and Psychiatric Care

This article describes a five year follow-up survey of severity of mental handicap, behavioural disturbance, psychotropic medication and psychiatric illness in residents of a mental handicap hospital in South East London. Levels of behavioural disturbance had dropped since the previous survey, and the vast majority of residents had no diagnosable psychiatric illness. Residents' medical needs are met by general practitioners with psychiatrists providing expert advice and treatment where necessary.

Clients' community and social contacts: results of a 5-year longitudinal study

Clients' contacts with a range of community amenities and with their friends and relatives were examined to assess the impact of a new community-based service. Results over a 5-year period were compared for clients in different residential settings: supported ordinary housing, mental handicap hospital and private family homes. Findings indicated increased use of community amenities for those in supported housing and in their family homes. Little change was noted in clients' contact with relatives, and the paucity of social contact with friends was highlighted. Use of community amenities in relation to the development of social networks is discussed.

Predicting the next Maidstone disaster

2008 is the 40th anniversary of a regional health authority independent inquiry into patient care problems at Normansfield mental handicap hospital (as such hospitals were then called) in Teddington. The inquiry was sparked by a strike by nursing staff on 5 May 1976 over their grievances concerning Dr Terence Lawlor, a consultant psychiatrist in mental subnormality (again, the nomenclature has moved on).

A step in the right direction: people with learning difficulties moving into the community

It is more than a decade since the government announced that Regional Health Authorities (RHAs) should close their long-stay mental handicap hospitals. The North West Regional Health Authority's (NWRHA) commitment to the resettlement of people with learning difficulties into ordinary housing in the community pre-dated the government's cost-driven initiative. In 1982 the Region published A Model District Service, a strategy document supported by both the District Health Authorities (DHAs) and the local social services departments, in which it set out a user-centred philosophy for community services for people with learning difficulties. This paper is based on an evaluation of the impact of that strategy, the central part of which was an examination of the experiences of 102 people who moved out of three large mental handicap hospitals between March 1990 and March 1991. The research team's primary concern was to obtain information from the people with learning difficulties who had moved into the community. Unstructured interviews were conducted with those with an adequate level of communication, photographs were used to assist those with very limited communication; Observations were made over a period of time of those without any communication skills at all. Interviews were also conducted with the formal care worker in the community and, where there was one, a relative who had meaningful contact with their learning disabled relative. The research found that the move into the community offered the people concerned a much improved quality of life, with greater independence and choice in everyday living. However, there is a need to build on this so that people's life experiences are not merely better than those offered by the already discredited institutions, but so that they can become fully integrated and respected members of society.

A Register for Patients with Learning Disabilities in General Practice

The shift of people with learning disabilities out of the large mental handicap hospitals mainly into residential homes in the community is now almost complete. This means that almost all people with learning disabilities are registered with general practitioners, both those discharged from long-stay institutions, and those who have always lived with their families in the community. This present paper reports on a study undertaken to assess the amount of disability and the workload by comparing the annual consultation rates of those recently discharged from long-stay institutions with those always in the community, and also against matched controls in a large fundholding practice. This was achieved by the practice learning disability register being imported from the local community learning disability team’s special needs register and checked against the local social education centre and special school records and then with the practice held records. Those whose records showed that they had been discharged from either hospital or specialist school within the last10 years of the study end (April 1996) were assigned as a past long-stay institution group; the remaining patients formed a second group, and both were compared with a matched control group. The study found that out of a total practice list of 14,410 patients, 57 were identified as patients with a known learning disability and constituted the register. They consulted 1.7 times as often and were prescribed 1.8 times as many repeat prescription drugs as matched control patients. However, of the57, the10 patients from long-stay institutions consulted4.9 times as often and took 4.9 times as many repeat prescription drugs as controls. The patients with learning disability who had always lived in the community consulted and took repeat prescription drugs at rates similar to controls. Making a detailed register of patients with learning disabilities highlights the multiple associated disabilities of this patient population and reveals an increase in consultation rate and central nervous system drug consumption. This is mainly due to patients who formerly lived in long-stay institutions and who were discharged to this practice. Similar changes are likely to have occurred in other primary health care teams.

An inpatient treatment model for adults with mild intellectual disability and challenging behaviour.

