Members of the Executive Committee of the Royal College of Psychiatrists' Faculty of Rehabilitation and Social Psychiatry did a postal survey of Rehabilitation service in the UK
It raised concerns Psychiatric Bulletin
The majority of people requiring lengthy admissions have a diagnosis of schizophrenia complicated by treatment resistance6 and/or co-morbidities such as cognitive impairment, substance misuse and challenging behaviours. Many do not meet eligibility criteria for specialist community teams since they are unable to manage community living.
At any one time it has been estimated that around 1% of people with schizophrenia receive intensive in-patient rehabilitation in order to recover adequate social function to live outside hospital.
Rehabilitation services provide ...
'a whole system approach to recovery from mental ill health which maximises an individual's quality of life and social inclusion
by encouraging their skills, promoting independence and autonomy
in order to give them hope for the future and which leads to successful community living through appropriate support'.
Service users tend to be referred for rehabilitation once the National Institute for Health and Clinical Excellence guidance on the treatment of schizophrenia has proved unsuccessful and other approaches have failed.
However, we cannot estimate from our results whether the non-response from services undergoing expansion or reductions were similar.
Potential impact of reductions in rehabilitation services
Bearing this in mind, the results of this survey appear to suggest that
there has been a net loss of in-patient rehabilitation services across the UK over recent years and an expansion of low secure provision.
In 2004, 15% of rehabilitation services reported having low secure service provision.
Our results suggest that since then, a further 15% of services had opened or planned to open a low secure unit.
Services appear to be being reconfigured within small geographical areas without any strategic coherence or reference to the wider mental health system.
This has led to patchy provision across the UK, with services in neighbouring areas or within the same trust
reporting reductions or expansion, often without recourse to any specified service plan.
This lack of coherence renders rehabilitation services vulnerable to cuts when the health economy is under pressure.
The results of this 'snapshot' survey suggest that rehabilitation services are undergoing a period of rapid change.
It is unclear what the impact of these changes will be on individual patient care and the wider mental health service.
One obvious problem with reductions in local rehabilitation services is that
individuals with complex needs and treatment resistance become stuck in acute in-patient settings
with no rehabilitation expertise.
This affects the whole in-patient system and increases referrals to the independent sector for in-patient treatment.
Although we welcome investment in community rehabilitation services,
this cannot be made at the cost of in-patient services since it may only benefit those with more prospects of recovery
and disadvantage those with higher levels of need.
Framework for Mental Health may have been at the cost of rehabilitation services.
Mental health commissioners, under considerable financial constraints,
have focused on targets for the provision of these new services.
The lack of emphasis on the delivery of rehabilitation services as part of the National Service Framework for Mental Health
may therefore be directly responsible for the current incoherence in provision of these services, at least in England.
The mental hospital closure programme has led to the development of a 'virtual asylum'in the form of independent sector hospital, residential and nursing placements.
Individuals with severe impairment of their social and every day living skills
who require a high level of support are increasingly being placed in 'out of area treatments'
at a cost to the National Health Service of around a quarter of a billion pounds for working age adults alone.
The cost of out of area treatments is much more than financial: service:
Users are often placed long distances from their area of origin leading to social dislocation from family and other support networks
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some do some do not: rehabilitation services.