Quality of life for patients detained in hospital

Quality of life for patients detained in hospital JW Coid The British Journal of Psychiatry 1993 162: 611-620 Access the most recent version at doi:10.1192/bjp.162.5.611

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British Journal of Psychiatry(1993),162, 611—620

Quality of Life for Patients Detained

in Hospital

JEREMYW. COlD The quality of life of detained patients has not received adequate attention despite the responsibilities placed on hospital staff and the special problems faced by these patients. Legal

principlesto ensurequality of life have not beenformalised,and the acceptablestandards that a patient can expect havenot beentested in the UK courts. Contemporarymodelsof ensuring quality are being imposed with increasing pressure on health care professionals, but high-quality management has sometimes lagged behind. This has led to a poor quality of life for certain patients. It is important for future research to overcome difficulties in developing objective measurements and set the appropriate standards of quality of life that detained patients should expect. This would provide a basis against which both appropriate standards of care and the necessary resource allocation could be measured.

There is increasing interest in the quality of life of patients in all branches of medicine, not merely as an outcome measure of clinical procedures but as an overall measurement of the adequacy and acceptability of care provided. Increasing political pressure on health care professionals to be financially accountable for their activities has given an added impetus. Government policy in the UK now emphasises the need for patients to become involved in the care they receive, with a right to expect wider choice, improved responsiveness to needs, specific standards of care, and satisfaction if these standards are not achieved (Citizens' Charter, 1991; Secretary of State for Health, 1991). Within psychiatry, the increasing public concern over the plight of the deinstitutionalised mentally ill has led to a growing literature examining the quality of life of patients in the community. In contrast, the quality of life of those compulsorily detained in hospital has received little systematic evaluation, except when serious shortcomings are brought to light after media attention. Current mental health legislation in the UK emphasises the principle of using informal persuasive measures to achieve psychiatric care in hospital. In the case of the mentally abnormal offender, the

Mental Health Act 1983 also embodies the principle of treatment instead of punishment. Both principles place a duty on those responsible for providing clinical care to patients detained under Parts II and III of the Act to ensure that they have an adequate quality of life. This paper examines certain basic concepts of quality of life, and principles that must be considered

when assessing quality for detained patients. The literature on quality of life studies in psychiatry is not reviewed in detail, owing to the paucity of research on detained patients. The intention is to promote developments in this area. Moral and legal responsibilitiesfor detained patients Any discussion on the quality of life of a detained person (whether in prison or in hospital) must proceed on the principle that basic or moral rights exist and that they provide an essential safeguard for the individual against the state (whatever its ideological orientation), and that they should be reflected in the law. Any person who is compulsorily detained, whether a prisoner or a patient, will be separated from society, subject to a variety of constraints, and with alterations in their legally

recognised rights and liberties. Morgan & Richardson (1987) have described civil liberties in a loose prescriptive sense to convey the combination of rights and freedoms which any acceptable institutional regime must respect. The use of legislation to protect the general health, safety, and well-being of the public (as wellas detained patients) from poor medical care is more apparent in the USA. US ‘¿licensure' laws are based on the assumption that the public must be protected from unqualified, unscrupulous, and unethical practitioners. Regulatory goals can also include cost containment (a different issue than in the UK), ensuring quality standards, and perhaps ensuring that some minimal care will be available to all (Hall, 1988).

An earlier draft of this paper was prepared for the Committee for the Reviewof Servicesfor Mentally Disordered Offenders (Reed Committee), July 1991.

