Hospital bed types

Older adult beds are provided for the psychiatric care of patients aged 65 years and older. Beds can typically be provided for 2 main types of care;

1. Organic mental illness which is a dysfunction of the brain associated with decreased mental function

2. Functional mental illness which covers a range of psychiatric illness including; psychosis, affective and behavioural disorders.

Patients on older adult mental health wards, often exhibit complex co-morbidities including enhanced levels of physical frailty. Patients typically stay longer on older adult wards than on general psychiatric wards given their poor state of physical and mental health, and need for ongoing care and support.

A PICU is a type of psychiatric inpatient ward. These wards are secure, meaning that they are locked and entry and exit of patients is controlled. Staffing levels are usually higher than on an acute inpatient ward, usually multi-disciplinary and sometimes with 1:1 nursing staffing ratios. They usually receive patients who cannot be managed on the acute inpatient wards due to the level of risk the patient poses to themselves or to others.

In some cases, patients may also be referred from prisons or rehabilitation wards. Patients will usually be detained under the Mental Health Act. Length of stay is normally short (ranging from a few days to a few weeks, depending on the patient’s needs), and patients are usually returned to the acute inpatient ward as soon their risk has reduced and the more intensive treatment has started.

Psychiatric intensive care is for compulsorily detained patients of adult working age, who are in an acutely disturbed phase of a serious mental disorder.

Specialist beds associated with the care of mothers and their babies for a range of mental illness associated with the puerperium. This can include psychosis and affective (mood) disorders.

Perinatal mental health units care for both mother and baby, and typically have high intensity input from medical, nursing, and therapy staff.

Adult acute mental health inpatient services specifically for people who have a learning disability and for autistic people - Some people refer to this as a ‘specialist’ service, or an ‘enhanced’ service but it simply means that the acute mental health inpatient service, and its team, has been designed especially with the needs of these groups of people in mind to ensure they receive high quality care for short periods of time where adult or older adult services cannot be reasonably adjusted sufficiently. People who are admitted to these hospitals are still being assessed and treated within the requirements of the MHA (whether admitted formally or informally).

An admission to an acute mental health inpatient setting which is specifically for autistic adults and adults with a learning disability should only take place when:

• the person has a learning disability or is autistic, and
• they meet the criteria for admission to an acute mental health hospital, and
• sufficient reasonable adjustments cannot practicably be made to the physical environment, staffing, or general approach within adult and older adult acute mental health inpatient services to provide equitable outcomes (and this is evidenced).

Further detail can be found in the National guidance to support ICBs to commission acute mental health inpatient services for adults with a learning disability and autistic adults (NHS England, 2023)

Low secure units deliver intensive, comprehensive, multidisciplinary treatment and care by qualified staff, for patients who demonstrate disturbed behaviour in the context of a serious mental disorder and who require the provision of security. This is according to an agreed philosophy of unit operation underpinned by the principles of rehabilitation and risk management.

Such units aim to provide a homely secure environment, which has occupational and recreational opportunities, and links with community facilities. Patients will be detained under the Mental Health Act and may be restricted on legal grounds needing rehabilitation usually for up to two years. Access to this service is typically from local mental health services (including PICU), from medium secure services or from the criminal justice system

Medium secure services work within a framework of clinical governance, specialised assessment, treatment, rehabilitation and aftercare services for offenders with mental health problems, or those at risk of offending. Thereby seeking to reduce the distress associated with mental health problems, and their behavioural consequences, with reduction of risk of harm to others.

Most patients enter medium secure care from court, although some may be referred from general mental health services. All will be detained under the Mental Health Act. They may also move to medium secure services by means of transfer from low to high secure services, as a consequence of changing needs.

The average length of stay in medium secure care is 18–24 months, although some may require medium security for longer.

High secure services work within a framework of clinical governance, specialised assessment, treatment, rehabilitation and aftercare services for offenders with mental health problems or those at risk of offending. Thereby seeking to reduce the distress associated with mental health problems and their behavioural consequences, with reduction of risk of harm to others.

