OBJECTIVE:Sleep disturbance in hospital predicts worse mental health outcomes and is associated with increased length of stay. Enhanced observations are used routinely on mental health wards but disturb sleep and may not be needed for all patients. We have implemented a sleep improvement program (SleepWell) across multiple hospitals within a large UK mental health trust over 5 years. This includes ward adaptations to reduce night noise, increase daytime activity and natural light, screening for sleep disorders, and a 6-hour protected overnight sleep period if assessed as safe. Our objective was to assess the long-term patient safety and potential benefits of a ward-based sleep improvement program that includes a protected sleep period. METHODS:A detailed review of every inpatient mortality was undertaken over 4 years with a comparison of age-adjusted mortality rates and both their causes and the time of death on wards with and without the SleepWell program. RESULTS:Protected sleep was seen to be safe; there were 77 deaths over the 4 years, with the majority in older adults, but specifically there were no deaths that occurred overnight or during a protected sleep period. Older adult wards that implemented the SleepWell program had lower mortality rates than those that did not over the 4 years. CONCLUSIONS:We challenge the perceived benefit to patient safety of frequent overnight observations for all inpatients and suggest that nursing observations that disturb sleep may increase risk in themselves. A ward-based sleep improvement program that includes a protected sleep period can be safely implemented, but staff education and a personalized risk assessment are key.

OBJECTIVES:To examine the reduction in NHS inpatient hospital beds in England from 1960 until 2020, including five categories: Acute, Geriatric, Maternity, Mental Illness and Learning Disability beds; and to measure regional differences at the end of the study period. DESIGN:Retrospective observational study. SETTING:NHS in England. PARTICIPANTS:Inpatient hospital beds. MAIN OUTCOME MEASURES:NHS inpatient bed provision per 100,000 population. Rate of reduction calculated as percentage change each year. NHS bed provision in 7 regions of England compared for the year 2019/20. RESULTS:NHS inpatient bed provision declined for sixty consecutive years. The overall reduction was 78.0% between 1960 and 2020. Greatest reduction was in Learning Disability beds (98.7%), followed by Mental Illness (90.6%), Geriatric (75.0%), Maternity (67.4%) and the least reduction in Acute beds (63.0%). There were two periods of accelerating rates of bed reduction, the first in the 1980s, and the second in the 2000s. At the end of the study period there was significant regional variation in bed numbers. CONCLUSIONS:Bed reductions were a constant feature, with important differences between bed categories and across time. This needs to be addressed when planning for future pandemics and winter bed pressures. By the end of the study the NHS was no longer providing the same level of inpatient care in different regions of England, particularly for Learning Disability.

The Mental Health Bill, 2025, proposes to remove autism and learning disability from the scope of Section 3 of the Mental Health Act, 1983 (MHA). The present article represents a professional and carer consensus statement that raises concerns and identifies probable unintended consequences if this proposal becomes law. Our concerns relate to the lack of clear mandate for such proposals, conceptual inconsistency when considering other conditions that might give rise to a need for detention and the inconsistency in applying such changes to Part II of the MHA but not Part III. If the proposed changes become law, we anticipate that detentions would instead occur under the less safeguarded Deprivation of Liberty Safeguards framework, and that unmanaged risks will eventuate in behavioural consequences that will lead to more autistic people or those with a learning disability being sent to prison. Additionally, there is a concern that the proposed definitional breadth of autism and learning disability gives rise to a risk that people with other conditions may unintentionally be unable to be detained. We strongly urge the UK Parliament to amend this portion of the Bill prior to it becoming law.

Aims and method The study evaluated a package of measures to improve sleep on psychiatric wards admitting patients from children and young people's services (CYPS). Sleep disturbance has significant impact on adolescent mental health, and in-patient wards can directly cause sleep disturbance, independent of the problem that led to admission. We developed a CYPS-specific package (TeenSleepWell) that promoted a better sleep environment, enhanced staff education about sleep, screened for sleep disorders, and raised awareness of benefits and side-effects of hypnotics. This included personalised sleep care plans that allowed a protected 8 h sleep period when safe. Results Evaluation over 2 years showed enhanced in-patient care: 57% of patients were able to have a protected sleep period. There was no increase in adverse events and there was a decrease in hypnotics issued. Clinical implications Improving sleep during in-patient CYPS admissions is possible and personalised sleep care plan should be a care standard.

