Peaks and Troughs

When I start an EARLY shift at 7am, the cell block is usually quite full.  There will be prisoners there who have been arrested but not yet charged, who await investigation and those who have been arrested, charged and denied bail who are waiting for the truck to take them off to see the Magistrates.  Once that morning truck run is done, the cells are obviously emptier.  We then spend the rest of the day filling them up again, whilst kicking out a few who have their investigations finished and released without further action, released on bail for further enquiries or charged and bailed to appear before the courts on a future date.

In the background of daily comings and goings we also have bail management – those offenders arrested last week and last month who were released on bail pending further enquiries who will answer their bail today.  Some of them will be re-detained for interview and further investigation, some will be detained to be charged with an offence, some may just attend to have their bail varied if enquiries necessitate a further period of investigation beyond the initial bail hearing.  Usually, custody systems allow one person to answer bail each hour, on the hour, so there is no rush of people arriving at once.  Especially important as no-one could know last week and last month how busy or otherwise custody may be today.

Finally, there will be some detainees in custody who may be there for some while, comparative to your average shoplifter or burglar.  You get immigration service prisoners: if relevant processes are completed to deport someone, it can take a few days to organise.  We obviously detain some people under s136 of the Mental Health Act 1983 who can be there for two or three days and some prisoners under arrest for serious offences, can spend up to 96hrs in police custody, subject to court oversight.

Why am I boring you with all of this custody stuff?  I want to make some comparisons with bed management.

CAPACITY

There is evidence if you look for it, that some managers think having greater use of capacity is inherently efficient.  So if you have X number of beds and you use them 95% of the time, this is “better” than using them just 90% of the time.  It’s common sense, isn’t it?  Having empty beds only 5% of the time is better than having them empty 10% of the time, not least because you have to pay staff to provide for 100% occupancy, so the fewer prisoners / patients they have in, the less work there is to do, surely?!  Maybe – but let’s do some maths!

If you have 100 beds and you have an average 90% occupancy rate, there will be occasions where you have admitted fewer than ninety patients and times when you’ve admitted more.  So on occasion, you may have 96% occupancy of beds and on other occasions 84%.  We know, for example, that MHA detentions and vary across times of the week and at certain times of the year.  The extent of the fluctuation should determine where you try and “run your average” rate because you need to leave room for peaks of demand.  Unless of course, you have effective contingency arrangements.

This is not different in custody.  My initial description, above, talks of custody on a typical day but a typical week would look different again.  For example, courts don’t sit on Saturday afternoons or Sundays so prisoners who are charged and denied bail after about 10am on Saturday morning cannot go to court until Monday morning – they spend that time in a cell that now can’t be used for any other purpose.  So when you analyse a week’s cell occupancy, you will see a squeeze on capacity that starts to build around Saturday lunchtime and reaches a peak on Sunday evening and overnight until a lot of people are sent to court on Monday morning.  And Sunday LATE shifts and Sunday NIGHTS shifts, see higher than average rates of fresh arrests, just to help!

I’m not an NHS bed manager, but I’ve heard it repeatedly said, that MHA admissions over weekends, bank holiday and especially over Christmas, puts a real pressure on supply to match demand.  And of course where “beds” you refer are specialist in nature – CAMHS, forensic beds in medium secure units of female PICU beds, this problem is more acute because actual numbers of beds are low to start with a percentage point either way is a good slice of the overall resource.

FAILURE DEMAND

So you remember those 100 beds and cells?  What happens when you have to detain the 101st patient or the 101st prisoner?  You’ll remember that quiet Tuesday when you (briefly!) had 79% occupancy, well this is the point where your peak of demand hits you, although your average is still 90%.  And you start improvising through external processes:  the NHS will look at out-of-area beds or even private provision.  If Birmingham doesn’t have the right kind of MH bed, we wonder whether Coventry or Wolverhampton has one spare?  Of course, that then eats into their 100 beds and increases the likelihood that they will also reach capacity and we look farther afield, like Manchester or London.  So it becomes more important to understand how often we breach that upper limit of demand to avoid expensive contingencies that don’t do much good for patients and their families either.

