In the second article in his series on old age psychiatry, Dr Eamonn Fottrell with Mahommad Mohamoodally and Dr Paul Heenan discuss the role of NHS nursing homes for old age psychiatric patients. Using the functioning of the Greenvale nursing home in Lambeth, London over a two year period (1996-98) as an example, he describes how these units form part of the comprehensive old age service.

The run down and closure of old mental hospitals in the eighties and nineties outpaced a concurrent build up of community services, particularly mental health residential facilities for chronic illness. Most ongoing care for old age psychiatric patients is now provided in the private sector but there are concerns about the quality of care. It was perceived that new purpose build NHS nursing homes for old age psychiatric patients would quickly become over-subscribed with little or no through-put and little contribution to a community service. As a result such homes are very few in number. As little is known of the contribution they could make to comprehensive old age psychiatric service, this article describes the functioning of such a unit (Greenvale Nursing Home) over a two year period Ð 1996-1998.

The Greenvale unit
The catchment area is the southern region of the western sector of the London Borough of Lambeth, an inner city area, which has a population of people aged 65 and over in excess of 13,000. It was built with funding from the sale of the ground of the old local mental hospital Ð Tooting Bec Hospital.

The unit is part of the South London and Maudsley NHS Trust and is funded by the trust. It is thought to be cost effective as it avoids admission to costly private Band 1 hospital care.

It has thirty beds, which were used initially to facilitate the closure of the old hospital by transferring 30 elderly long-stay patients who were both mentally and physically frail and for whom there was no alternative facilities in the community to meet their needs. It was expected that these patients would have high attrition rate and gradually the home would evolve a more specialist role and cater for four categories of patients.

Category one Ð long stay
A long stay population whose needs could only be met in an NHS setting with psychiatric nurses and a weekly visit from an old age consultant psychiatrist and a multidisciplinary team. These patients were categorised as Band 1. The type of patients who might need this input would be patients with dementia or chronic psychosis and enduring challenging behaviour such as aggression or physical violence. From the complement of thirty beds, a flexible number ranging from 17 to 20 was allocated. It is now thought that outreach, supportive input by NHS teams makes the need for such beds far less.

Category two Ð respite care
Two to four beds were allocated for respite care. Carers, particularly relatives, could have up to 6 weeks respite yearly. This was only a guideline and in practice the amount of respite provided depended on individual needs. Frequently the number of patients in respite numbered six or seven. It is anticipated that the numbers of respite beds should increase.

Category three - discharge delay
Two or three beds designated as Ôdischarge delayÕ were available for use by the acute old age psychiatric assessment ward at St ThomasÕ Hospital, the local general hospital. For example, the type of patients who would occupy these beds were those who although having completed assessment could not be discharged home because the caring spouse had fallen ill or the residential or nursing home of choice could not immediately accommodate them.

Category four - intermediate care and assessment
The fourth group were described as intermediate care and assessment patients. For those it was unclear which type of care was appropriate after assessment on the acute old age psychiatric assessment ward in the general hospital during a four to six weeks period. They were mostly patients with challenging behavioural disorders such as disruptive behaviour, aggression and violence, frequently in the setting of a dementia or a psychosis. It was anticipated that the behavioural problems would resolve if given sufficient time.

Experience suggested that many patients were prematurely sent to high dependency units, unjustified by their subsequent behavioural improvement, but then it was difficult to go back down the line of dependency because of stigmatization with a reputation for aggression, violence or other challenging behaviour. If necessary they were given a maximum period of six months to assess their behavioural problem because a decision as to whether they needed on-going high dependency NHS care (Band 1) or whether to transfer to a lower dependency setting such as an Elderly Mental Health (EMI) nursing or residential home or indeed their own home might be feasible. Improvement was commonly seen long before expiry of a six month period and the majority were discharged to less dependency settings than earlier thought appropriate.

Team input
The team was comprised of the consultant old age psychiatrist, a GP from a large local practice who provided regular medical input to the unit, a placement officer, the individual patientÕs social worker, the team leader and involved relatives. It met weekly on a Thursday from 11am to 1pm. The main focus of discussion centred on the intermediate care population of patients as it was considered that they were the group around which the overall throughput and activity of the unit centred. The respite care group also received considerable attention as there was a relationship in many cases with the timing of respite and the development of adverse behavioural features which made life difficult for the carer. The continuing care Band 1 were reviewed physically and mentally twice yearly with particular attention to medication and quality of life.

