FINAL REPORT APRIL 2001

ROYAL COLLEGE OF PSYCHIATRISTS FACULTY FOR THE PSYCHIATRY OF OLD AGE Old Age Psychiatric Day Hospital Survey FINAL REPORT APRIL 2001 Bernard Audini Paul Lelliott Sube Banerjee Cait Goddard John Wattis Ken Wilson Senior Research Fellow, Royal College of Psychiatrists Research Unit Director, Royal College of Psychiatrists Research Unit Assistant Director, Royal College of Psychiatrists Research Unit Consultant Old Age Psychiatrist, Project management group Consultant Old Age Psychiatrist, Project management group Consultant Old Age Psychiatrist, Project management group THE ROYAL COLLEGE OF PSYCHIATRISTS RESEARCH UNIT 6 th Floor 83 Victoria Street London SW1H 0HW

Contents 1 Executive Summary... 5 1.1 Background...5 1.2 Aim...5 1.3 Method...5 1.4 Results...6 2 Introduction... 8 2.1 Old age psychiatric day hospital survey...9 3 Aims... 10 4 Methods... 11 4.1 General methodology...11 4.1.1 Site visits/project advice...12 4.2 Questionnaire design...12 4.2.1 Piloting of questionnaires...12 4.3 Missing data and data management...12 4.3.1 Data preparation...12 4.3.2 Missing data survey one...13 4.3.3 Missing data survey two...13 4.4 Data analysis...14 5 Results... 15 5.1 Survey one...15 5.2 Survey two...17 5.2.2 Organic day hospital service...21 5.2.3 Functional day hospital service...21 5.2.4 Other patient groups day hospital service...22 6 Findings... 35 6.1 Survey 1...35 6.2 Survey 2...35 3

7 Discussion and Conclusions... 39 7.1 Limitations of the study...39 7.1.1 The representativeness of the data...39 7.1.2 The quality of the data...39 8 References... 41 9 Appendices... 43 9.1 Appendix I: Persons who provided assistance on this project...43 9.2 Appendix II: Questionnaire I...44 4

1 EXECUTIVE SUMMARY 1.1 Background The Faculty of Old Age Psychiatry of the Royal College of Psychiatrists commissioned the College Research Unit to undertake a preliminary survey of day hospital provision as part of a program of research and audit of Psychiatric Day Hospitals for older people. The objective of the research program is to promote best practice within Day Hospital services through out the UK and to review Day Hospital provision in the context of the impending changes within health and social service communities. Two surveys were conducted in order to provide a preliminary description and establish a database of Psychiatric Day Hospital services for older people. The next stage of the project is to develop a net work of participating day hospitals so as to share examples of good practice and develop audit and research collaborations. 1.2 Survey Aims To quantify the provision of day hospital services provided by the NHS and Ireland to specifically cater for older people with mental illness. To include: The identification of all consultants for the psychiatry of old age practising in the UK (NHS) and Ireland The identification of all consultants in psychiatry of old age with and without access to an old age psychiatric day hospital A description of the distribution and capacity, of old age psychiatric day hospital units Preliminary characteristics of the units Generalised patient characteristics of old age psychiatric day hospital services 1.3 Method The main components of this study included: A period of assessing the nature of the task by consulting with senior personnel and active clinicians from within the psychiatry of old age field; The preparation of databases and the design and piloting of two questionnaires; 5

Two questionnaire surveys were sent to all clinically active consultants for the psychiatry of old age working within the UK (NHS) and Ireland. 1.4 Results Survey one: 70% (n = 339) of consultants for the psychiatry of old age responded to the first survey; 553 clinically active consultants for the psychiatry of old age were identified in England, Scotland, Wales, Northern Ireland and Ireland; 462 consultants had access to an old age psychiatric day hospital in England, Scotland, Wales, Northern Ireland and Ireland; 440 old age psychiatric day hospitals were identified in England, Scotland, Wales, Northern Ireland and Ireland. Survey two: Demographic characteristics Valid returns were obtained from 47% (n = 207) of identified day hospitals from survey one The sample catchment population served by health organisations returning questionnaires was. 35,826,420 (all ages). Each country in the United Kingdom was represented in the returns. The proportion of people aged 65 and over, served by the returning health organisations was similar across the UK and Ireland: Mean; 16.5%, range 13.6% (Northern Ireland) to 18.7% (Wales) The population of older people ( 65) served by the returning health organisations in England, Scotland, Wales, Northern Ireland and Ireland was 6,045,496. The population of older people ( 65) served by day hospitals of the returning health organisations was 4,325,432. 11,864 older people ( 65) attended the day hospitals, with a mean of 33 patients per day hospital Service characteristics Over 80% of all consultants have access to a day hospital service 6

There was wide variation in the numbers of consultants for the psychiatry of old age per 100,000 old age day hospital population, with Scotland demonstrating the highest rate Just over 50% of all day hospitals operated a service for between 10 and 20 patients The mean number of sessions for all day hospitals was 7 sessions per day hospital; In 31% (n = 64, and n = 68) of day hospitals, staff provided administration and domestic duties in addition to their therapeutic roles Clinical characterisitics Organic services 6602 patients suffering with organic disorders attended the day hospitals with a mean of 34 per day hospital The mean number of sessions for organic patients was 8 sessions per day hospital Just under 40% of day hospitals operating an organic service were full time (i.e. 10 sessions) Functional 5262 functional patients attended the day hospitals with a mean of 31 per day hospital Only 24% of day hospitals operating a functional service were full time The mean number of sessions for functional patients was 5 sessions per day hospital Mixed/others 76% (n = 157) of old age psychiatric day hospitals operated a mixed service (organic and functional) 19% (n = 39) of day hospitals had patients from other patient groups (i.e. adult mental illness, learning disabilities etc.) attending the day hospital in addition to organic or functional patients 615 patient from other patient groups attended the day hospitals with a mean of 15 per day hospital Implications of findings The main concerns of those who work in old age psychiatric day hospitals were found to be the shortage of day care facilities and the number of day hospital places available; There is some evidence that day hospital services are becoming silted-up with patients who would be better provided for by social care. This is by no means conclusive and requires further investigation; In addition to their therapeutic duties many day hospital staff had to provide all of the day hospital s administration and domestic requirements; Comparison with previous surveys indicate that there has been an increase in the number of old age psychiatric day hospitals places 7