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Abstract Background Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density – the so-called ‘ethnic density’ hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. Methods Data from the 2010–2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. Results Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95–0.99 and 0.94, 95% CI 0.93–0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11–1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. Conclusions We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

BACKGROUND NHS Psychiatric beds comprise mental illness and intellectual disability beds. Penrose hypothesised that the number of psychiatric in-patients was inversely related to prison population size. AIMS To ascertain whether the Penrose hypothesis held true in England between 1960 and 2018-2019. METHOD A time-series analysis explored the association between total prison population and NHS psychiatric beds; this was also tested for the male and female prison populations, using non-psychiatric beds as a comparator. Associations were explored with time lags of up to 20 years. Linear regression was conducted to estimate the size of the effect of bed closures. RESULTS NHS psychiatric beds decreased 93% and the prison population increased 208%. A strong (r =-0.96) and highly significant negative correlation between these changes was found. Annual reduction in psychiatric bed numbers was associated with an increase in prison population, strongest at a lag of 10 years. The closure of mental illness and intellectual disability beds was associated with increases in female prisoners 10 years later. The only significant explanatory variable for the increase in male prison population was intellectual disability bed reduction. CONCLUSIONS The Penrose hypothesis held true between 1960 and 2018-2019 in England: psychiatric bed closures were associated with increases in prison population up to 10 years later. For every 100 psychiatric beds closed, there were 36 more prisoners 10 years later: 3 more female prisoners and 33 more male prisoners. Our results suggest that the dramatic increase in the female prison population may relate to the closure of NHS beds.

AimsTo assess the feasibility and utility of introducing the following changes on to in-patient units:Structural and cultural adaptation to create a sleep friendly ward environmentA “Protected Sleep Time” between midnight and 6amRoutine screening for sleep disorders, including obstructive sleep apnoea and restless leg syndromeBackgroundInsomnia and other sleep disturbances are cause, correlate and consequence of psychiatric disorders. Routine hourly night time observations, ward noise, bright lights at night time, sleep disorders, insufficient exercise, insufficient day light exposure, too much caffeine and inappropriate psychotropic use are all causes of disturbed sleep (Horne 2018).MethodSeven wards participated in a pilot (SleepWell). These consisted of one male and two female Acute Wards (General Adult), a High Dependency Unit, a Neurorehabilitation ward, an in-patient dementia service and one rehabilitation ward. These wards were supported via an existing trust management structure and the pilot was specifically supported by two trust managers (RW and RB) and by a clinical director (PK). The expectation was that each ward would identify a sleep champion from existing staff to facilitate the changes. A “product” was developed which identified core sleep management features but, in addition, wards were not confined to these. The existing policy that all inpatients should be checked each hour over night was suspended for the pilot wards and the patients had protected sleep time (PST) if the MDT agreed that it was clinically appropriate.Quantitative and qualitative techniques were used to identify facilitators of change, impact on sleep and, outcome.ResultProtected sleep was viewed positively by all staff and approximately 50% of patients on the pilot wards were able to have PST at some point in their admission. Routine sleep disorder assessments were harder to implement and 33% of patients were screened. There were no deaths or significant events on patients due to PST. Hypnotic use on the pilot wards reduced. It is anticipated that PST where it is safe will be rolled out across all adult and old age wards in the trust.ConclusionWith support, it has been feasible to change many aspects of sleep management across a breadth of inpatient units in a large NHS trust.

Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial-based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large-scale datasets.

Aims and method Sleep disturbance is common in psychiatry wards despite poor sleep worsening mental health. Contributory factors include the ward environment, frequent nightly checks on patients and sleep disorders including sleep apnoea. We evaluated the safety and feasibility of a package of measures to improve sleep across a mental health trust, including removing hourly checks when safe, sleep disorder screening and improving the ward environment. Results During the pilot there were no serious adverse events; 50% of in-patients were able to have protected overnight sleep. Hypnotic issuing decreased, and feedback from patients and staff was positive. It was possible to offer cognitive-behavioural therapy for insomnia to selected patients. Clinical implications Many psychiatry wards perform standardised, overnight checks, which are one cause of sleep disruption. A protected sleep period was safe and well-tolerated alongside education about sleep disturbance and mental health. Future research should evaluate personalised care rather than blanket observation policies.