But let’s imagine the Chief Constable and the local NHS commissioners reduce capacity by shutting a cell block and a mental health ward.  Let’s say that we now have 90 beds.  Let’s further imagine that reducing arrest rates and quicker discharge of some patients means that with 90 beds / cells we are now averaging 95% occupancy.  This is not more efficient than before, even though it probably costs less on paper – you will still have peaks and troughs of demand and it will be now be harder still to manage the peaks, meaning you will probably have to do it more often.  It doesn’t matter how low your troughs are to bring down the average, if you’ve got 92 human beings who need admission or detention and only 90 beds, you now have two out-of-area problems and they cost real money to sort.  And the more of these instances you have, the more it pressurises both your system and the back-ups into which you tap when you’re pushed.

The difference I notice between the police management of cells and the NHS management of beds simply this:  the police are far more relaxed about empty cells than the NHS are about empty beds.  I doubt that cell occupancy is anything near 90% or 95% on average.  NHS staff have told me directly, that because of the way services are commissioned, NHS hospitals must average 90% bed occupancy to break-even financially – even though peaks and troughs of demand show that demand can vary as much as 20% from the mean.  This financial structure and the consequential planning for averages pushes the possibility that supply will not be available when demand comes along.  That will create failure demand, which is infinitely more expensive than doing it properly.  This is why we are seeing lots of media, currently, about how much is being spent on private provision by our NHS.  It’s probably just cheaper to do it properly.

CONTINGENCY PLANNING

I once took part in a series of exercises with NHS colleagues to test reactions to a major incident.  How would NHS staff handle a major fire in a medium secure mental health unit if the building needed to be evacuated?

All three 999 services were there in order that NHS managers could bounce requests / questions off us, as undoubtedly all three would have a significant role if a medium secure unit were ablaze.  Somewhere in the exercise, I remember asking, “Where are your contingency places for medium secure care?”  Blank faces, so I followed up with “Surely all medium secure MH units run let’s say, 90% occupancy rates, so that you have contingency for things like this? – unexpectedly high levels of demand, fires and other major incidents?”  I admit that I knew the reality was that they didn’t but I posed the question so I was able to say this:  “If a police station with a cell block were taken out of play right now, we could either spread those prisoners around existing capacity in other operational custody areas OR, if we really needed to, we could select one or more of over half a dozen “mothballed” custody blocks that can be activated.”  We simply put the staff from the evacuated building into the mothballed building, turns on the lights and computers and off we go.

The next question was: “Could we put patients into your cell blocks if we also put our staff in there?!”  It was a serious question.  But I think we’re missing the point!


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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7 thoughts on “Peaks and Troughs

  1. Yet another common sense blog from you mhcop. Wish that you could be employed by NHS England!

    I had a short stay in psychiatric hospital a couple of weeks ago and knowing that beds are at a premium looked at the occupancy board. The 26 of the 27 beds were occupied with 7-8 patients listed as on leave. Good job none of those on leave had a crisis – where would they have gone? Possibly a 100 miles + away if recent events were repeated. It is well known that locally getting a bed if you’re not sectioned is nearly impossible.Three times last year I was unable to go into hospital despite being in serious crisis even though that option being part of my care plan. I also know that shorter and shorter stays are being implemented and that it is being encouraged that patients are being sectioned under section 2 rather than section 3.

    What worries me is a tweet I came across yesterday from another trust:

    ‘my trust is managing to not send people out of town. Use of crisis house helps and taking positive risk’.

    Now crisis houses are a great facility as far as I’m concerned there should be more but positive risk taking – I would question whether this is just the trust in question crossing their fingers and hoping that the person they are keeping out of hospital remains safe. I quote below about risk taking theory. Are trusts making decisions on patients’ risk levels based on beds available and acting in the best interests of the patients or not?