2 INTRODUCTION Day hospitals in Geriatric Medicine grew out of a profound conviction that, where possible, it was best practice to avoid hospital admission for older people (Broklehurst, 1979). Difficulty in discharge planning, institutionalisation and rehabilitation continue to present both users and the health services with considerable morbidity. The high prevalence of treatment resistant infections and associated complications present significant hazards for older, frail people. Psychiatry of Old Age followed the development of Geriatric Medicine in the UK (Wattis, 1994, 1994) and adopted a similar model of day services. In the early 1970 s (DHSS, 1970) the need for Day Hospital places for people with dementia was officially recognised with a recommended provision of 2-3 places per day per thousand over the age of 65 years for people with dementia. There was no separate recommendation for old people with functional mental illness (mostly depression). Most authors assumed that the provision for adults of all ages should be applied pro-rata to the elderly population. This gave 0.65 places per day per thousand elderly for functional mental illness (Health Advisory Service, 1982). The first national survey in 1980 showed that 75% of services had a day hospital for those with mental health problems in old age. The survey found that there were 0.82 places per thousand over 65 population, with 30% of services for assessment and treatment, 42% for dementia care and 20% for chronic functional mental illness (Wattis, 1981). By 1985 this had risen to 1.2 places per thousand elderly overall. There was a great deal of geographical variation in provision (Wattis, 1988). By 1995 rates had risen to 0.6 and 0.9 for organic and functional illness respectively (Wattis, 1999). The audit commission conducted a detailed survey of a limited number of day hospitals and again came out with a very varied picture of provision (Audit commission, 2000). To understand the extent of this variation, it is necessary to go back to the history of how services developed. The NHS in the 1970 s was still attempting to provide a comprehensive cradle to grave service and the recommended day hospital provision for people with dementia was clearly intended to provide a large component of continuing care. The recommendation for continuing care beds at the same time was equally high (DHSS, 1972). Services with their roots in the large asylums at this stage were often able to develop relatively generous day hospital provision. In the absence of asylum resources to asset-strip other services started with a more limited provision, often linked to a more rapid turnover and more acute assessment and treatment model. The presence and extent of social services day care provision also affected this evolution. In the 1980s there was a move to reduce NHS continuing care provision and to transfer much inpatient continuing care to the private sector (Alzheimer s disease society, 1993). At the same time in many places social services day centres began to assume a role in continuing care of people with dementia living in the community. In some places this enabled NHS facilities to reduce in size and increase in activity. In the era of the internal market, guidelines for provision were withdrawn and in some places inequity probably 8

increased. More recently psychiatric day hospitals for working age adults have begun to be seen as an alternative to acute admission for at least a subgroup of people and evidence has begun to be gathered about their effectiveness in this role (Creed, 1997). The recent past has witnessed the development of significant initiatives. The National Service Framework for Older People describes Day Hospitals as integral to comprehensive Old Age Psychiatry services. However, this must be seen in the context of change as represented by the development of Care Trusts and potential for combined commissioning between Local Authority and Health organisations. In the light of these developments and the relative lack of information concerning the characteristics of day hospital care for older people with mental health problems the Research Unit was commissioned to conduct a preliminary survey. It is anticipated that this will provide a background against which further service development, audit and research can be carried out. These include the establishment of a network enabling day hospital staff to compare and contrast current practice. It is anticipated that members will be able to share audit material, learn from others experience and develop common research interests with view to improving the quality of care of older people attending these services. 2.1 Old age psychiatric day hospital survey Exceptional funding was provided by The Royal College of Psychiatrists (RCP), Faculty for the Psychiatry of Old Age (FPOA) to The College Research Unit (CRU) to address the identified deficit in the knowledge base by conducting a national survey of old age psychiatric day hospitals. The intention was to count, describe and compare mental health day hospital provision for older people in the UK and Ireland (including its distribution, capacity and other characteristics). The project had two phases: In phase I A list of the total number of clinically active consultants for the psychiatry of old age in the UK and Ireland was developed by examining and cleaning the RCP and FPOA databases. These consultants were then sent a postcard questionnaire asking whether they had an old age psychiatric day hospital as part of their service. A follow-up procedure involved telephoning the outstanding consultants/nhs trusts. This identified about 420 old age psychiatric day hospitals. In phase II basic information was collected on old age psychiatric day hospitals using a national postal survey. Data included: location, purpose, size and the nature of their client group. 9

3 AIMS To conduct the first UK (NHS) and Ireland wide audit into the characteristics of old age psychiatric day hospitals and the general characteristics of the patients who attend them. To describe the extents of variation in the provision of old age psychiatric day hospitals. Survey one aims were: The identification of all consultants for the psychiatry of old age practising in the UK (NHS) and Ireland; The identification of all consultants for the psychiatry of old age with and without access to an old age psychiatric day hospital. Survey two aims were: Quantify the provision of day hospital services provided in the UK (NHS) and Ireland to specifically cater for older people with mental illness. To include; A description of the distribution and capacity, of old age psychiatric day hospital units; The characteristics of the units; The overall patient characteristics of old age psychiatric day hospital service. Additional aims of the project were: 1. To start the process enabling the identification best practise and to establish the basis for an old age psychiatric day hospital network. To establish a network for the collaboration and dissemination of good practise; Set up a national programme for continuous quality improvement and to promote clinical governance. 2. To obtain the required data necessary for the preparation of a grant application for a more detailed study into old age psychiatric day hospitals. 10

