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Friern Hospital: where have all the patients gone?
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Friern Hospital: what is the real truth?
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Industrial therapy at Friern Hospital.
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The cost effectiveness of specialised facilities for service users with persistent challenging behaviours.
Little systematic research relates specifically to the last people to leave a psychiatric hospital at the end of a closure programme. The long-running evaluation of the reprovision of services from Friern Hospital in North London allowed a special study to be made of such a group (67 people in all), whose range of problem behaviours made placement in community settings most difficult. The patients were relatively young, with a shorter length of stay than the remainder of the former long-stay hospital population. They were assessed three times: before leaving Friern, and one and 5 years after relocation. The social and clinical characteristics of each person were measured, and the full costs of their care calculated. The "difficult-to-place" patients moved to four highly staffed rehabilitation facilities, where the total cost of their care was, on average, 1230 UK pounds per week. There was no overall change in their psychiatric state over the 5 years after they left Friern Hospital although, in the longer-term, they gained skills in several areas of daily functioning. Most importantly, there was a fall of almost 50% in the number of challenging behaviours exhibited by the study group. At the five-year follow-up point, the cost of care had fallen, on average, by 170 UK pounds per week, and 24 people had been able to move to more independent accommodation arrangements. Study participants had gained a new network of community service contacts, and used services provided by a greater variety of agencies. The indicators suggest that high expenditure on alternative care was justified retrospectively by overall long-term outcomes. An important policy lesson from the Friern Hospital reprovision study is that adequate funds should be reserved until the end of the closure programme to allow the investment of resources in provision for patients with the most severe problem behaviours.
Individual patient--doctor contact in a mental hospital.
Patients admitted to Friern Hospital in 1972 stayed on average for about 5 weeks and spent a total of less than 2 hours individually with senior and junior doctors. Long-stay patients (1 year or more) saw their doctors for an average of less than 1 hour a year. These findings, which in the case of junior doctors were corroborated in 1974, refer only to the time doctors spent with patients alone. The admission, and long-stay discharge rates were greater in the Islington than in the Camden division, and probably reflect differences in clinical practice. It is argued that more psychiatrists are needed--precisely how many will depend on studies of the relative efficiency of different services and training programmes, and on agreement among psychiatrists about minimum professional standards.
[Evaluation of the closure of large psychiatric hospitals in England].
In Britain, we are in the process of closing the majority of the old psychiatric hospitals. In 1954, there were 148,000 psychiatric beds, and in 1990 about 50,000 still remained. At Friern Hospital, in North London, a research team has studied 1,000 long-term in-patients who have been discharged from hospital. This paper sets out the results for the first 350 of these patients, discharged from Friern and Claybury hospitals between 1985 and 1990, comparing before and after discharge. In the first year after discharge 16% were readmitted to hospital. We used the following scales to measure the function of these patients: Present State Examination, Social Behaviour Schedule, Physical Health Index, Social Network Scale, Patient Attitude Questionnaire. One year after discharged, the majority of these measures showed no change. However, significant changes (p < 0.01) were noted for: the attitude of patients (who preferred their new way of life in the community), the costs of care (which were initially reduced by 5% for patients discharged from hospital), and for the improved quality of accommodation (which allowed more choice for patients). These first results suggest that care in the community is no worse, in many respects is better, and is no more expensive than hospital care.
Service use and costs of supporting the most socially disabled patients in a hospital reprovision programme. A two-hospital comparison.