Background: Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives: To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design: Secondary analysis using multilevel statistical modelling. Setting: England, including 61 NHS mental health provider trusts. Participants: A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures: Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources: The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results: There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81). Limitations: Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once. Conclusions: Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death. Future work: These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation. Study registration: The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623). Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

BACKGROUND:The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.AIMS:To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.METHOD:Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.RESULTS:Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.CONCLUSIONS:Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Background: Sexual dysfunction is common among people who are prescribed antipsychotic medication for psychosis. Sexual dysfunction can impair quality of life and reduce treatment adherence. Switching antipsychotic medication may help, but the clinical effectiveness and cost-effectiveness of this approach is unclear. Objective: To examine whether or not switching antipsychotic medication provides a clinically effective and cost-effective method to reduce sexual dysfunction in people with psychosis. Design: A two-arm, researcher-blind, pilot randomised trial with a parallel qualitative study and an internal pilot phase. Study participants were randomised to enhanced standard care plus a switch of antipsychotic medication or enhanced standard care alone in a 1 : 1 ratio. Randomisation was via an independent and remote web-based service using dynamic adaptive allocation, stratified by age, gender, Trust and relationship status. Setting: NHS secondary care mental health services in England. Participants: Potential participants had to be aged ≥ 18 years, have schizophrenia or related psychoses and experience sexual dysfunction associated with the use of antipsychotic medication. We recruited only people for whom reduction in medication dosage was ineffective or inappropriate. We excluded those who were acutely unwell, had had a change in antipsychotic medication in the last 6 weeks, were currently prescribed clozapine or whose sexual dysfunction was believed to be due to a coexisting physical or mental disorder. Interventions: Switching to an equivalent dose of one of three antipsychotic medications that are considered to have a relatively low propensity for sexual side effects (i.e. quetiapine, aripiprazole or olanzapine). All participants were offered brief psychoeducation and support to discuss their sexual health and functioning. Main outcome measures: The primary outcome was patient-reported sexual dysfunction, measured using the Arizona Sexual Experience Scale. Secondary outcomes were researcher-rated sexual functioning, mental health, side effects of medication, health-related quality of life and service utilisation. Outcomes were assessed 3 and 6 months after randomisation. Qualitative data were collected from a purposive sample of patients and clinicians to explore barriers to recruitment. Sample size: Allowing for a 20% loss to follow-up, we needed to recruit 216 participants to have 90% power to detect a 3-point difference in total Arizona Sexual Experience Scale score (standard deviation 6.0 points) using a 0.05 significance level. Results: The internal pilot was discontinued after 12 months because of low recruitment. Ninety-eight patients were referred to the study between 1 July 2018 and 30 June 2019, of whom 10 were randomised. Eight (80%) participants were followed up 3 months later. Barriers to referral and recruitment included staff apprehensions about discussing side effects, reluctance among patients to switch medication and reticence of both staff and patients to talk about sex. Limitations: Insufficient numbers of participants were recruited to examine the study hypotheses. Conclusions: It may not be possible to conduct a successful randomised trial of switching antipsychotic medication for sexual functioning in people with psychosis in the NHS at this time. Future work: Research examining the acceptability and effectiveness of adjuvant phosphodiesterase inhibitors should be considered. Trial registration: Current Controlled Trials ISRCTN12307891. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 44. See the NIHR Journals Library website for further project information.

There is growing interest in the health correlates of people detained in police custody, and a number of innovations have been introduced to try to meet the complex needs of detainees. The implementation of Criminal Justice Liaison and Diversion (CJL&D) Services commissioned by the Department of Health in England is a substantial part of this investment. In this paper, we describe data from 858 detainees who were referred to the CJL&D service of a busy metropolitan police station in the North East of England. The detainees referred to the service had complex mental health needs, substance misuse and a range of vulnerabilities requiring specific intervention. The effective operation of these teams and how they interface with health and criminal justice systems also depend upon a number of systematic issues that emanate both from within the teams, and from external policy drivers.