4 METHODS 4.1 General methodology The main components of this study consisted of a period of assessing the nature of the task by consulting with senior personnel in the field and active clinicians. This was followed by a period of database preparation and the design of two postal questionnaire surveys which were sent to all clinically active consultants for the psychiatry of old age working within the in the UK (NHS) and those in Ireland. 1. First survey: Was based upon a freepost postcard questionnaire with 4 questions. This identified the relevant facilities and personnel who would facilitate further study. All consultants for the psychiatry of old age within the UK (NHS) and Ireland; All consultants for the psychiatry of old age who have access to an old age psychiatric day hospital; Total number of old age psychiatric day hospitals within each trust; Name and location of old age psychiatric day hospitals; Name and contact number for the day hospital manager (or person able to provide information). 2. Second survey: A questionnaire consisting of 23 questions, generating 150 items designed to provide information concerning day hospital utilisation and configuration. Topic headings include: Catchment populations (trust total, trust total old age, and day hospital old age population); Overall times and days of operation, times and days of operation for specific client groups; Total number of staff, and the total number of patients; Diagnostic category of patients; Main concerns for old age psychiatric day hospital professionals; Physical environment of old age psychiatric day hospital. 11

4.1.1 Site visits/project advice A series of old age psychiatric day hospital site visits were undertaken. The remit was to gain an understanding of the range and diversity of old age psychiatric day hospital practise, the range of treatments available, and an understanding of the concerns of professionals, users and carers. In addition to the advice given by the members of the project steering group, discussions were held with other senior professionals involved with service delivery, research into old age services, and service evaluation (a full list of facilities and personnel are listed in appendix I). 4.2 Questionnaire design The design for the first survey was limited by the desire to maximise the number of returns. The research team opted to use a freepost postcard questionnaire. This approach limited the number of questionnaire items to 4 (see appendix II). Building upon the information gained from the site visits, the design of the second survey questionnaire aimed to maximise the amount of useful information while limiting the burden on health professionals in completing the questionnaire (see appendix III). 4.2.1 Piloting of questionnaires The questionnaires were subject to limited period of piloting, this was to ensure that they; identified the most appropriate information, that the design would maximise the number of returns, that the questions asked could be answered without to much difficulty by all professionals, and that the questions were clearly written and were unambiguous. Questionnaire piloting was provided by those involved old age psychiatric day hospital service delivery, other health professionals, researchers and the project steering group (see appendix I). Piloting of the second questionnaire took place in situ in seven old age psychiatric day hospitals in the north and Southeast of England. As a result the questionnaires underwent revision and was subject to limited further piloting. 4.3 Missing data and data management 4.3.1 Data preparation Initially the database of consultants for the psychiatry of old age was provided by the FPOA and was examined regarding its suitability for use. The advisory group thought that the overall numbers of clinically active consultant psychiatrists would number around 500 members. Due to its size (over 1000 members), the cost in terms of research staff time and postal charges precluded the use of the main faculty database. A member of the faculty Dr Susan Benbow gave the project use of a file containing 537 clinically active members. This was then converted into a database and underwent further cleaning. 12

Based upon the information gained from survey one, the databases were subject to further cleaning and updated. To ensure that the survey did not miss any day hospital an over inclusive approach was undertaken. All the outstanding non-responders from the first survey were approached with the second survey. Questionnaires were sent to all practising consultants for the psychiatry of old age (n = 521). 4.3.2 Missing data survey one There was some confusion with regard to the total number of old age psychiatric day hospitals within some trusts. As a result a telephone follow-up had to be undertaken to establish a clearer picture. The confusion in the main appears to be due to the ongoing reconfiguration too fewer trusts, with many unaware of the total provision within the newly formed trust. A telephone follow-up of all trusts was undertaken to establish the total number of consultants currently practising in psychiatry for old age,. The collected data was entered into an Access database file and summary results produced. Ireland presented a particular problem in attempting to define the full complement of consultants for the psychiatry of old age and their old age psychiatric day hospital complement (the figures represented are an underestimate). 4.3.3 Missing data survey two The questionnaire was correctly completed on all items for the majority of responders. However, many trusts had difficulty in answering several of the items. The catchment population items (question 4) caused most problems for respondents. This was expected, as health authorities no longer provide this information. Catchment population areas no longer exist since the introduction of the internal market (Griffiths, 1993: Department of Health, 1994). However many health authorities and trusts have calculated their populations. Staff also appeared to have difficulty in determining the whole time equivalent (WTE) of the staff complement of day hospitals (questions 10, 11, 12). Another frequently occurring problem in completing the questionnaire was due to staff ticking boxes when a number should have been entered (particularly question 15). Many telephone calls were undertaken to define more accurate information. Missing, incomplete or contradictory information occurred on all questions. This necessitated a telephone follow-up to determine the most accurate information. As this was not done for all questionnaire items the number of cases is given in most of the presented results. When duplicate questionnaire forms were returned only one was entered onto the database, if there were inconsistencies a telephone check was made to determine accuracy. 13