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The National Health Service Act 1946 was designed to ensure that a degree of care would be available to all in the UK, but has never been tested in court regarding the need for treatment of detained patients. Mills et al (1983) described how developments in the legal area of right to treatment led to substantial improvements of many institutional inadequacies in the USA. In the UK, however, radical changes in the quality of life of detained patients tend to follow public enquiries (Martin, 1984). Two of the most important functions of the Mental Health Act 1959 were (a) the facilitation of admission of mentally abnormal offenders to

deprivation produced by harsh regimes containment in a cell for long periods.

and

The Home Office(1990b)hasformally stated that

mentally ill persons should not be contained and treated for long periods in prison. However, the principles that should guide the legal responsibilities of the state for detained patients have not been formalised. Four basicprinciples, however,have

been proposed that could shape this responsibility. These apply to patients detained under both Parts II and III of the Act. (a) The ‘¿minimalist' approach: once in detention, the conditions within an institution should be as near as possible to those outside. hospital as an alternative to prison and (b) allowing (b) The ‘¿least restrictive alternative': this doctrine the transfer of mentally abnormal prisoners to states that the treatment setting, and the therapy hospital. Imprisonment is the most severe legal provided, must impose no greater curtailment of penality intheUK and yetitcannotautomatically freedom than is necessary to protect the state and the public's interests. This concept can include be assumed that detention in hospital improves quality of life or is necessarily the best venue for Gostin's (1986) argument that patients should not psychiatric treatment. Scott (1974) argued that be detained in unnecessarily high levels of security, resources should be diverted to the prison system for and that there should be flexibility according to the the treatment of mentally abnormal offenders. The needs of the patient at any one time. For example, Butler Committee (1975) took the broader view that there should be flexibility of movement from special “¿whilst those suffering from mental disorder should hospital to medium secure unit, to open ward, etc., generally be treated in hospital, there are certain but dependent on true needs for security rather than circumstances in which exceptionally there may be mere administrative convenience. good reason for preferring a penal disposal.―The (c) ‘¿Proportionality' of the period detained: Committee was referring primarily to dangerous Ashworth & Gostin (1985) argued that the length of antisocial psychopaths posing security risks. deprivation of liberty should not be disproportionate More recently, concerns have arisen over the to the gravity of the offence and antecedents of the potential for misuse of the Mental Health Act to offender. To this could be added the period necessary prolong the detention of dangerous individuals under to effect treatment. the guise of receiving treatment in hospital (Dell (d) Care for detained patients should be provided & Robertson, 1988; Grounds, 1991). The Butler as near to where the patient lived as is reasonably Committee believed that, in the short-term, prisons possible (Reed, 1991). should be able to deal with acute disorders, but prison was not the place for the long-term treatment Administrative problemsof detained patients of psychotic illness. Unfortunately, the chronic mentally ill appear least likely to be accepted Detained patients may be subject to especially for transfer from prison to hospital (Cheadle & negative and punitive attitudes from society (Hill, Ditchfield, 1982; Coid, 1988a). Nevertheless, the 1982), and the limitations to their rights and Court of Appeal has taken a firm line in condemning freedoms make them particularly vulnerable to the sending of mentally abnormal offenders to prison punitive attitudes and restrictive management as a form of “¿cruelty― (see British Medical Journal, practices by staff. The Boynton Report (1980) 1983). This ruling has recently received support from described prolonged systematic abuse and ill the highly critical report of the Chief Inspector of treatment of patients in Rampton Special Hospital. Prisons (Home Office, 1990a). His description The fact that this had been concealed successfully of medical services does not encourage optimism for and was revealed only after a television documentary the quality of life of mentally abnormal inmates. emphasised the need for formal mechanisms to Maldistribution of resources was observed: poor regularly review the quality of life and care sanitation, contravention of health and safety patients receive. However, the Rampton review regulations, poor pharmaceutical services, the body also received highly critical evidence from presence of archaic medicines in several prisons, MIND (National Association for Mental Health) and the potentially destabilising effect of sensory on the shortcomings of central management by

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QUALITY OF LIFE IN HOSPITAL

the Department of Health and Social Security. Restructuring was recommended with an expectation that there would be monitoring of managerial performance and accountability (Gostin, 1986). The Mental Health Act Commission,the Hospital Advisory Service, and other bodies, currently regulate the behaviour and expertiseof health care professionalswho provide careto detainedpatients, and it is widely assumed that health authorities monitor their own managerial quality and success in implementing improvements in health care delivery. This assumptionignoresseriousmanagerial shortcomings and failures to implement service development (particularly at the medium level of security, and of locked (intensivecare)wards). This hasled to a poor servicefor patientsandconsequently a poor quality of life. For example, the monies provided to the regional health authorities for the development of secure units were initially spent elsewhere(Parker, 1985);little even reached psychiatry. Most regional health authorities now have purpose-built units, with certain notable exceptions(Snowden, 1990).Unless monitoring of the use of funds by health authorities becomes systematic, further monies will be provided by the Department of Health without any guaranteethat they will be spent on the purpose intended. Current fragmentation of clinical and managerial responsibilitybetweendifferent levelsof securityalso fails to ensure quality from one tier to another.