    ‘ When implementing this policy in day-to-day practice, ******* Council recognises that any positive risk-taking approach must be balanced with its responsibilities to ensure vulnerable adults are protected under Safeguarding Adults Policy and procedures, care standards and health and safety legislation.’

    It all seems like an increasing recipe for disaster and the likelihood that maybe more patients lives are being put at risk (my own included). It has been well tweeted about patients sent far away from their home area being very unhappy even worse if to be unable to get a bed when you need it and being left to the tender care of an overstretched crisis service who defer to the police when a patient goes into meltdown. I find myself going round in circles with the mental health service not knowing where to turn these days when feeling desperate – no bed to go to, crisis team too busy.

  2. There are fundamental differences between detention in the cells and and admission to hospital.

    The way to demonstrate this difference is to ask: Are people ever bailed/released for no other reason than there is a shortage of space in custody? I don’t mean a decision is made that it is not in the public interest to prosecute or the custody sergeant is a bit unsure if conditions for bail are met but are serious offenders released because you don’t have a cell?

    Bed occupancy in a psychiatric unit can, and frequently does, go over 100% because when there is a crisis and a bed is needed the bed of a patient who is on overnight leave is used – so to use your analogy the 100 bedded unit technically houses 101 people. I have seen, some time ago, during a previous bed crisis occupancy across a trust of 108% and even 112% for quite some time. If there person is a detained patient this defers the bed issue until the patient returns.

    These bed occupancies are less common now for a different reason: staff are actively encouraged to send on leave or discharge voluntary patients on to Home Treatment (Early Discharge) which can be extremely counterproductive if it is done for the wrong reasons when P is not ready.

    Additionally we see something much more pernicious- Bed states are such that you are only able to admit a patient if they are sectioned/detained. Because once someone is detained there is a statutory responsibility to secure (IE pay for a bed ) there is frequently a situation where an individual who a clinician feels should be in hospital, and the individual agrees they need to be in hospital cannot be admitted because the bed is prioritised for a detained patient. I believe this is one significant misuse of CTOs because a CTO recall involves detaining P but bypassing the need for AMHP involvement – the AMHP would always be predisposed to the least restrictive option – informal admission.

    Preventing an informal admission should be subject to challenge under s 131 of the MHA but as with many things we have yet to see this happen. In the meantime there is increased dependence on Home Treatment Teams or Crisis Teams managing the individual at home. Done properly this is incredibly resource hungry but can be effective, however under resourced and with demotivated staff it’s a disaster waiting to happen.

    The cuts in beds have only been achieved ‘successfully’ by increased dependency on these community services who cannot cope effectively and then we see the ‘failure demand’ and dependency on other services which I know you deplore.

    And there we see the other peak and trough: Funding for MH services. Serious and tragic incidents happen and new initiatives and spending occurs to improve things. Time passes, there is complacency and fiscal pressures reduce funding. Problems start to appear but are not addressed until further serious and tragic incidents occur.

    Coming back to your original point, if a PC arrests someone and then finds the cells at his base are full, who is responsible for finding somewhere else and how is it done – I sadly don’t think, while there is no direct duty on a trust to take an informal patient there would be anything as structured within the NHS.

    1. Tell me if you think I’m missing your point, but I’ve read that three times and I think your point reinforces mine. Happy to learn if I’ve misunderstood.

      Occasions where offenders have been released for demand-management related reasons as opposed to genuine legal / investigative reasons. I can’t remember any in my direct experience of over fifteen years. I also can’t think of occasions where room has been made the serious offender by releasing someone else on bail who could very easily be administratively managed at a later time without causing risk to the public. If a PC arrests someone and the cells at their station are full, the force have a process for identifying the next nearest custody area which can accept them. On rare occasions, this can mean a thirty mile journey to custody and sometimes, a drive into a different police force area. I know West Midlands Police have had West Mercia suspects in custody and vice versa when demand in South Birmingham / North Worcestershire has been unexpectedly high, for example.