To determine the range and diversity of treatments, a request was made of the day hospital to provide a timetable of the day hospital s daily program of events together with a list of available treatments (question 23). Many trusts were unable to do this stating they were being rewritten or completely overhauled at the time of the survey and they did not wish to provide inaccurate information. The location and personnel data from the second survey was used to update the Access database created from survey one. The quantitative data was entered onto computer using the SPSS version 9 for windows statistical package (SPSS Inc, 1999). 4.4 Data analysis Survey one: This data was analysed using a summary description of data items in total and by country of origin. This in the main was formed of simple counts and proportions determined by percentages. Survey two: SPSS Version 9 for windows (SPSS Inc, 1999) was used to create a database and to undertake the statistical analysis. Many original variables in the data set were subject to a variety of computations to create compound variables, this data was also analysed using summary descriptions in the form of simple counts, frequencies and proportions displayed in percentages. Where appropriate a t-test or chi-squared statistical test for significance was used to test for difference between groups. A Pearson s productmoment correlation coefficient (r) was used to test for the level of correlation where appropriate. 14

5 RESULTS 5.1 Survey one Out of 487 postcard questionnaires distributed, 339 (70%) replies were received. Of those replies only 7% (n = 25) of consultants for the psychiatry of old age stated that they have no access to an old age psychiatric day hospital. Supplementary telephone follow-up was conducted on the outstanding 30% nonresponders. All NHS Trusts with currently active consultants in the psychiatry of old age currently were followed up. Retired Consultants (n = 25) have been replaced on the newly created database with active clinicians from the respective NHS trust. The Clinically Active Consultant Psychiatrists in Psychiatry of Old Age database has now been extended to 553 consultants. Table 1 contains the results of the first survey, which identified the following number of old age psychiatric day hospitals, trusts and consultants for the psychiatry of old age: Number of identified Old Age Psychiatric Day Hospitals is 440. One hundred and ninety one health delivery organisations (NHS Trusts and services in Ireland) and 553 Consultants of Old Age delivered psychiatric services for older people. In England 147 NHS Trusts and 441 Consultants in Old Age Psychiatry were identified. These trusts supported 354 old age psychiatric day hospitals. In Wales 10 NHS trusts with 25 consultants in psychiatry of old age were identified. The Trusts supported 30 old age psychiatric day hospitals In Scotland 16 NHS trusts with 61 consultants in psychiatry of old Age were identified. The Trusts supported 45 old age psychiatric day hospitals. In Northern Ireland 12 health boards 1, and 16 consultants in psychiatry of old age were identified, providing 8 old age psychiatric day hospitals, with; In Ireland 6 health boards and 10 consultants in psychiatry of old age were identified, supporting 3 old age psychiatric day hospitals. 1 The term health board is used in Northern Ireland and is a joint health and social care organisation. 15

5.1.1.1 Table 1: Number of day hospitals, health trusts (boards), and consultants in psychiatry of old age No. of consultants for Country No. of day hospitals No. of trusts/boards the psychiatry of old age England 354 (80%) 147 (77%) 441 (80%) Wales 30 (7%) 10 (5%) 25 (5%) Scotland 45 (10%) 16 (8%) 61 (11%) Northern Ireland 8 (2%) 12 (6%) 16 (3%) Ireland 3 (1%) 6 (3%) 10 (2%) Total 440 191 553 (%) = percentage of the total returned/identified Table 2 contains the results of the number of consultants for the psychiatry of old age, with, and without access, to an old age psychiatric day hospital by country of location. The total: Eighty three percent (n = 462) of responding consultants had access to an old age psychiatric day hospital. Six percent (n = 32) of consultants for the psychiatry of old age stated that they had no access to an old age psychiatric day hospital, with 11% (n = 59) of consultants failing to submit a response or the project team were unsure about their status; England: Eighty four percent (n = 369) of responding consultants had access to a day hospital. Four percent (n = 20) stated that they had no access to a day hospital, with 12% (n = 52) of consultants failing to submit a response or the project team were unsure about their status; Wales: All (n = 25) consultants who responded had access to an old age psychiatric day hospital; Scotland: Ninety percent (n = 55) of responding consultants had access to a day hospital. Three percent (n = 2) stated that they had no access to a day hospital, with 7% (n = 4) of consultants failing to submit a response or the project team were unsure about their status; Northern Ireland: Fifty six percent (n = 9) of responding consultants had access to a day hospital. Thirty eight percent (n = 6) stated that they had no access to a day hospital, with 6% (n = 1) of consultants failing to submit a response or the project team were unsure about their status; Ireland: Forty percent (n = 4) of consultants who responded had access to a day hospital. Forty percent (n = 4) stated that they had no access, with 20% (n = 2) of consultants failing to submit a response or the project team were unsure about their status. 16

5.1.1.2 Table 2: Consultant access to Day Hospitals Country No. of psychiatrists of old age No. of consultants with DH access No. of consultants without DH access No. of consultants not available for analysis England 441 (80%) 369 (84%) 20 (4%) 52 (12%) Wales 25 (5%) 25 (100%) 0 0 Scotland 61 (11%) 55 (90%) 2 (3%) 4 (7%) Northern Ireland 16 (3%) 9 (56%) 6 (38%) 1 (6%) Ireland 10 (2%) 4 (40%) 4 (40%) 2 (20%) Total 553 462 32 59 5.2 Survey two Using the information gained from the first survey 521 questionnaires were distributed and 240 (46%) were returned. Of the 240 questionnaires returned, 86% (n = 207) met the criteria for data entry and analyses. Fourteen percent (n = 33) of questionnaire returns not meeting the criteria for data entry were either incomplete or duplicates. Table 3 summarises valid returns by country, total adult population, older population and day hospital population. The number of valid responses was 207, representing 46% of those distributed. This related to 64% (n = 122) of health trusts/boards. The adult population of the returning health organisations was 35,826,069, with 6,045,496 aged sixty-five and over. 4,325,432 fell into the catchment of the day hospitals identified by the survey. England submitted 83% (n = 172) of all responses. Sixty nine percent (n = 101) of English health trusts had an adult population of 30,297,351, 5,120,612 of which were aged 65 and over. 3,809,193 fell into the catchment of day hospitals. Wales submitted 5% (n = 11) of all responses. Fifty percent (n = 5) of Welsh health trusts had an adult population of 1,635,000, with an older population ( 65) of 306,000 and a day hospital catchment population of 176,000; Scotland submitted 9% (n = 18) of all responses. Sixty three percent (n = 10) of Scottish health trusts had an adult population of 3,290,069, with an older population ( 65) of 535,586 and a day hospital catchment population 238,941. Northern Ireland submitted 2% (n = 5) of all responses. Forty two percent (n = 5) of Northern Ireland s health boards had an adult population of 604,000 with a health board and day hospital catchment population of 83,298 aged. Ireland submitted only 5% (n = 1) of all responses. 17% (n = 1) of Irish health boards. Only the day hospital catchment population over 65 was submitted of 18,000. 17

