At least twenty-five years have passed since the term ‘psychiatric intensive care unit’ (PICU) was imported into the UK and Western Europe from the United States. During that time the concept of psychiatric intensive care has continued to develop, with a number of important milestones.

The National Minimum Standards (NMS) for General Adult Services in Psychiatric Intensive Care Units (PICUs) and Low Secure Environ ments were published by the Department of Health in April 2002 (DOH, 2002). As a Policy Implementation Guide, the document provides each unit with a tool for benchmarking their own service and gives any stakeholder or staff member associated with PICUs/Low Secure Services something to take from it.

Background: Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs) provide care for the most disturbed inpatients in adult mental health services. Little is known about levels of provision or how these units operate within local services. In 2002 the Department of Health (DoH) published National Minimum Standards of Care for Psychiatric Intensive Care and Low Secure Environments, but there remains a paucity of service level data to inform the specialism.

Aim: To offer the first large-scale systematic survey describing service structure and functioning of PICU and LSU.

Method: A questionnaire was sent to ward managers of every PICU and LSU in London. Information was gathered on provision, physical structure, staffing and aspects of unit functioning.

Results: 17 National Health Service (NHS) PICUs containing 193 beds, and 16 NHS LSUs containing 199 beds were identified in London. An additional one third of PICU provision was privately (non NHS) funded and managed. Bed occupancy was high (90%, PICUs; 95%, LSUs in the 8 weeks prior to census day) and waiting lists for LSU beds long (64 patients on waiting lists for LSU beds on the census day, mean waiting time for LSU bed, 93 days). The use of agency nursing staff was high (33% of staff per shift on PICUs, 28% of staff per shift on LSUs).

Conclusions: All but two units failed to meet the National Minimum Standards for PICU and LSU Environments. Improvements need to be made in provision and staffing levels for permanent nursing staff, psychology and other therapies. Idiosyncrasies exist in admission criteria, particularly with regard to informal patients in LSUs and Personality Disordered patients across the board.

Declaration of Interest: The project was part-funded by Department of Health.

Background: Psychiatric intensive care facilities have previously been poorly defined, with uncertainty existing about the appropriateness of admissions.

Aim: To offer the first large-scale systematic survey describing the clinical characteristics of patients admitted to Psychiatric Intensive Care Units.

Method: A questionnaire was sent to ward managers of every Psychiatric Intensive Care Unit in London for completion on a chosen census day. Individual demographic and clinical patient characteristics were collected, along with admission and discharge pathways.

Results: Of 186 patients on 17 NHS PICUs in London, we obtained data for 172. 80% of patients were male, with a mean age of 33; 50% were Black and all but 2 were involuntarily detained. 66% had a diagnosis of schizophrenia and 55% of admissions were due to physical aggression. 73% of the sample had at least one ‘complex need’, which was most commonly substance misuse. Black patients were younger, more likely to be male and to have a forensic history (54% vs. 31%) than white patients. A slightly lower percentage (70% vs. 79%) of Black patients were described as having complex needs. White patients were more likely to have a personality disorder or a second diagnosis.

Conclusions: Patients admitted to psychiatric intensive care units were most likely to have major psychosis, complex needs and to use illicit substances. Ethnic variations warrant further study.

Declaration of Interest: The project was partly funded by the Department of Health.

Aim: To survey the twenty low secure mental health and learning disabilities units in the South Thames Region.

Method: Ward Managers were interviewed and data gathered on: (1) Buildings and security; (2) Beds; (3) Staffing; (4) Therapeutic activities; (5) Policies; (6) Issues of concern.

Results: Learning disabilities units tended to be smaller, older and not purpose built with more issues of security and observation. There was an under provision of Clinical Psychology, Occupational Therapy and Social Work staff.

Conclusion: Any issues of concern raised by staff tended to reflect any structural and staffing deficiencies.

Aims: (1) To ascertain characteristics of patients in low secure units; (2) To examine whether standard 5 of the National Service Frameworks was being followed; (3) To investigate reasons for any delays in discharge and how these could be addressed.

Method: Audit survey of National Service Frameworks for Mental Health standard 5 patients being treated in least restrictive environment as close to their home as possible by case notes, interviews with ward manager and questionnaires.

Results: Patients in mental health units had greater numbers of admissions to hospital than those from learning disabilities units. They had more contact with the criminal justice system and had spent time in prison. The main diagnosis was schizophrenia.

Patients in learning disabilities units were more likely to be Black Caribbean or African and to have had special needs at school. They exhibited current higher risk to others and to self, by deliberate and non-deliberate self-harm. They had diagnoses of mild learning disabilities and autism. About a third of both groups of patients were assessed as being able to move to a lower level of security. The most suitable facility for these patients was an open unit in the community staffed by nurses.

Conclusion: For a third of the patients standard 5 of the National Service Frameworks was not met because they were not ‘in the least restrictive environment’. Open community facilities staffed by nurses over 24 hours was the most appropriate unit for a majority of these patients.

A major social policy aim in the UK is to promote social inclusion in order that people with mental ill health have the same opportunities as other people to have a family, work and live. However, people with mental ill health remain amongst the most socially excluded in the UK and their social needs are largely unmet. In this article, the social policy, theoretical underpinning, and evidence base for the development of a social work model is considered with a focus on social inclusion. It is argued that in order to provide a more holistic package of care, each low secure service should have a dedicated social worker as part of its multi-disciplinary team. A social work model linking the areas of social work to an individual's progress through a low secure environment and into the community is presented and the social work process is discussed using a case vignette.

It has become evident that Psychiatric Intensive Care Units (PICU) accept aggressive, violent patients often with criminal histories and personality disorders. This paper aims to document the effects that this patient group can have on a PICU and the significant role that psychotherapy can offer this complex patient group. The conclusions have been drawn from psychotherapeutic work on a PICU (Pathways on Tagore, NELMHT). Such patients present unique therapeutic and emotional challenges to staff. As a result staff need to recognise and address these issues. This paper identifies and discusses a number of central themes, challenges and practical skills that may be important in enabling the successful treatment of such patients within a PICU setting.