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Models of Day Care: Learning from the past, planning for the future Professor Geoff Shepherd (Director of Partnerships and Service Development)

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Presentation on theme: "Models of Day Care: Learning from the past, planning for the future Professor Geoff Shepherd (Director of Partnerships and Service Development)"— Presentation transcript:

1 Models of Day Care: Learning from the past, planning for the future Professor Geoff Shepherd (Director of Partnerships and Service Development)

2 Models of day care - ‘Better Services for the Mentally Ill’ (Department of Health, 1975) oDay ‘hospitals’ - NHS funded, ‘acute’ function, aimed at preventing inpatient admission (where possible) and facilitating early discharge oWork & employment programmes - mainly LA (or NHS funded if hospital-based) to provide assessment, ‘training’ and preparation for return to work oDay ‘centres’ - LA funded, mainly to provide ‘social support’ oWhere did these ideas come from?

3 Day ‘hospitals’ oPioneered in Russia in the 1930s, then developed in Europe - particularly Germany and Switzerland - also in Canada oBecame very popular in England in the post-war period, as institutions began to reduce in size oWHO (1953) ‘the modern system of mental health services will be one in which inpatient, day care, domiciliary care operate as tools in the hands of the community and the hospital becomes only one tool at the disposal of the medico-social team’ (cited in Jones, 1972).

4 The case for day hospitals (Harris, 1956) oInpatient admission is expensive oIt removes the patient from his/her normal environment oAlso may be separated from family and children (adding to ‘stress’) oThe family may ‘close ranks’ while the patient is admitted, closing the patient’s social ‘niche’ oThe patient - and their family - then has to be carefully prepared for discharge, so that it is not a ‘shock’, risking further relapse oDay care is much more flexible (‘partial hospitalisation’)

5 Problems with day care (Farndale, 1961) ãSurveyed 65 day hospitals and day centres 1958 - 1959) ãNoted great variations in staffing, range of treatments offered, ‘casemix’, location, etc. ãConcluded that day hospitals were most effective if they worked very closely with inpatient units ãCautioned against viewing day hospitals as a ‘panacea’, noted that some patients would continue to need inpatient admission (e.g. violent or acutely suicidal)

6 So, what can we learn from the history of day hospitals? 4Need to remain focussed on those people who are ‘at risk’ of inpatient admission 4Need to work closely with other ‘crisis resolution’ services (e.g. inpatient units, home treatment teams) to provide a flexible range of responses 4Need to think about how to preserve social role functioning (the social ‘niche’) 4If you are working ‘in the community’, then need to involve families and other carers

7 How might these elements fit together? Primary care Social Services Emergency Duty Team ‘ Respite’ beds (alternative to admission) Acute inpatient beds Acute day treatment CMHTs Support workers Specialist crisis / ‘home treatment’ team (linked in to A&E) 7 day service, etc. Urgent outpatient appointment

8 Work and employment - ‘distraction’ and ‘normality’ in the early institutions oIn the nineteenth century, ‘work’ was one of the primary methods of treatment (perhaps the most important) o“Is it the opinion of the superintendent that a state of entire and mental inertness is decidely prejudicial to the patient?” (Standards of the Parliamentary Reform Group, 1827) o“How far has manual labour been adopted? …… o[also] ….. active engagement of the mind to the sciences, fine arts, literature or mechanical arts for patients of ‘superior description’ ….. o….. where graver studies have been found unsuitable [have other occupations been provided?] - drawing, painting, design, models, gardening o…… where the mind is very diseased [have ‘innocent amusements’ been furnished?] music, domestic animals, birds, flowers, etc.

9 Work and employment - the beginnings of research êWing & Brown (1970) ‘Institutionalism and Schizophrenia’ - engagement in constructive activity was the most important factor contributing to a reduction of negative symptoms - reduce the length of time spent doing nothing êWHO (1979) ‘Schizophrenia: An International Follow-up Study’ differences in outcomes associated with greater economic and social opportunities in ‘developing’ - as opposed to ‘developed’ - countries êWarner (1985) ‘Recovery from Schizophrenia’ - the availability of employment opportunities influences outcomes in schizophrenia at a ‘macro’ and ‘micro’ (i.e. individual) level. Also emphasises the importance of ‘reintegration’ and the problems of stigma

10 So, what can we learn from the history of providing work and employment opportunities? o‘Work’ (in the broadest sense) is good for you! (especially if you have serious mental health problems) oThere is no one solution to what people ‘need’ in terms of work and occupation - different people ‘need’ different things oNHS and LAs are not necessarily very good providers of work and employment opportunities - the independent sector is usually better oWhat is important with work is not just the activity itself, but also the social role it provides (an escape from being a ‘patient’) oBroad social and cultural factors - and stigma - influence the extent to which work and employment opportunities will be offered (and accessed)

11 The need for a ‘balanced’ range of services oThere is no single model that can apply to everyone - no ‘one size fits all’ oDifferent people have different needs in terms of the degree of ‘shelter’ provided and the degree of independence expected oAll vocational schemes dealing with people with disabilities have to struggle with the balance between commercial and therapeutic aims oThe range of provisions must be well-integrated and well- coordinated - hence the role of ‘vocational specialists’ - so that individuals can ‘mix-and-match’ choices oPeople should be offered stability and the opportunity to move on. Progress shouldn’t mean a loss of support

12 Finally, ‘social support’ ….. éSocial support is the most obvious ‘natural’ ingredient for recovery éBut, it must be ‘individualised’, “it is a supreme moral duty and medical obligation to respect the insane individual as a person” (Chiarugi, 1788) éAlso, it should be ‘normalising’, “the patient on all occasions should be spoken to and treated as much in the manner of a rational being as the state of mind will allow. By this means the spark of reason will be cherished” (Tuke, 1811) éShould support primarily be provided by paid carers (staff) or ‘informal carers’? (i.e. family and friends) éWhat about the stressful aspects of ‘support’? (e.g. High ‘EE’, stigma). ‘Support’ isn’t always positive.

13 The role of ‘patients’ in providing social support o1955 - 1975 ‘Therapeutic Communities’ - an emphasis on the value of ‘patient experiences’ in helping others learn strategies to keep them out of hospital o1978 > the ‘Clubhouse’ model - patients supporting one another and working together to provide accessible and enduring support systems (‘always there for you’) oMitchell & Birley (1983) - long-term social support in the community, 2 groups: (a) those who were ‘socially engaged’; (b) those needing ‘company-without-intimacy’ oHence, need for a range of social supports, to meet a range of needs

14 How to provide ‘social support’ in a ‘modernised’ system of day care? 4Emphasise the role of service users as supporters, rather than paid staff 4Shift provision towards the voluntary and independent sector, rather than statutory 4Don’t ignore social support in the drive to produce ‘evidence-based’ work and employment provisions 4Provide support for the ‘non-engaged’, as well as the ‘engaged’ 4Provide ‘Segregated’ support, as well as ‘Integrated’ support (‘multiple identities’)

15 Conclusions oHistory is useful stuff! (‘Those who are ignorant of history are condemned to repeat it’ George Santayama, 1953) oThe history of day care is a progressive attempt to answer specific questions, ‘What works for whom under what conditions?’ oNeed to separate social ‘recovery’ models, from ‘treatment’ models oNeed to provide a range of work, occupation and social supports to meet a range of individual needs oThe value of work and occupation remains probably the most neglected therapeutic tool in psychiatry oNeed to balance ‘separate’ and ‘integrated’ supports. Stigma remains a problem oWhen are we really going to make social goals our primary targets?


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