BACKGROUND: The UK, in common with other Western countries, has seen a marked reduction in the number of long-stay hospital beds over the past few decades and most asylums have been closed. Whilst hospital closure and discharge programmes differ, a common characteristic is likely to be that those patients who are "difficult-to-place" in the community are amongst the last to be discharged. This paper compares service use and costs of difficult-to-place patients from two UK hospitals (Friern and Warley) and identifies predictors of cost. One of these hospitals (Warley) provided a more intensive programme of rehabilitation. METHOD: The study included 84 patients (Friern 63, Warley 21). Patient characteristics prior to discharge were recorded. Service use was measured and costs calculated for the year following discharge. Comparisons were made between the Warley and Friern groups and cost predictors were identified using multiple regression analysis. RESULTS: Post-discharge accommodation, in-patient and outpatient costs were substantially higher for the Friern group, whilst the Warley group had higher day care costs. The total mean costs were pound 13,432 higher for the Friern group. However, non-accommodation costs were substantially higher for the Warley group. Patients with more social skills had higher non-accommodation costs. Higher total costs were associated with more self-care skills, fewer domestic skills and younger age. Longer length of stay prior to discharge was associated with higher non-accommodation and total costs. CONCLUSIONS: The costs of care following discharge differed substantially between these two groups. This is partly a supply effect given the different strategies for caring for these difficult-to-place patients. In common with other studies, patient characteristics can explain some of the differences in future costs.
Difficult to place patients in a psychiatric hospital closure programme: the TAPs project 24.
A group of 72 long-term patients, who were retained in Friern Hospital until the final stage of its closure programme, underwent a comprehensive psychiatric and social assessment shortly before moving to other hospitals. These patients were then compared with the rest of the long-stay patients who were considered suitable for community placement. The residual group consisted of younger patients with shorter duration of stay, compared with the rest of the hospital population. Although not excessively disabled functionally or physically, the residual patients were slightly more disturbed in mental state in comparison with the rest, with notably higher levels of subjective anxiety. A range of 13 problem behaviours were designated by staff as a direct impediment to placing a patient in a community setting. Most common problem areas were aggressiveness, non-compliance with medication and inappropriate sexual behaviour. Fourteen per cent of the residual group had none of these special problems. Some other patients have remained in hospital solely because they refused to leave. It is argued that a distinction should be made between the residual patients who were actually transferred to other hospitals, and a core group of extremely disturbed patients for whom further hospitalization is likely to be the only alternative.
The Taps Project 40: quality of care provisions for the elderly mentally ill--traditional vs alternative facilities.
The study evaluates some aspects of care reprovision for psychogeriatric patients. Seven hospital wards are compared with four community settings, established as part of the reprovision programme for Friern Hospital in London. Each facility was assessed for policy and programme, social climate and physical characteristics; staff attitudes in regard to their tasks, training needs and job satisfaction were also explored. Community settings were superior to hospital wards in providing more privacy for the residents and were better equipped with physical amenities and safety features. There were relatively small differences between the way staff perceived the social climate in community homes and in hospital. The former were regarded as encouraging greater independence. Care staff in the hospital were more likely to express dissatisfaction with pay, working conditions and social status, while community staff were more dissatisfied with the quality of cooperation between staff members. Clients transferred to Social Services facilities had a higher level of functioning and needed less on-site medical care. This was further reflected by the lower frequency of nursing care tasks being performed by staff in community facilities. Overall, the shift towards a less medical model of care in community-based homes appears to be beneficial to psychogeriatric patients, provided that current and prospective physical needs of the residents are adequately addressed.
Outcome of long stay psychiatric patients resettled in the community: prospective cohort study.
OBJECTIVE: To examine the outcome of a population of long stay psychiatric patients resettled in the community. DESIGN: Prospective study with 5 year follow up. SETTING: Over 140 residential settings in north London. SUBJECTS: 670 long stay patients from two London hospitals (Friern and Claybury) discharged to the community from 1985 to 1993. MAIN OUTCOME MEASURES: Continuity and quality of residential care, readmission to hospital, mortality, crime, and vagrancy. RESULTS: Of the 523 patients who survived the 5 year follow up period, 469 (89.6%) were living in the community by the end of follow up, 310 (59.2%) in their original community placement. A third (210) of all patients were readmitted at least once. Crime and homelessness presented few problems. Standardised mortality ratios for the group were comparable with those reported for similar populations. CONCLUSIONS: When carefully planned and adequately resourced, community care for long stay psychiatric patients is beneficial to most individuals and has minimal detrimental effects on society.