Patients enter high secure care from court, and all will be detained under the Mental Health Act. The average length of stay in high secure care is around ten years with lifetime stays also evident due to the specific requirements of the justice system.

Neuro-psychiatry and acquired brain Injury beds, are complex inpatient services for people who have suffered a brain injury or other impairment due to both traumatic and non-traumatic events. Patients suffer from brain cell damage that requires specialist brain injury help.

Patients may suffer from progressive symptoms that require ongoing specialist management. Patients can suffer from complex physical, cognitive and behavioural co-morbidities that require specialist care. This specialist care can be associated with complex diagnostic and rehabilitation services, which include a large therapy component. Services provided typically span neuro-psychological and neuro-psychiatric services as well as a range of supporting physical and cognitive therapies.

Personality disorder inpatient beds offer a highly structured environment designed to promote recovery. Care and support are provided in therapeutic environments by comprehensive multidisciplinary teams. Services offer a range of interventions including Dialectical Behaviour Therapy (DBT) and Therapeutic community treatment, along with a number of additional interventions to enhance patients’ recovery journey. Medication can also be helpful in dealing with distressing symptoms.

Prior diagnosis of personality disorder and associated mental health needs before admission. Patients often have co-morbid presentations.

These wards are now expected to meet the single sex accommodation standards.

These beds offer assessment, treatment and interventions for a full range of mental illnesses, behavioural and psychological problems in adults with severe to profound hearing loss, and also work with deaf people with visual impairment. Care is provided by a mixture of deaf and hearing professionals supported by BSL interpreters. Hearing staff within the inpatient service are supported to train in BSL.

These wards are now expected to meet the single sex accommodation standards.

Low secure rehabilitation services are hospital based, providing care for clients who have all been involved in offending or challenging behaviour.

Clients will all be detained under the MHA and will have varying levels of functional skills. They are likely to require therapeutic programmes tailored to their offending behaviour in addition to their mental disorders.

The usual aim of treatment is to move on to a high dependency or community rehabilitation unit. Length of stay varies depending on the nature of the offending or challenging behaviour and psychopathology but is usually around two years.

Client group and focus: people who need this kind of facility will be highly symptomatic, with multiple or severe co-morbid conditions, significant risk histories and challenging behaviours. Most will be detained under the MHA.

Around 20% will have had forensic admissions. The focus is on thorough ongoing assessment, maximising benefits from medication, engagement, reducing challenging behaviours and reengaging with families and communities. These units have a major role in repatriating patients from secure services and out-of-area placements to local services and, ultimately, to local community living.

• recovery goal: to move on to community rehabilitation unit or to supported community living. • Site: ward usually based in the local mental health unit to benefit from support from other wards and out-of-hours cover
• expected length of admission: up to 1 year*

• functional ability: domestic services provided by the unit, although participation in domestic activities with support encouraged as part of therapeutic programme

• risk management: higher-staffed (often locked/lockable) units able to manage behavioural disturbance

• degree of specialisation: should be available in all trusts. One unit is needed for a population of 600 000 to 1 million

Child and Adolescent Mental Health (CAMHS) Tier 4 Children’s Services, deliver tertiary level care to children who are suffering from severe and/or complex mental health conditions.

Units admit children aged pre-school to 13; one unit offers family admissions allowing admission for younger children and parents together. Services are provided for children with a wide range of disorders (including severe emotional and behavioural disorders, eating disorders, severe anxiety disorders and severe psychosomatic disorders).

Tier 4 Child and Adolescent Mental Health Services (CAMHS) General Adolescent Services, deliver tertiary level care and treatment to young people with severe and/or complex mental disorders.

Services are provided for young people between 13 and 18 years, with a range of mental disorders (including depression, psychoses, eating disorders, severe anxiety disorders, emerging personality disorder and severe psychosomatic disorders). All associated with significant impairment and/or significant risk to themselves or others, such that their needs cannot be safely and adequately met by community Tier 3 CAMHS.