concern (Coid 1988a,b). Reduction in the number of locked wards for acutely disturbed patients (Faulk, 1985) and the increasing pressure of re admissions on a diminishing number of psychiatric beds,particularly in the inner-city areas(Hollander et al, 1990), must inevitably

reduce the ability of

hospitals to accept detained patients, irrespective of staff attitudes. Consequently,any increaseddemand for services for detained patients is unlikely to be met in the very areas where need is greatest under current systemsof per capita resourceallocation from the Department of Health. It hasbeenshownthat a dis proportionate number of patientsare detainedwhen admitted from socially deprived areas (Harrison et al, 1984), supporting

arguments

that resource

allocation should be weighted for factors that relate more closely to service needs (see Hirsch, 1988; Thornicroft, 1991).Thus, researchindicating need for additional bedsfor mentally abnormal prisoners (Gunn et al, 1991), or that significant numbers could be diverted from custody via the court (James & Hamilton, 1991), will inevitably be ignored, particularly in those areas where both the need for additional resources and pressure on beds are most acute. What Is an adequate quality of life?

Maintaining an adequatequality of life for patients detainedin hospitalis anessentialcomponentof their from onelevelto anotherwhenthereis no continuity care, but it is still an undefined concept and there of clinical, managerial, or financial responsibility. are problems in attempting to measureit (Walker & This lack of continuity canleadto opposingpressures Rosser, 1988; Bowling, 1991). No existing scale from one institution, or clinical team, to displace a coversall life situations and placementpossibilities. patient into another, irrespectiveof security needs. Patient satisfaction may actually bear little relation Lack of long-term planning and fragmentation of to objective assessmentof conditions. Thus, in any responsibility have contributed to the emergence attempt to measurelife satisfaction, care must be of a group of patients termed ‘¿difficult to place' taken that responsesdo not simply reflect factors (Day, 1988; Coid, 1991a). However, the private such as the individual's mood, social desirability, sector has shown that services can be organised enduring temperamental characteristics, or mental to improve quality and to provide a service for state at the time. Furthermore, it must be asked whose view (the patient or the carer's) is correct. thesepatients, recognisingthem asa ‘¿market niche' inadquately cateredfor in the Health Service(Coid, Personal satisfaction in spheresof life which are rated as high and low in importance by observers 1991b). may have different implications for an individual Regulatory bodies such as the Mental Health Act Commission have no direct responsibility to patient (Murphy & Keenan, 1991). What is clear from previous attempts to define quality of life is ensure that certain patients, such as mentally abnormal offenders, are actually admitted and that no simple, unidimensional approach is sufficient, detained when necessary.A study in Winchester and quality of life must be judged on a series of Prison showed that the process leading to compulsory different dimensions. Maslow's (1943) hierarchy of human needs admission can be extremely haphazard, and a proportion of mentally abnormal offenders can be has been usefully applied by Jones (1985) to rejectedby the clinical teamresponsiblefor their care deinstitutionalised patients. The model proposes on spurious grounds that give considerable cause for that there are five basic types of human need Perverse fmancial

