Over the next year there will be a major change in the way mental health services are funded within the UK. Block contracts will be dismantled and the future will be populated by clusters of patients along pathways that are costed for and agreed upon locally between commissioners (who will pay for the pathway) and service providers (who will deliver what is specified within the agreed pathway) (Department of Health, 2011). However, will these pathways lead to gold or be muddied by confusion within a maze of complexity due to variations of ill defined care? This paper highlights potential difficulties with the proposed arrangements and gives possible solutions.

Background: Staff working on psychiatric intensive care units (PICUs) are routinely exposed to aggression or threats of aggression from the patients they care for. This phenomenon is identified as an ongoing factor that influences both work performance as well as staff sickness, and as such requires understanding and management.

Aims & method: This study utilized questionnaires assessing the extent to which PICU staff thought violence was a problem and how safe and supported they felt. Semi-structured interviews were conducted with five nurses to gather in-depth information on the factors involved in perceptions of safety and support.

Results: The analysis indicated that as a whole, staff feel safe and supported by their immediate team. Interview analysis produced two main domains and ten sub-domains of experiences that contribute to managing threats, these being grouped in either personal or systemic factors. It particularly highlighted that although patient aggression is a concern, the perception of threat most directly relates to beliefs about a lack of support from other teams and senior management, not the patients themselves.

Conclusions: More research and attention is needed on systemic factors in the management of threatening patients.

Background: There are few studies that describe differences in measures of burden and participation in care relating to whether the relatives live with or apart from the person with a mental illness. Aim: To investigate different aspects of family burden, need for support and participation in care situations specifically considering whether the relative and the patient are living together or apart. Method: 162 relatives (73 relatives of committed patients and 89 relatives of voluntarily admitted patients) answered a semi-structured questionnaire concerning their situation as a relative of a severely mentally ill person. Results: There was increased experienced family burden in several aspects due to the relative and patient living together. However, relatives who lived with the patient were less likely to believe that the patient would be better off dead, experienced more participation in the patient’s treatment and more often viewed the psychiatric services as being of good quality than those relatives who did not live with the patient. Conclusion: Persons with a severe mental illness who are admitted to inpatient units are in need of different aspects of intensive psychiatric care. Some of these needs are supplied by relatives in everyday life, often without any support. In providing for the needs of relatives, in relieving their burden, the psychiatric services needs to implement different methods according to whether the relatives live with or apart from the patient.

Aim: To follow up a series of patients admitted to a low secure mental health unit for challenging behaviour. Method: Clinical outcome measures (Health of the Nation Outcome Scale (HoNOS), Global Assessment Scale (GAS) and Staff Observed Aggression Scale (SOAS)) and keyworker interviews were used to follow up the progress of patients at least one year after discharge. Results: 33 patients had a mean time since discharge of 43 months. The typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The observed improvement on HoNOS and GAS during admission had been maintained at follow up. There had been no re-convictions. All patients were compliant with medication. Five patients had been re-admitted to hospital during the follow up period. The current placement showed that more of the patients were in the community compared with at discharge. Conclusion: Patients admitted to a low secure unit improved during their stay and this improvement was maintained at follow up.

Background and case description: Virchow-Robin spaces are fluid filled perivascular spaces in the brain which are rarely found in asymptomatic children. Their frequency increases with age and they are associated with cognitive decline in otherwise healthy elderly. They are common in high altitude mountain climbers, mild traumatic brain injury and in certain hereditary vascular diseases. In children they are associated with mental retardation, developmental delay and headache. They have been identified in children with autistic disorder.

We describe a 28 year old female with severe catatonia, auditory hallucinations and delusions, and prominent Virchow-Robin spaces, who responded to ECT and olanzapine. Conclusion: MRI was valuable in the management of this case. While prominent Virchow-Robin spaces may have been a coincidental finding (not aetiologically significant) there was loss of brain parenchyma and we believe this contributed to the severity of the presentation and suggests a less favourable prognosis.

Those requiring inpatient psychiatric care should be managed in the lowest level of security necessary in a ward close to their home area. The presence of informal (voluntary) patients on secure wards appears incompatible with this principle. Can such situations be justified?

The National Institute for Clinical Excellence (2005) published guidance on the management of disturbed behaviour in mental health settings and emergency departments. The guidance included some of the recommendations made in the Independent Inquiry into the death of David Bennett (2003). One important recommendation requires that staff implementing physical interventions (restraint) and/or parenteral rapid tranquilisation are able to effectively manage the physical health of the patient including any immediate complications that may arise.

This article provides background and a syllabus for training for staff to be able to meet the physical assessment skills and interventions required by recent UK national guidance. Also reported is the creation, role and deployment of a 24-hour Medical Emergency Response Team in an in-patient mental health setting to ensure responses to both medical and psychiatric emergencies offer improved safety and adhere to the new guidance. The article describes the provision of a person with the sole responsibility monitoring a patients physical safety during restriant, 24 hour a day, 7 days a week.

The article will be of interest to those working in in-patient mental health and learning disability services, especially those where they are not served by a resuscitation team as part of a District General Hospital and where there is no resident Duty Medical Officer.

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.

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.