Following the closure of the large mental handicap hospitals in the UK, the majority of people with intellectual disability (ID) are currently living in the community. However, people with ID who also exhibit challenging behaviour (CB) have been the most difficult-to-place group and use a large amount of service resources. A variety of service options have been proposed for the assessment and treatment of CBs, but there is little information on the effectiveness of these alternatives. The Mental Impairment Evaluation and Treatment Service (MIETS) is one of these service options and the aim of the present study is to describe and evaluate this service. The present authors studied the first 64 patients admitted to MIETS following its opening. A within-subject comparison research design was used. Demographic and clinical data were obtained from case records and the effectiveness of MIETS interventions was evaluated by comparing the number of incidents of challenging behaviour, the use of seclusion, and the place of residence before and after the MIETS intervention. Only 10 (17.5%) of the patients had been admitted from community facilities, but 48 (84.2%) of the patients were discharged to community placements (P < 0.000 I1). The MIETS also significantly reduced the frequency and severity of challenging behaviours (P < 0.0001). It is concluded that the MIETS is an effective treatment model for people with ID and CB, and that there is no place for therapeutic nihilism in this difficult-to-place group of patients.

Priorities for mental health and learning disability nurse education in the UK: a case study.

The closure of psychiatric and mental handicap hospitals, the emphasis on community rather than hospital care and the distinction between health and social care for people in the community, with its funding implications, have demanded that mental health and learning disability nurses face the challenges of developing new skills and new ways of working. In this paper the findings of a study funded by the English National Board for Nursing, Midwifery and Health Visiting (ENB) are reported. This study explored the impact of these reforms on nurses and their practice, and identified the educational needs of mental health and learning disability nurses that have changed as a result. The study took a multiple-case study approach and involved interviews with 22 'key informants' and 88 mental health and 59 learning disability stakeholders in six sites, three in each nursing specialty. Inductive analysis of the interview data revealed 20 categories which summarize the major issues facing the two nursing specialties. These categories are discussed under seven themes and issues for nurse education are raised.

A three- to six-year follow-up of former long-stay residents of mental handicap hospitals in Northern Ireland.

Little is known about the first cohorts of long-stay hospital residents with learning disabilities who moved to the community. This study describes the pattern of residential reprovision for all former long-stay residents discharged from the three mental handicap hospitals in Northern Ireland between 1987 and 1990 (N = 283) as well as describing aspects of quality of life for a smaller sample of people. The study employs a retrospective survey design and the method and findings are discussed within a quality of life framework. Information about destinational outcomes between 1987 and 1993 was collected for each former resident. Several instruments were also used to assess material, emotional and social well-being and development and activity for a 40 per cent sample of people (114/283) discharged from hospital during 1987-1990 and followed up in 1993. Approximately 70 per cent of residents were discharged to, and subsequently remained in, highly supported settings such as residential and nursing homes. Only 3 per cent were discharged to 'independent living' with their own families or foster families. Few of the sample had 'major' problems with daily living skills and serious behavioural problems were uncommon. Former patients were also more satisfied with their new homes and reported feeling happier, healthier and more independent since discharge. However, social networks were poor and there was no evidence to suggest that people were undertaking new or 'ordinary' daytime activities. Although the material needs of former hospital residents (many of whom may have been 'cream skimmed' from the long-stay population) appeared to be met and they were content with their new homes in the community, they had a limited choice of mainly private sector accommodation and few opportunities for personal and social development.

Use of clozapine in a mental handicap hospital — report of the first 17 patients

AbstractObjectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

DISABILITY ASSESSMENT IN A POPULATION WITH LEARNING DISABILITIES IN THE COMMUNITY: A FOLLOW-UP STUDY

With the philosophy of community care and implementation of resettlement programmes the large mental handicap hospitals have discharged the majority . . of their patients into thelocal communities. ~ e f i Barnes Hospital in St. Albans, Herts. is one of these hospitals where active resettlement programmes are going on at present, and some of its long stay patients have been in the community for some time now.

Book Reviews

Book reviewed in this article:Day Services for People with Learning Disabilities Philip Seed (ed).Mental Illness in People with a Learning Disability Andrew Swift.Insights Into Inspection — The Regulation of Social Care Roger Clough (ed.).Brain Development and Epilepsy P.A. Schwartzkroin, S.L. Moshe, J.L. Noebels and J.W. Swann (eds).Behavioral Interventions with Brain‐Injured Children A. MacNeill Horton and William G. Miller.Assessment of Mental Capacity: Guidance for Doctors and Lawyers British Medical Association and The Law Society.Teachers with Special Needs: Training for Teachers of Adults with Learning Difficulties M. Boice.St Lawrence's. The Story of a Hospital, 1870–1994 Robert Malster.Mothers, Babies and Cocaine M. Lewis and M. Bendersky (eds).Opening New Doors. An Evaluation of Community Care for People Discharged from Psychiatric and Mental Handicap Hospitals Michael Donnelly, Sinead McGilloway, Nicholas Mays, Sarah Perry, Martin Knapp, Shane Kavanagh, Jennifer Beecham, Andrew Fenyo and Jack Austin.