disincentives

can displace patients

COlD

614

and that each must be largely satisfied before the individual can fully experience the next, in a hier archical fashion. Starting from the most important and fundamental stages these are as follows: (I) physical survival —¿ this includes food, drink, sleep and shelter from the elements; extreme circumstances hunger, heat, cold, etc., can obscure all other needs (II) stability - security and support in an uncertain and possibly threatening world; this includes the individual's desire for stability, and avoidance of uncertainty and possible danger (III) purpose in life —¿ work, leisure activities, companionship, the need to be valued (IV) autonomy —¿ a degree of independence (V) aesthetic and intellectual stimulation. The hierarchy of needs for detained patients, based on Maslow's model, is as follows: (I) Physical and psychological needs (i) high-quality medical treatment (ii) high-quality psychiatric treatment (iii) suitable accommodation (iv) adequate food (II) Stability and security (i) personal safety and protection (ii) adequate hygiene, clothing, etc. (iii) personal privacy (iv) access to counselling, psychotherapy, etc. (v) a therapeutic milieu (vi) minimum level of security necessary (vii) visits from relatives and friends (III) Purpose in life (i) occupation/work activity/education (ii) physical exercise (iii) leisure activity (iv) companionship and belonging (v) religious freedom (vi)freedom of sexualexpression

(IV) Autonomy (i) material comfort (ii) personal (iii) personal

possessions space

and intellectual

of measuring standards of quality that, in relation to life in the community, cannot ultimately be met. But levels I and II include basic features of quality of life which detained patients should be able to expect. As the hierarchy is descended, the items become more problematic. For example, freedom of sexual expression may be determined by the staff of an institution and their attitudes to what is acceptable or appropriate. Patients and prisoners now have the right to marry while detained, yet few institutions in the UK have seriously addressed the issue of facilities or opportunities for consummation. Similarly, the patients' sense of control over their lives may be a fiction in relation to the ultimate control that can be exercised. Several elements in the hierarchy may also challenge issues of security. However,

imaginative

use of architectural

‘¿therapeuticcommunity',

have shown that security

does not inevitably have to be compromised or challenged by detained patients.

satisfaction

(i) art and music (ii) pursuit of personal successand achieve ment. It is preliminary and does not cover all secure hospital settings, where it needs further modification.

Access to high-quality

models must be put intothe proper perspective

design of secure facilities, innovative therapeutic programmes, and new approaches to patient advocacy, many derived from principles of the

(iv) quiet space (v) patient's advocacy and sense of control over life (V) Aesthetic

treatment is considered of major importance and within the highest level (I) of the hierarchy. The fifth levelis perhaps the most difficult, and least developed, area. It risks the assumption that detained patients, a proportion of whom will be from the lower social classes and deprived backgrounds, will wish to appre ciate the same aesthetic and intellectual interests as their carers. Most observers would agree however that patients have the right to expect containment in a therapeutic milieu, to have accessto staff for counselling and psychotherapy, and to have adequate personal safety and protection from other disturbed inmates. The development of a check-list derived from Maslow's model might be one starting-point to ensure quality of life for detained patients, but it does not address the fundamental issue that many items, such as autonomy, freedom, and sense of control, have already been removed from the patient's life. There is a danger that applying a check-list from the items summarised above may give the misleading impression that the patient's needs have been met, whereas this may, in effect, be false. The usefulness of future

medical and psychiatric

Measuring quality of life It is important to develop valid, reliable measures of the quality of life of detained patients. Admission to hospital is an important event for most patients; when this admission is compulsory, civil liberties may be restricted and the length of stay may be extended.

QUALITYOF LIFE IN HOSPITAL Research in this area presents problems; it has tended to have beenbasedon questionnaires,none of which has been specifically developed for detained patients. Jones (1988) has cautioned that apparent patient satisfaction may bear little relation to objective assessments of community based samples. For some patients it has to be questioned whether life outside hospital is better than insideit, despitetheir statedpreferences.Any measure of the quality of life of detained patients could be distorted by negative attitudes towards their detention. General scales of life satisfaction which are relevant to the population asa whole may be of little relevance to people who have lost, or have never possessed, occupational status, income, or property (Abrams, 1974; Campbell et al, 1976; Szalai & Andrews, 1980). Measures of social activity may also be of limited value when applied to detained patients, if it is assumed that the opportunity for such activities is standard. Measures of physical disability are much