It was regarded as absolutely essential to the rehabilitation of the intermediate care and assessment group for the individual patientÕs worker to stay involved until either the patient was discharged from the unit or was accepted for permanent Band 1 care. Giving the patient sufficient time to accommodate to strange surrounding, to put time between them and what was frequently the traumatic circumstances of admission, the identification by the staff of Ôtrigger pointsÕ likely to set off challenging behaviour, were the main factors in rehabilitation. The prolonged time component allows staff to gain a very good knowledge of the patient dependencies and needs, behavioural patterns and the type of care most suitable for them. There is simply no substitute to daily contact with a patient by trained staff over a period of months to get to know their needs. The results of an audit done over a two year period 1996-1998 were very encouraging on the contribution this unit made not only to more accurate placement of patients in units more appropriate to their dependency levels but to the development of a more comprehensive community old age psychiatric service.

The patients
There were 157 individuals admitted over the two year period. Some of them returned more than once during that time. For example, those patients returning for respite or patients who failed to cope in a less dependent setting who returned for assessment for ongoing Band I care. Overall there was a total number of 227 attendants. Seventy per cent of these attendances were followed by discharge home or to other care units such as nursing or residential homes. The remaining 30 per cent either stayed at Greenvale as Band I patients or died. Not only was there flexibility with the number of allocated beds to each group but patients moved between the groups while in the unit. For example, a patient admitted for respite care might not be discharged after expiry of the respite period either because an elderly caring spouse could not again assume the role, had died during the respite period or because of some other cause. Such a patient would transfer onto to the intermediate care and assessment category for long term planning and hopefully rehabilitation and then discharged to an appropriate setting.

Of all the patient attendances over the two years 60 per cent of those discharged had left the unit within 100 days and 73 per cent within 200 days. Over the two year period there were 36 patients in the intermediate care and assessment unit. Some of these patients having been discharged, failed in their placement and returned for re-assessment (each time a patient was admitted it was called an ÔattendanceÕ). Among the 36 patients there was a total of 43 attendances. A total of 25 patients were discharged (70 per cent of 36). This was encouraging and suggested the majority of patients leaving old age psychiatric assessment wards and thought to be in need of Band 1, NHS care could have their needs met in less dependent settings.

A longer time for assessment, if necessary, up to six months before a decision is made, is needed. Premature decisions may have life long implications for the individual and adverse financial and administrative considerations for the NHS.

Emergency beds
Better relationships with the main players in the care of elderly mentally infirm in the community also resulted. The policy of the unit was to try and keep two places vacant to respond to emergencies and this was much appreciated by local GPs, social workers and carers. It was refreshing to be able to make a no fuss quick response to a request for a bed in emergencies. It is not necessary to refer a old age psychiatric agent to Band 1 private hospital care since the unit opened. Barriers between private residential and nursing homes were removed as the private home knew that should problems arise with any resident they would be admitted or readmitted for assessment and hopefully discharged if the problem resolved. As a result private homes were more ready to accept discharges form the unit.

Conclusion
While we realise there are differences between catchment areas and needs differ, requiring local approaches, we are convinced that an NHS old age psychiatric nursing home, functioning broadly in the above manner has a very definite contribution to make to a comprehensive old age psychiatric service and should be more widely available. This is a form of creeping reorganisation from the bottom up, addressing local needs and conducive to fruitful bonding by care workers lay and professional and the private and public sectors. This would be a refreshing change to the cataclysmic periodic interventions from on high to which the NHS has been subjected to over the last 35 years. Unless there is a willingness for professionals to reach out, network with each other, try new approaches, billions of pounds alone will not resolve the problems presented by the increasing population of Ôold oldÕ people with their multiple pathologies, mental, physical and social needsl

Eamonn Fottrell is a Locum Consultant for the Elderly for Surrey Oaklands NHS Trust, Mahommad Mohamoodally is Clinical Manager at Greenvale NHS Nursing Home and Dr Paul Heenan is a General Practitioner in Clapham, London

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