The Resettlement Game – Policy and Procrastination in the Closure of Mental Handicap Hospital, Jean Collins

The Resettlement Game – Policy and Procrastination in the Closure of Mental Handicap Hospital, Jean Collins

One hundred admissions to a regional secure unit for people with a learning disability

Abstract Information was collected about 100 successive admissions to a regional secure unit for people with a learning disability (mental handicap). Most of the patients were males under the age of 30, with a mild or borderline learning disability. A majority also had a psychiatric disorder. The most common offences committed were sexual, arson and assault. After discharge, most patients returned either to the community or to a mental handicap hospital. A comparison of the first cohort of 50 admissions with the second cohort of 50 admissions showed that the unit had changed its admission policy and had increasingly admitted those with a mild or moderate learning disability referred by the courts. In addition, the average length of stay had doubled, and the number of admissions each year had halved. This reflects a lack of local facilities which can provide intensive supervision.

DISABILITY ASSESSMENT OF A LARGE HOSPITAL POPULATION WITH A MENTAL HANDICAP

The current study describes the results of the evaluation of the entire population of a mental handicap hospital using the Disability Assessment Schedule (DAS) with a view to identify the weaknesses, strengths, needs and comparing their correlation with demographic variables. The different populations in this study illustrate the changes in admission policies to mental handicap hospitals over the last decades, and the future need for facilities for psychiatrically unwell, behaviorally difficult, and multiply handicapped people in the community.

An economic analysis of the resettlement of people with mild learning disabilities and challenging behaviour

New models of care are needed following the closure of long-stay mental handicap hospitals. Based on an evaluation of a recently established assessment and treatment service in south-east England, this paper is concerned with the costs and likely benefits of different patterns of services for people with mild learning disabilities and severely challenging behaviour. Different models of provision are compared in terms of their costs and quality of life opportunities for clients. The assessment and treatment services provided a better understanding of the care needs, and achieved a reduction in challenging behaviours. It was therefore possible to give access to care settings closer to a normal life. For approximately 25% additional expenditure, 20 out of 34 clients who received the service moved to community placements, including three who had been referred following a breakdown in the community. If community care is to be implemented as a policy for clients with learning disabilities and serious challenging behaviours, it is necessary to recognise the financial implications. Better quality of life opportunities for this client group are associated with higher costs. When seen in the dynamic context of the costs and quality of life opportunities of the subsequent care, a high cost assessment and treatment service may be a good investment. On current evidence, the additional benefits of community homes, with a closer association with the local community, and greater freedom for clients is bought only at quite a high cost.

Impaired autonomy–the challenge of caring

The aim of this paper is to present an informed argument in favour of changing power relationships between learning disability nurses and their clients and to do so through an examination of the influence that they have on quality of life issues for people whose autonomy is impaired. The challenge of empowerment and enhanced autonomy is considered to be at the 'cutting edge' of the learning-disability agenda with its increasing focus on the provision of supported living opportunities for clients in the community. Features related to institutional methods of care delivery continue to exist in some services and as a result clients may still be expected to conform to the dominant themes of time, order, control and regimentation. The application of social and environmental engineering techniques to the field of learning disability care is prerequisite for the development of more positive alternatives to the mental-handicap hospital as a focus for care provision. The main requirement for persons whose autonomy is impaired will be the promotion of equal power sharing between clients and carer. This process will involve a number of transactional considerations such as advocacy, risk taking and shared action planning. The emergence of a new paradigm for nursing practice will result in the solution for shifting the balance of power in the emergent world of consumerism for clients whose autonomy is impaired.

The hazards of prescribing from serum levels

Clinical audit at a mental handicap hospital suggested that doses of antiepileptic drugs were being altered in response to suspiciously high or low serum level results. In order to assess the reliability of such results, sequential serum levels for individual patients were examined for consistency. Correlation between results which should have been the same was found to be so low as to call into question the value of drug serum level sampling in this hospital. Investigation of the source of the variability continues. In the meantime, clinical staff are reminded that it is unsafe to make any decision on the basis of a single drug serum level.

The use of electroencephalography in an in-patient mental handicap population

The use of electroencephalography over a three year period in a large mental handicap hospital was studied. There were no significant differences in its use according to sex or intelligence. The majority of requests were made following seizures and in the investigation of behavioural abnormality. In over a quarter of cases the EEG requests appeared to be inappropriate. It is suggested that a more cost-effective use would result if EEGs were requested only in those cases in which the result will lead to a change in the management of the patient.