Background The Mental Health Act in England and Wales allows for two types of detention in hospital: civil and forensic detentions. An association between the closure of mental illness beds and a rise in civil detentions has been reported. Aims To examine changes in the rate of court orders and transfer from prison to hospital for treatment, and explore associations with civil involuntary detentions, psychiatric bed numbers and the prison population. Method Secondary analysis of routinely collected data with lagged time series analysis. We focused on two main types of forensic detentions in National Health Service (NHS) hospitals and private units: prison transfers and court treatment orders in England from 1984 to 2016. NHS bed numbers only were available. Results There was an association between the number of psychiatric beds and the number of prison transfers. This was strongest at a time lag of 2 years with the change in psychiatric beds occurring first. There was an association between the rate of civil detentions and the rate of court orders. This was strongest at a time lag of 3 years. Linear regression indicated that 135 fewer psychiatric beds were associated with one additional transfer from prison to hospital; and as the rate of civil detentions increased by 72, the rate of court treatment orders fell by one. Conclusions The closure of psychiatric beds was associated with an increase in transfers from prison to hospital for treatment. The increase in civil detentions was associated with a reduction in the rate of courts detaining to hospital individuals who had offended. Declaration of interest None.

BackgroundCommunity treatment orders (CTOs) were introduced in England in 2008.AimsTo measure the rate of CTO use in England during the first 5 years following introduction.MethodThe number of involuntary detentions and CTOs in National Health Service (NHS) hospital trusts was collected between 2009 and 2014. Rates of CTO use and the ratio of CTOs to detentions on admission were calculated, and how these varied between trusts.ResultsThe number of new CTOs each year ranged between 3834 and 4647. The number subject to a CTO per 100 000 population increased from 6.4 in 2009/10 to 10.0 in 2013/14. There was variation between NHS trusts in the use of CTOs when compared with the number of involuntary detentionsConclusionsThe number of patients on CTOs increased year on year. Those on forensic sections were more likely to be discharged on a CTO than those on civil sections. There was considerable variation in the pattern of use between hospitals.Declaration of interestNone.

Background: A second antipsychotic is commonly added to clozapine to treat refractory schizophrenia, notwithstanding the limited evidence to support such practice. Methods: The efficacy and adverse effects of this pharmacological strategy were examined in a double-blind, placebo-controlled, 12-week randomized trial of clozapine augmentation with amisulpride, involving 68 adults with treatment-resistant schizophrenia and persistent symptoms despite a predefined trial of clozapine. Results: There were no statistically significant differences between the amisulpride and placebo groups on the primary outcome measure (clinical response defined as a 20% reduction in total Positive and Negative Syndrome Scale score) or other mental state measures. However, the trial under recruited and was therefore underpowered to detect differences in the primary outcome, meaning that acceptance of the null hypothesis carries an increased risk of type II error. The findings suggested that amisulpride-treated participants were more likely to fulfil the clinical response criterion, odds ratio 1.17 (95% confidence interval 0.40–3.42) and have a greater reduction in negative symptoms, but these numerical differences were not statistically significant and only evident at 12 weeks. A significantly higher proportion of participants in the amisulpride group had at least one adverse event compared with the control group ( p = 0.014), and these were more likely to be cardiac symptoms. Conclusions: Treatment for more than 6 weeks may be required for an adequate trial of clozapine augmentation with amisulpride. The greater side-effect burden associated with this treatment strategy highlights the need for safety and tolerability monitoring, including vigilance for indicators of cardiac abnormalities, when it is used in either a clinical or research setting.

Background, The current Mental Health Act (MHA 1983) in England and Wales allows for two broad types of detentions in hospital: civil detentions under Part II; and forensic detentions under Part III. Concern has recently been expressed about the rising rate of detention. A strong association between the closure of mental illness beds and the rise in civil detentions has previously been reported. We will test whether there has been an association between the reduction of beds and the rate of forensic detentions, as well as the size of the prison population. We will explore any association between the rate of civil detentions and the rate of forensic detentions.

BACKGROUND:Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016.METHOD:Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year.RESULTS:Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold.CONCLUSIONS:The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

Aims and methodTo compare rates of admission for different types of severe mental illness between ethnic groups, and to test the hypothesis that larger and more clustered ethnic groups will have lower admission rates. This was a descriptive study of routinely collected data from the National Health Service in England.ResultsThere was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates.Clinical implicationsOur findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression.Declaration of interestNone.