5.2.1.1 Table 3: Number of returns by country, number of day hospitals, trust, and psychiatrists with population statistics 2 Country No. of day hospital returns 3 No. of trust returns Total trust adult population 1 Total trust population over 65 1 Day hospital catchment population (over 65) England 172 (49%) 101 (69%) 30,297,351 5,120,612 3,809,193 Wales 11 (37%) 5 (50%) 1,635,000 306,000 176,000 Scotland 18 (40%) 10 (63%) 3,290,069 535,586 238,941 Northern Ireland 5 (63%) 5 (42%) 604,000 83,298 83,298 Ireland 1 (33%) 1 (17%) 18,000 Total 207 122 35,826,420 6,045,496 4,325,432 Question 4: What is the catchment population (Trust total, Trust over 65s, and Day Hospital over 65)? The results for this question have been described in several ways and summarised in tables 3, 4 and 5. Consultants in psychiatry of old age per 100,000 adult population: The number of old age psychiatrists per 100,000 adult population varied widely within countries, providing an overall mean of 1.08 with a range of between countries of.88 in Wales to 1.47 in Scotland. As expected this figure rose per 100,000 old age population ( 65) providing an overall mean of 6.64 with a range between countries of 4.80 in Wales to 8.80 in Scotland. The number of consultants for the psychiatry of old age per 100,000 old age day hospital catchment population (over 65) overall was 5.28 with a range between countries from 5.04 in England to 7.32 in Scotland. These figures are based only upon those who were designated consultant rank within trust but does not take into account whether the psychiatrist was part-time or whether they covered other mental illness duties. Day hospital places per 100,000 over 65s day hospital specific population: Based upon the standardisation of the over 65s day hospital specific population, the number of old age psychiatric day hospital places varied widely within countries. The overall mean was 260 places per 100,000 people ( 65) day hospital population with a range between countries from a mean of 143 in Northern Ireland to a mean of 326 in Wales. 5.2.1.2 Table 4: Summary data on population 2 3 The total population figures is based upon the number of trusts who provided this information therefore the total figures described are underestimates Percentages (%) in table 1 refer to the rate of returns when compared with the total number of identified in the survey 1 data 18

Country Total No. of trusts Total range trust population Total No. of trusts Total range of trust population over 65 Total No. of trusts Range of DH catchment population (over 65) England 87 58,681 to 1,254,698 91 9,205 to 203,392 136 4,200 to 98,569 Wales 5 180,000 to 500,000 5 28,000 to 90,000 9 12,500 to 28,500 Scotland 8 106,000 to 900,000 8 21,000 to 145,000 11 4,000 to 45,500 5 84,000 to 160,000 5 8,500 to 23,000 5 8,500 to 23,000 Northern Ireland Ireland 1 18,000 Table 5 describes the rate and range per 100,000 population of consultants for the psychiatry of old age and the rate and range of old age psychiatric day hospital places by diagnosis. 51% (n = 105) of the total number of valid responses provided a total population figure of 35,826,420 with an average of 341,203 population per trust. 19

5.2.1.3 Table 5: Population data by trusts who provided data England Wales Scotland Northern Ireland Ireland Total Mean Total Trust Population Range 58,681 to 1,254,698 180,000 to 500,000 180,000 to 900,000 84,000 to 160,000 35,826,420 341,203 No. of Trusts who provided information 87 5 8 5 105 Trust Old Age Population Range 9,205 to 203,392 28,000 to 90,000 21,000 to 145,000 8,500 to 23,000 6,045,496 55,463 No. of Trusts who provided information 91 5 8 5 109 Day Hospital Population Range 4,200 to 98,569 12,500 to 28,500 4,000 to 45,000 8,500 to 23,000 18,000 4,325,432 26,700 No. of Trusts who provided information 136 9 11 5 1 162 Mean percentage % of the proportion of over 65 in the Total population 16.6 18.7 16.8 13.6 N/A 16.5 Range 8.1 to 30.0 15.5 to 24.33 12.4 to 23.9 10.1 to 18.0 N/A 8.1 to 30 χ No. of consultants per 100,000 1.05 Number of consultants for the psychiatry of old age per 100,000 0.88 1.47 1.13 1.08 Range.18 to 3.33.56 to 1.20.31 to 2.52.87 to 1.38.18 to 3.33 χ No. of cons per 100,000 OA pop 6.44 4.80 8.80 8.65 6.64 Range 1.54 to 32.0 2.74 to 6.15 2.47 to 18.29 5.56 to 11.76 1.54 to 32.0 χ No. of cons per 100,000 OA DH catchment pop 5.04 5.54 7.32 6.78 5.56 5.28 Range 1.01 to 23.81 3.51 to 8.0 2.20 to 25.00 4.35 to 11.76 5.56 1.01 to 25.0 Day hospital places by diagnostic category per 100,000 over 65s day hospital specific population DH places per 100,000 DH pop 4 256 326 309 143 260 Range 10.5 to 1085 23.0 to 750 107.1 to 575.2 23.5 to 362.37 10.6 to 1085.9 Organic DH places per 100,000 DH pop 162.1 286.7 391.5 99.7 181 Range 7 to 738 23 to 423 113 to 779 5. to 194 5 to 779 Functional DH places per 100,000 DH pop 89 239 42 137 125 Range 26 to 155 178 to 300 42 23 to 362 23 to 362 Combined DH places per 100,000 DH pop 5 268 361 299 977 282 4 5 Includes organic, functional and other patient groups using an old age day hospitals Organic and functional patients only