easier to measurethan loss of functioning due to mental illness, where complicated scales are required. Some of these problems have been successfully dealt with in more recent instruments for non-detained psychiatric patients (Walker & Rosser, 1988), but much can be gained by simple observation and the recording of detained patients' comments regarding their experience.Raphael (1969) provided a useful early model for suchobservationsin a simplesurvey of physicallyill patients' viewsof the quality of their life in general hospital wards. This study could be easily replicated, after modification, among detained patients. A seriesof questionswereaskedabout the ward and its equipment, sanitary accommodation, meals, activities, and care. Overall measuresof contentment appeared high, but were related to the ages of the patients and whether they were interviewed at home or in hospital. Contentment was not closely related to sex, clinical condition, the plan of the wards, or weekly hospital expenditure per in-patient. It seemedthat wards and equipment were generally liked, whatever their plan, but the main criticism was that the wards were too hot, stuffy, and noisy, especially at night. Most patients disapprovedof the sanitaryaccommodationand lack of privacy. Meals in generalwere liked when there was a choice, and satisfaction did not relate to catering costs. Boredom was frequently mentioned as a problem of being a patient, with suggestions of better visiting hours, radio service, and more diversional activities. The patients criticised being woken so early, and the lack of opportunities to rest. The majority spoke with warm appreciation of the care given by the staff, especially the nurses. However, patients criticised the shortageof nurses,

615

especially at night, and complained about getting insufficient information about their conditions, and about the reasons for various tests and treatments. Amenities (referring to appeal, comfort, and privacyof care facilities) and the relationship betweenthe carerand the patient, have been identified as importantin studies of long-stay psychiatricpatients(MacDonald et al, 1988;Elzinga & Barlow, 1991).Improvements upon the patient's autonomy, including a greater say in running the wards, and a greater choice of activities, were more important than the physical surroundings in contributing to improved satisfaction with life in hospital. Of the two main aspects of care, amenities were far less a cause of dissatisfaction thantheperceived carer/patient relationship. Elzinga & Barlow

(1991) noted a potential

for

error

when survey researchersask patients about their satisfaction withstaff behaviour, particularly inthe hospital environment wherestaff arealwayspresent. The positive and negative aspectsof the quality of life of patientsdetainedunder maximum security are not too dissimilar from those of the physically ill or long-term psychiatric patients. Powell et al (1989) avoided some of the problems observed by Elzinga & Barlow by surveying a third of both staff

and patients in Broadmoor Hospital. Daily life under maximum security was found to have a fixed and rigid structure. Patients appeared to do everything at the sametime, and a high degreeof conformity existedacrosspatients,wards, and daysof the week. There was strong support for a fixed schedule, especially among staff, since the general belief was that a fixed schedulewas necessaryfor good care—¿ however, the authors noted that once such a systemis structured, all subsequentchangesand conditions are aligned to it, and that a highly structured systemis usually the cheapest.There was also widespread,but understandable,concernabout changing a system that was thought to work and risking adverseeffects on patients' care, reducing discipline, and making the staffs job more difficult: a fixed schedule made it easier to supervise the patients, and strengthened security. The time available

and prioritisation pressureson staff and management provided insufficient opportunity to attend to issues such as quality of life at a high level. A strict, rather than fixed, schedulewasconsideredof prime importance where patients, staff, and management know where patients are and what they are doing. It was concluded that a strict schedule is not necessarilya fixed one, and that strict schedulingis compatible with quality of life and quality of carein maximum security, whereashaving a fixed schedule is not.

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Patient satisfaction in Broadmoor was related primarily to the amount of choice they had in their routine and whether it prepared them for leaving. Powell et a! (1989) also observed that the structure of life in Broadmoor was abnormal. For example, more than half the patients were in bed at 9 p.m., and a large proportion of staff time was spent on security. Staff perceived that a more varied routine could threaten security. The majority of patients felt safe within the current structure and enjoyed their work and education, although less than half were satisfied with their leisure, social, and sports activities. Many findings on quality of life under maximum security correspond to the hierarchy of needs as described above, and to previous research findings. In their conclusion, Powell et a! put forward certain proposals, paying attention to the essential component of security. They did not propose sudden change and they realised the risk of destabilisation of patient security and safety, recommending a process of change aimed at the daily timetable meeting the needs of both patients and their carers. They recognised