Long-stay patients discharged from psychiatric hospitals. Social and clinical outcomes after five years in the community. The TAPS Project 46.
BACKGROUND: There have been no large-scale prospective studies evaluating the transfer of care from psychiatric hospitals to district-based services. AIMS: We aimed to compare the quality of life of patients in two north London hospitals scheduled for closure with that in the community homes to which they were discharged. METHOD: The total long-stay population of Friern Hospital and several hundred long-stay patients in Claybury Hospital were assessed with a batch of eight schedules while in hospital. They were followed up after one year in the community and then at five years. RESULTS: Of the 670 discharged patients, 126 died before the five-year follow-up. Data were obtained on 523 (97%) of the survivors. There was no change in the patients' clinical state or in their problems of social behaviour. However, they gained domestic and community living skills. They also acquired friends and confidants. They were living in much freer conditions and the great majority wanted to remain in their current homes. CONCLUSIONS: Community care has enhanced the quality of life of this group of patients, involved in a well-planned and adequately resourced reprovision programme.
The TAPS project. 3: Predicting the community costs of closing psychiatric hospitals.
The planning of long-term care in the community as an alternative to in-patient care requires accurate information on the likely expense of altering the balance of provision. Unfortunately, as very few long-stay psychiatric hospitals have yet closed, the planning of these resource requirements has had to proceed in a vacuum. By examining the costs of community reprovision for the first 136 people to leave Claybury and Friern Hospitals, a prediction equation has been estimated from existing data which links the hospital-assessed characteristics (including psychiatric symptoms and behavioural problems) of these people to the subsequent cost of community care. About a third of the observed variation in these costs can be explained statistically by these 'baseline' characteristics. However, the first cohorts exhibit fewer behavioural problems and other symptoms of mental illness, they have been in hospital for shorter lengths of time, and they are younger. The prediction equation for the leavers is thus used to extrapolate community costs for those hospital residents yet to leave. It is found that community costs are lower than hospital costs, not just for the first cohorts of leavers, but for the full populations of the two hospitals scheduled to close.
The TAPS Project. 10: The long-stay populations of Friern and Claybury hospitals. The baseline survey.
As part of the TAPS project, the baseline long-stay populations of Friern and Claybury Hospitals were compared using the TAPS assessment schedules. Each hospital has reduced bed numbers by two-thirds, and although the two have been subjected to different influences, their remaining long-stay patients were similar, and characterised by severe problems with hygiene, florid psychotic symptoms, a high prevalence of negative symptoms, and impoverished social networks.
Closure of an asylum: the Friern study of older people.
This article reports a naturalistic study following the closure of Friern Hospital and the movement of elderly long-stay patients, who in the main suffered from severe dementia, to psychiatric nursing homes and hospital beds. It describes changes in the environments and in the patients' cognition, behaviour and use of medical services. The results suggest that psychiatric nursing homes seem able to care for the majority if patients with severe dementia. Future studies should consider whether long-stay hospital beds may, however, be necessary for those with both psychiatric and physical health needs, where increased contact with health service personnel is essential. Prospective examination of the reasons for breakdown of placements in nursing homes and the differences between those placed in various settings may help future planning of services. Relatives' opinions of the long-stay settings also require study.
The TAPS project 32: social networks of two group homes ... 5 years on. Team for the Assessment of Psychiatric Services.
Long-stay psychiatric patients discharged to two group homes from Friern Hospital were studied 1 year and 5 years after discharge. A much greater cohesiveness of social relationships was noted in the smaller home at both time points, whereas in the larger home residents had failed to develop friendships and intimacy within their social group. A number of hypotheses were explored to explain this difference. None of the factors investigated provided an explanation, including the mental state of the patients prior to discharge, their problems of social behaviour, the size of the group homes, whether they were staffed or unstaffed, and the patients' age. However, the development of friendships and intimacy over a 5-year period was strongly determined by the quality of the patients' social networks while in hospital. Consequently, when selecting groups of patients to share homes in the community, it is deemed advisable to form groups that fully reflect the range and diversity of their social networks.