Range 26 to 780 91 to 750 147 to 397 977 26 to 977 21 22

Question 6: What is the number of patients attending for each day? There were 205 valid responses, which enabled the calculation of the number of patients attending per day to be conducted. Thirteen percent (n = 27) of responding day hospitals had less than 10 attendees per day. Twenty six percent (n = 54) had between 10 and 15 attendees, 24% (n = 49) between 15 and 20, 17% (n = 34) between 20 and 25, 10% (n = 20) between 25 and 30, 10% (n = 21) had over 30 attendees per day. Question 5: For each diagnostic category, how many patients are using the Day Hospital? And Question 7: In addition to old age what other groups of patients does your Day Hospital cater for? The results for these questions have been described by diagnostic category. 5.2.2 Organic day hospital service 17% (n = 36) of all day hospital returns provided a service for organic patients only. 93% (n = 192) of all old age psychiatric day hospitals provided some sessions 6 for organic patients. The number of sessions provided varied. Twenty percent (n = 38) provided five sessions or less, 35% (n = 67) of day hospitals provided between six and nine sessions, 39% (n = 75) operated a full time service i.e. 10 sessions, with only six percent (n = 12) providing additional sessions or a weekend service. One day hospital, which serviced organic patients, did not provide information on the number of available sessions. The number of organic patients attending day hospitals varied widely. One hundred and ninety three day hospitals provided returns concerning organic patients. Thirty percent of these (n = 58) had 20 or less organic patients on their books, 54% (n = 104) have between 21 and 50 patients, 14% (n = 27) have between 51 and 100 patients. There were two percent (n = 4), which had in excess of 100 patients on their register. 5.2.3 Functional day hospital service Only seven (n =14) of all day hospital returns provided a functional only day hospital service. However 83% (n = 171) of all old age psychiatric day hospitals provided some sessions for functional patients. The number of sessions provided varied, 44% (n = 75) provided 5 or less sessions, 30% (n = 51) of day hospitals provided between 6 and 9 sessions, with 24% (n = 41) providing a full time (10 session) service, with only 2% (n = 4) providing additional sessions or a weekend service. The number of functional patients' serviced by returning day hospitals varied widely. Of the 171 day hospitals which provided some information on its functional patients, 38% (n = 65) had 20 or less patients on their books, 43% (n = 74) have between 21 and 50 patients, 19% (n = 32) have between 51 and 100 patients. No service had in excess of 100 functional patients on their register. 6 A session equals a half day

5.2.4 Other patient groups day hospital service 18% (n = 37) of all day hospitals had some provision for other groups of patients, of these day hospitals 50% (n = 21) catered for adult MI in addition to old age, however 95% (n = 20) of these had only 1 or 2 patients. The total number of other patient s serviced by returning day hospitals varied widely. Of the 40 day hospitals which provided information on its other patients 83% (n = 33) of day hospital services catering for 20 or less patients on their books, 5% (n = 2) have between 21 and 50 patients, 5% (n = 2) have between 51 and 100 patients. There were 8% (n = 3) which had in excess of 101 other patients on their day hospital register. 10% (n = 4) of day hospital services had patients with learning disabilities on their register, though none had more than 2 patients. Twenty three percent (n = 9) also had patients with drug or alcohol problems, though all had less than 4 patients. 5.2.4.1 Table 6: No. of days of day hospital operation for organic, functional and other patients (based upon actual No.'s attending per day) No. of days of operation Organic patients Functional patients Other patients No. of % No. of DH % No. of DH % DH 1 day 8 4% 12 7% 11 31% 2 days 27 14% 51 31% 2 6% 3 days 50 26% 34 21% 11 31% 4 days 22 12% 18 11% 4 11% 5 days 74 39% 44 27% 7 20% 6 days 3 2% 2 1% 0 7 days 8 4% 2 1% 0 Total 192 100% 163 100% 35 100% Question 8: How many sessions or half days does the Day Hospital function per week for those with mental health problems in old age? Working hours committed to the care of patients with, organic illness varied substantially. Of the 192 (93%) valid responses just under 5% (n = 9) were open for 5 hours or less, 82% (n = 157) were open for between 5 and 8 hours, with 13% (n = 26) operating between 8 and 11 hours per day. A similar number of working hours is devoted to care of older people with functional conditions. Of the 163 (79%) valid responses just under 7% (n = 11) were open for 5 hours or less, 81% (n = 133) were open for between 5 and 8 hours, with 12% (n = 19) operating between 8 and 11 hours per day. Responses to question 8 (see above) provide an overview of service provision by diagnostic group provided by returning day hospitals. Slight discrepancies are evident when these findings are compared to findings generated by answers to previously relevant questions (questions 5,6,7) because of variance in responders. Sixty percent (n = 124) of all day hospitals operated a mixed organic and functional day hospital. Sixteen percent (n = 34) operated an organic only service. Two percent (n = 4) of day hospitals serviced organic and other patients groups (drugs and alcohol, adult mental illness, or learning disabilities). Fifteen percent (n = 30) of all day hospitals contained organic, 22