Towards the end of 2005, a long running battle over the seclusion of mentally disordered patients in hos??pitals reached the House of Lords. Over-ruling the Court of Appeal, their Lordships decided in Munjaz vs. Ashworth Hospital Authority that the strict guidelines of the Mental Health Act Code of Practice on seclusion were not always legally binding, and could in certain circumstances be departed from. This was seen as a victory for the hospitals and practitioners, who had fought long and hard for the decisions on seclusion to be made as “close to the ground” as possible, and for there to be leeway in how the Code of Practice was applied. Many on the patients' side, who had argued for the Code to be strictly followed so that patients could always know where they stood, likewise saw the result as a defeat.

However, the authors – who were respectively junior counsel and solicitor representing the patient in the case of S vs. Airedale NHS Trust with which Munjaz vs. Ashworth Hospital Authority was paired and heard together in the Court of Appeal – argue below that Munjaz has been misunderstood and the circumstances in which the Code of Practice can be departed from are strictly defined, in such a way that important arguments on the patients' side must be seen to have succeeded.

A group psychoeducation programme for women in medium security was piloted. The programme aimed to increase participants’ knowledge about emotionally unstable personality disorder, decrease feelings of stigma, increase hope and motivate engagement in treatment. Treatment completers showed significant improvements on selected measures while non-completers did not. The implications of the findings are discussed along with suggestions for further research.

Although psychiatric intensive care is a relatively new speciality, it has been well defined. The use of lean management techniques in association with accurately defining services lends itself well to treating patients in an effective and efficient manner. This paper summarises the development of lean management, its use in health services, and its early application within psychiatric intensive care units (PICUs) when examining quality of care provided. It then discusses its possible function in conjunction with robustly describing needs of patients within psychiatric intensive care and how this further enhances patient care by grouping these needs into different types.

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.

Aims: To determine the prevalence of physical illness in patients admitted to a challenging behaviour unit and to assess whether they were physically examined and investigated.

Method: Retrospective case note analysis of patients admitted to the challenging behaviour unit during the period of July 1997 to July 2003.

Results: All patients were suffering from serious and enduring mental illness and challenged the ordinary mental health services by behaviour such as assault, fire setting, aggression, self harm, multiple substance misuse and non-compliance at least for six months.

On admission 76% of patients had examination of the cardiovascular, respiratory and gastro intestinal system and 69% of the central nervous system. During the hospital stay, all the patients had cardio vascular, respiratory and gastrointestinal system examination and 83% had central nervous system examination. All patients had base line investigations including full blood count, ESR, liver function test, urea and electrolytes, random glucose, thyroid function test and follow up investigations.

51(73%) patients were found to be suffering from some physical illness during their hospital stay. The physical illness spanned all the systems. There were newly detected cases of systemic lupus erythematosus, diabetes mellitus, glaucoma, hypertension, seizure disorder, male urinary tract infection, severe incontinence and haematological problems.

Conclusion: There is a high prevalence of physical health problems among patients admitted to a challenging behaviour unit. Some problems were associated with the mental illness, some as a complication of the mental health problem and others secondary to psychotropic medication. This study highlights the importance of a proper medical history, physical examination, base line investigations and regular monitoring of the physical health of mentally ill patients.

Aims and method: NICE guidelines provide a framework for decision making with regard to the management of disturbed or violent behaviour in inpatient mental health settings, although also point to the fact that there is a limited evidence base for the use of more high risk interventions such as rapid tranquillisation, restraint, and seclusion. The current study sought to elicit the views of a team of PICU staff regarding their preference for management strategies for such behaviour.

Results: Forty-three staff assigned ranks to five intervention options: restraint to administer medication, restraint without medication, seclusion, individual counselling, and offering PRN medication. The results revealed a clear preference for individual counselling as the first choice of intervention, and offering PRN medication as a second choice. The three remaining options could not be statistically separated.

Clinical implications: The results indicate that respondents viewed the choice of intervention beyond counselling and the offer of PRN medication as an issue of clinical judgement, dependent on a range of factors relevant to the presenting clinical situation. As such they offer support for the current NICE guidelines. The results are discussed with reference to the NICE guidelines, and areas for further study are highlighted.

The prevalence of violent behaviour within acute psychiatric services is about 10%.

This article presents the initial implementation and adaptation of a group for people who hear voices in a psychiatric intensive care unit (PICU) using a cognitive behavioural therapy (CBT) approach. It highlights the lack of evidence-based psychosocial group interventions designed specifically for the PICU environment and challenges the traditional medical-model of PICU care. It also highlights national policy and guidelines advocating the implementation of CBT approaches for severe and enduring mental illness. An overview of the group sessions is described, with particular focus on adaptations of the group content and delivery for PICU populations. The authors note that twenty three clients have attended the PICU voices groups to date, demonstrating the feasibility of voices groups in PICU environments. Further work is currently being undertaken including formal evaluations of group outcomes using standardised measures.

A total of 54 patients treated in psychiatric observation and intensive in-patient care units completed the questionnaire Quality in Psychiatric Care – In-patient (QPC-IP). The patients rated the quality highest in the dimension Encounter and lowest in the dimension Discharge. Those patients who knew who their doctor was, or where to complain, having prescription of medication, being discharged to their own homes, having a planned contact after treatment or having a supportive talk, rated significantly higher quality of care. Demographic factors were shown to have had only a minor impact on quality of care. Using the QPC-IP gave valuable information about patient's perceptions of quality of care and identified areas important to improve.