      I’m aware that bed occupancy goes over 100%, my point is that there is an extent to which this needed be so which I think you’re almost acknowledging, particularly in your penultimate paragraph?

      1. Well the point is for the police I think law is sacrosanct whereas the NHS always treats everything as guidance unless it is forced to. I don’t know whether failure to admit informally and then someone coming to harm would be a civil or criminal case of negligence but until it happens NHS managers will largely ignore it.

        The police has been, until very recently, untouchable on respect of cuts and their infrastructure still remains intact, this is just not the case with the NHS now. We don’t have enough desks for workers let alone spare spaces to reopen wards.

      2. NHS spending on mental health rose every year in real terms by 59% between 2002-2012 and reduced only marginally last year. Added to that, the Department of Health returned £2.2bn to the Treasury in underspend in 2013, having returned £1bn the previous year. So the idea that these conditions are force, is demonstrably false and everything to do with bureacracy.

      3. I think I largely agree.

        Unfortunately we are now in the realms of politics. The last labour government threw money at the NHS but not all of it wisely.
        One the one hand in the early years in mental health we had the initiaition of early intervention services for psychosis in young people and assertive outreach services for working with disengaged people both extremely expensive interventions but both incredibly useful when done well with certain patient groups.

        However alongside injections of cash came the introduction of (some) counter productive targets and increasing decentralisation. The introduction of Foundation Trusts will, I think in retrospect, be seen as the start of eliminating the NHS with each PCT and Trusts negotiating their own little bizarre versions of what is thrown down by govt. (ironically increasing the ‘postcode lottery’ despite commitmentns to eliminate it). Trusts started operating to financial and governance targets and ignoring quality to become FTs (see South Staffs and many other places that have yet come to light)

        FTs have increased the amount of managers and seen millions wasted on external consultants and existing managers meeting largely pointless targets whilst day services, wards an staffing are being slashed.

        Of course under ConDem with the Health and Social Care Bill we see even more chaos with CCGs representing tiny populations forcing changes in trusts care provision and forcing the involvement of bidding and private companies in all areas. We also see long standing cooperation in provision of MH services between the NHS and local authorities breaking down with multidisciplinary teams being broken up and both sides desperately trying to make cuts by offloading costs to each other.

        In terms of staffing we had significant pay increases in the early labour years with mixed results. Laterly consultants and GPs were given massive pay rises but with reduced hours and reduced responsibilities and the introduction of Agenda for Change for other staff which introduced massive beaurocracy and destroyed career structures. Most recently with ConDem alongside massive cuts in staff we see trusts on top of frozen wages trying to wiggle out of national pay bargaining.

        In the end managers are employed primarily in the NHS to save money not improve care. Government say the opposite but then set targets that prove this.

    2. Tell me if you think I’m missing your point, but I’ve read that three times and I think your point reinforces mine. Happy to learn if I’ve misunderstood.

      Occasions where offenders have been released for demand-management related reasons as opposed to genuine legal / investigative reasons. I can’t remember any in my direct experience of over fifteen years. I also can’t think of occasions where room has been made the serious offender by releasing someone else on bail who could very easily be administratively managed at a later time without causing risk to the public. If a PC arrests someone and the cells at their station are full, the force have a process for identifying the next nearest custody area which can accept them. On rare occasions, this can mean a thirty mile journey to custody and sometimes, a drive into a different police force area. I know West Midlands Police have had West Mercia suspects in custody and vice versa when demand in South Birmingham / North Worcestershire has been unexpectedly high, for example.

      I’m aware that bed occupancy goes over 100%, my point is that there is an extent to which this needed be so which I think you’re almost acknowledging, particularly in your penultimate paragraph?

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