functional and other groups of patients. Six percent (n = 12) operated a functional only service and one percent (n = 3) of all the day hospital returns were for the use of functional and Other patient groups only. Question 9: What proportion of the funding of the Day Hospital is provided by each of these agencies (NHS, Local Authority, Private or Voluntary Sectors)? Of the 205 health providers returning information of the source of funding 92% (n = 190) were wholly funded by the NHS. The 15 remaining day hospitals were subject to joint funding with NHS with the local authority providing 50% of funding for 8 of the day hospitals and providing between 10 and 30% for 5 of the day hospitals. Private or independent agencies provided some funding for two day hospitals, providing 2% and 40% respectively. Question 10: What is the staffing complement of the Day Hospital? All 207 returns gave some information on numbers of whole time equivalent (WTE) staffing levels. Day hospitals were predominantly staffed by nurses, representing 99% (n=204) of the staffing compliment and providing 93% of service provision. Three percent of day hospital services (n = 7) were predominately staffed by occupational therapists, two percent (n = 4) were evenly staffed by occupational therapists and nurses and one percent (n = 2) were evenly staffed by nurses, occupational therapists and social workers. Only one day hospital reported social workers as the main professional provider. Staff deficits: Nineteen percent (n = 40) of all day hospitals did not have any occupational therapy input with 56% (n = 115) not having any psychologist sessions and 81% (n= 39) had no social worker input. In addition many day hospitals had low levels of administration, with 31% (n = 68) reporting they had no administrative support. There was a similar finding for the lack of domestic support with 31% (n = 64) of all day hospitals. 23

> 30 5.2.4.2 Figure 1: Level of WTE staffing per day by No. of patients attending per day (nonmedical) 8 7 6 Mean; WTE Staff 5 4 3 2 1 Staff Unqualified 0 <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Staff Qualified No. of patients attending day hospital per day 5.2.4.3 Figure 2: Level of WTE staffing, nursing and occupational therapist per day by No. of patients attending per day 6 5 Mean; WTE staff 4 3 2 Nurse Qualified 1 Nurse Unqualified OT Qualified 0 >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 OT Unqualified No. of patients attending per day 24

> 30 > 30 5.2.4.4 Figure 3: Level of WTE staffing, physiotherapists, psychologists and social worker per day by No. of patients attending per day.7.6.5 Mean; WTE staff.4.3.2.1 Physio Qualified Physio Unqualified Psychol Qualified Psychol Unqualified SW Qualified 0.0 >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 SW's Unqualified No. of patients attending per day 5.2.4.5 Figure 4: Level of WTE Medical input per day by No. of patients attending per day 2.5 2.0 Mean; WTE staff 1.5 1.0.5 Psychiatrist 0.0 >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 Medical Other No. of patients attending per day 25

5.2.4.6 Table 7: Mean WTE staffing level by No. of patients attending the day hospital per day Profession WTE staffing level Number of patients attending the day hospital per day >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total Mean No. Mean No. Mean No. Mean No. Mean No. Mean No. Mean No. Staff qualified 3.10 27 3.60 54 4.46 49 4.34 34 5.77 20 7.83 20 4.49 205 Staff unqualified 1.76 25 2.74 50 2.54 46 3.82 34 4.15 20 6.16 20 3.25 196 Nurses qualified 2.13 27 2.49 54 3.29 49 3.15 33 4.22 20 5.33 20 3.19 204 Nurses unqualified 1.44 19 2.06 48 1.89 44 3.10 31 2.86 20 4.28 20 2.46 183 OTs qualified.91 21.97 40 1.04 37.95 32 1.02 18 1.63 19 1.05 168 OTs unqualified 1.18 12.93 29 1.04 25 1.02 21 1.38 14 1.55 14 1.11 116 Psychologist qualified Psychologist unqualified Physiotherapy qualified Physiotherapy unqualified.34 4.70 8.35 12.34 9.70 4.64 7.48 44. 0.65 4.20 1.31 4.20 1 1.00 1.47 11.41 11.59 17.46 25.37 16.68 12 1.15 11.57 93.30 2.48 10.66 12.57 5.79 8.73 9.62 47 S W's qualified.34 4.55 10.34 10.52 8.53 3.48 4.46 39 SW's unqualified.70 3.88 4. 0 2.07 4. 0 4.25 2 1.71 13 Psychiatrist.56 20.62 33.84 23.44 21.79 16 2.61 17.89 131 Medical Other 1.06 16.55 27 1.03 31.66 19.94 14 1.36 17.91 125 Admin/sec; 1.16 13.58 32.86 37.79 27.72 15 1.47 17.86 142 Domestic.74 13.66 37 1.04 37.84 26.61 13 1.26 16.85 143 Volunteer.97 7.49 12.52 14.97 11 1.20 5 2.25 4.86 53 26