This includes young people with mild learning disability and Autism Spectrum Disorders, who do not require Tier 4 CAMHS Learning Disability Services.

Tier 4 CAMHS specialist eating disorder units, are for children and young people suffering from severe eating disorders, resulting in significant weight loss and/or severely impaired growth. Such that their health, growth and development are at risk, and who have not responded to Tier 3 CAMHS outpatient treatment.

Children and young people may also be referred for treatment where at the point of referral, to Tier 3 CAMHS if they are within a high-risk low weight range and could not be safely treated within Tier 3 CAMHS.

The primary reason for referral to such services, is the presence of a severe eating disorder, although units are able to treat the psychiatric co-morbidities which commonly accompany severe eating disorders.

Tier 4 CAMHS specialist eating disorder services admit children and young people with anorexia nervosa, atypical anorexia, eating disorders not otherwise specified (EDNOS), food avoidant emotional disorder, refusal syndromes and phobias leading to severely restricted eating.

Low secure settings accommodate young people with mental and neurodevelopmental disorders at lower, but nevertheless significant levels of physical, relational and procedural security. Young people in such settings may belong to one of two groups: those with ‘forensic’ presentations involving significant risk of harm to others, and those with ‘complex non-forensic’ presentations principally associated with challenging behaviour, self-harm and vulnerability.

Medium secure settings accommodate young people with mental and neurodevelopmental disorders, who present with the highest levels of risk of harm to others, including those who have committed serious crimes.

In such settings, there are prescribed stringent levels of physical security and high levels of relational and procedural security.

Young people admitted to medium security generally have significant lengths of stay from months to years.

Low secure settings accommodate young people with mental and neurodevelopmental disorders at lower, but nevertheless significant levels of physical, relational and procedural security.

Young people in such settings may belong to one of two groups: those with ‘forensic’ presentations involving significant risk of harm to others and those with ‘complex non-forensic’ presentations principally associated with challenging behaviour, self-harm and vulnerability.

Young people admitted to low and medium secure settings generally require significant lengths of stay from months to years.

Medium secure settings accommodate young people with mental and neurodevelopmental disorders, who present with the highest levels of risk of harm to others including those who have committed serious crimes. In such settings, there are prescribed stringent levels of physical security and high levels of relational and procedural security.

Young people admitted to medium security generally have significant lengths of stay from months to years.

The national Obsessive-Compulsive Disorder and Body Dysmorphic Disorder service (OCD/BDD), is commissioned to provide highly specialised assessment and treatment for patients experiencing severe OCD or BDD through out-patient, homebased, residential unit or in-patient services on behalf of NHS England for the Population of England.

Psychiatric intensive care units (PICU) for young people, allow for containment of short-term behavioural disturbance which cannot be contained within an open adolescent in-patient unit.

This behaviour will be associated with a serious risk of either suicide, absconding with a significant threat to safety, aggression or vulnerability; for example, due to agitation or sexual disinhibition.

Levels of physical, relational and procedural security should be similar to those in low security.

Whilst educational and recreational facilities should be available to young people in intensive care and secure settings, these provisions will tend to be set up differently in PICUs, which do not have the same emphasis on providing support over a long period of time.

Inpatient: The Tier 4 CAMHS Specialist Learning Disability Unit provides day/ in-patient care and treatment for children and young people with:

• moderate to severe learning disabilities and co-morbid mental health problems, which cannot be adequately and safely treated within Tier 3 CAMHS/ learning disability services, because of the associated risk to self or others
• children and young people with mild learning disability and comorbid mental health problems which cannot be adequately or safely treated within Tier 3
• CAMHS because of risk to self or others, and whose needs cannot be met within a Tier 4 CAMHS General Adolescent Unit, or Tier 4 CAMHS Children’s Unit
• children and young people with moderate to severe learning disabilities, and with complex behavioural difficulties who exhibit a lower level of risk, but where physical illnesses may be contributing to their problems, and this requires in-patient investigation and assessment, and who because of their behaviours, cannot be adequately or safely treated within a paediatric ward or medical ward