5.2.4.7 Table 8: No. of WTE staff by No. of patients attending the day hospital per day Nursing WTE qualified Number of patients attending the day hospital per day >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 18 24% 31 42% 11 15% 11 15% 2 3% 1 1% 74 36% >= 2 to <=4 7 8% 18 20% 30 34% 16 18% 12 14% 6 7% 89 44% >= 4 to <=6 1 4% 3 11% 5 19% 5 19% 5 19% 8 30% 27 13% > 6 1 8% 2 15% 3 23% 1 8% 1 8% 5 39% 13 6% Total 27 13% 54 27% 49 24% 33 16% 20 10% 20 10% 203 Nursing WTE unqualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 18 16% 40 35% 32 28% 15 13% 8 7% 3 3% 116 64% >= 2 to <=4 1 2% 5 11% 11 24% 8 17% 10 14% 11 24% 46 25% >= 4 to <=6 0 0 0 6 50% 2 19% 4 33% 12 7% > 6 0 3 38% 1 13% 2 25% 0 2 25% 8 4% Total 19 10% 48 26% 44 24% 31 17% 20 11% 20 11% 182 OT WTE qualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 19 12% 39 25% 35 22% 32 20% 18 11% 15 10% 158 95% >= 2 to <=4 2 25% 0 2 25% 0 0 4 50% 8 4% >= 4 to <=6 0 1 100% 0 0 0 0 1 1% Total 21 13% 40 24% 37 22% 32 19% 18 11% 19 11% 167 OT WTE unqualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 10 9% 28 26% 24 22% 21 20% 12 11% 12 11% 107 93% >= 2 to <=4 2 29% 1 14% 1 14% 2 29% 1 14% 7 6% >= 4 to <=6 1 100% 1 1% Total 12 10% 29 25% 25 22% 21 18% 14 12% 14 12% 115 Psychologist WTE qualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 11 12% 16 18% 25 28% 16 18% 12 13% 10 11% 90 98% >= 2 to <=4 1 100% 1 1% >= 4 to <=6 1 100% 1 1% Total 11 12% 17 19% 25 27% 16 17% 12 13% 11 12% 92 Psychologist unqualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 2 4% 10 22% 11 24% 5 11% 8 18% 9 20% 45 98% >= 2 to <=4 1 100% 1 2% Total 2 4% 10 22% 12 26% 5 11% 8 17% 9 20% 46 Social Worker >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. WTE qualified >= 0 to <=2 4 10% 10 26% 10 26% 8 21% 3 8% 4 10% 39 Total 4 10% 10 26% 10 26% 8 21% 3 8% 4 10% 39 Social Worker unqualified >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 3 30% 4 40% 2 20% 1 10% 10 77% >= 2 to <=4 1 100% 1 8% >= 4 to <=6 1 100% 1 8% > 6 1 100% 1 8% Total 3 23% 4 31% 4 31% 2 15% 13 27

5.2.4.8 Table 9: No. of WTE administration and domestic staff by No. of patients attending the day hospital per day Administrati on WTE >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 12 9% 32 24% 35 26% 27 20% 15 11% 15 11% 136 96% >= 2 to <=4 2 67% 1 33% 3 2% >= 4 to <=6 1 50% 1 50% 2 1% Total 13 9% 32 23% 37 26% 27 19% 15 11% 17 12% 141 Domestic WTE input >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 13 9% 37 27% 35 25% 26 19% 13 9% 14 10% 138 97% >= 2 to <=4 1 33% 2 67% 3 2% >= 4 to <=6 1 100% 1 1% Total 13 9% 37 26% 37 26% 26 18% 13 9% 16 11% 142 5.2.4.9 Table 10: No. of WTE medical staff by No. of patients attending the day hospital per day Psychiatrist WTE input >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 19 16% 32 27% 22 19% 21 18% 15 13% 10 8% 119 92% >= 2 to <=4 1 13% 1 13% 6 75% 8 6% >= 4 to <=6 1 50% 1 50% 2 2% > 6 1 100% 1 1% Total 20 15% 33 25% 23 18% 21 16% 16 12% 17 13% 130 Other Medical WTE input >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. >= 0 to <=2 14 12% 27 23% 30 25% 19 16% 14 12% 15 13% 119 96% >= 2 to <=4 1 33% 2 67% 3 2% >= 4 to <=6 1 100% 1 1% > 6 1 100% 1 1% Total 16 13% 27 22% 31 25% 19 15% 14 11% 17 14% 124 5.2.4.10 Figure 5: WTE staff vacancies 4.0 3.5 3.0 2.5 2.0 Mean; WTE Staff 1.5 1.0.5 0.0 >= 1 to <= 10 > 25 to <= 30 > 20 to <= 25 > 15 to <= 20 > 10 to <= 15 > 30 Total Vacancies Qualified Unqualif ied 28 No. of patients attending per day

Question 11: How many WTE Day Hospital posts (overall) are at present vacant? Forty percent of (n = 82) day hospitals had vacant posts, this ranged from 0.2 to 4.0, with an overall mean of 1.35 WTE staff vacancies. There was no difference between size of day hospital and the number of staff vacancies. Question 12: What is the WTE per week staff posts covered by agency staff? Nineteen percent (n = 39) of day hospitals reported the use of agency staff at the time of the survey, with a mean of 0.9 WTE staff per day hospital. 5.2.4.11 Table 11: No. of WTE Vacancies and agency staff by No. of patients attending the day hospital per day Vacancies/Agency WTE input Number of patients attending the day hospital per day >= 1 to <= 10 > 10 to <= 15 > 15 to <= 20 > 20 to <= 25 > 25 to <= 30 > 30 Total No. Vacancy qualified and unqualified Mean No. Mean No. Mean No. Mean No. Mean No. Mean No. Mean No. 1.54 6 1.31 14 1.28 19 1.25 18 1.41 10 1.49 13 1.35 80 Qualified staff.90 5 1.27 9 1.14 16 1.20 13 1.25 10 1.42 10 1.21 63 Unqualified staff 1.58 3 1.00 7.76 8.99 7.80 2.87 6.96 33 Agency qualified and unqualified 1.90 4 1.10 8.75 9.76 5 1.40 5 2.08 8 1.30 39 Qualified agency 1.53 3.87 3.56 5 1.00 1 1.50 2.57 3.92 17 Unqualified agency 1.50 2.89 7.65 6.70 4 1.33 3 2.49 6 1.24 28 Question 13: Are any of the Day Hospital staff involved in providing outreach services? These day hospitals provided day services to residential homes and patients own home. 5.2.4.12 Table 12: No. of day hospitals and proportion of staff providing outreach services Number of day hospitals Staff >= 0 to <= 2 > 2 to <= 4 > 4 to <= 6 > 6 Total No. % No. % No. % No. % No. % All staff (combined) 38 67% 19 11% 9 5% 4 2% 57 100% Qualified staff 42 81% 6 12% 2 4 2 4 52 100% Unqualified staff 26 96% 0 1 4% 0 27 100% 29