that priorities

must be the

maintenance of security and safety, but with the additional pursuit of a therapeutic goal, the provision of a more normalising experience, and with an emphasis on preparation for leaving. Monitoring quality of care - quality assurance The term ‘¿quality assurance' may be applied to any attempt to monitor and enhance the quality of a service provided to patients. Quality of life is just one component that can be monitored. Methods adopted will depend partly on the underlying concepts of quality which are adhered to, and different concepts will lead to different measures (Clifford et al, 1989). For example, if quality is equated with economic efficiency then the emphasis will be on financial data. If quality is taken to mean consumer satisfaction, then consumer views might be sampled. In mental health circles, the goals of quality assurance might involve showing the public, or management, that resources are being used effectively, the facilitation of management's decision-making, a demonstration to show that clients are getting the good quality of service they are entitled to expect, ensuring the service is providing a minimum standard of care, helping set goals to change a service, and helping staff improve the quality of care they provide (Clifford eta!, 1988). Quality assurance must involve basic elements of good practice. Clifford et a! (1989) listed five main elements:

(a) clear conception of the overall task —¿ this involves a coherent philosophy of care and treatment, the issues that are of greatest importance, and internal consistency of goals within the organisation delivering care (b) appropriate selection and delivery of care —¿ this involves regular reviews of the mental and physical state of patients and the programme being delivered (c) attention to quality of life of patients receiving care (d) cohesive multidisciplinary team functioning to consider an individual's range of needs and balance them in an integrated programme (e) an integrated overall structure to the whole service —¿ this involves planning priorities and allocating

resources appropriately.

At a higher level, safeguards are also required to maintain quality assurance through quality management. In attempting to define ‘¿quality', Shaw (1986) has described quality health care delivery as including elements of: (a) appropriateness —¿ the service or procedure which the population or individual actually needs (b) equity - a fair share for the population served (c) accessibility —¿ service is not compromised undue limits of time or distance

by

(d) effectiveness —¿ achieving the intended benefit for the individual and for the population (e) acceptability —¿ services are provided to satisfy the reasonable expectations of patients, providers, and the community (f) efficiency - resources are not wasted on one service or one patient to the detriment of others. The practical realisation of ‘¿quality' according to these criteria inevitably involves decisions about priorities. Such decisionsare increasingly taken

by managers within the health service. Clinical staff have been encouraged to take on managerial responsibilities but reorganisation of health care delivery has simultaneously removed many of their executive powers under the NHS and Community Care Act 1990. In order to maintain quality assurance, Clifford et al (1989) recommended both internal and external review. Internal review might involve quality assurance groups and clinical audit. External review might involve inspectorates such as the Hospital Advisory Service or Mental Health Act Commission, research evaluation, examining whether

model care standards are met in a particular setting, individual case review, consumer feedback, and

QUALITY

OF LIFE IN HOSPITAL

consultancy, in the form of management consultants, to effect changein a servicethat is felt to bedeficient. However, good quality cannot be assuredunlessthe performanceof management,aswell asthe providers of health care, can be monitored. Finally, effective mechanismsshouldensurethat the identified, necess ary improvementsin managementdo actually occur. Maintaining quality of care - medical audit The principles of medical audit are fundamental in maintaining the quality of life of detainedpatients. Smith (1990)pointed out that good doctors always organise a systematic review of their daily work, recording and assessing the accuracy of their diagnosis and the outcome of treatment. This is audit in the basic sense, but Smith emphasised the importance of audit designedto achievechange, and that a ‘¿feedback loop' betweenthe cliniciansand the information obtained should be effected to result in change. The Standing Medical Advisory Committee (1990) stated that local audit is now recognisedas a component of medical practice and that all doctors are expectedto take their part. The Committee advised that the usual caseconference or clinical meeting doesnot meet the requirements of clinical audit, and went as far as recommending certain sanctions for doctors who fail to take part. A successfulaudit should involve a local medical audit coordinator and should be an educative procedure, eventually becoming an established

617

was not entirely successfulin its aim to exposethe shortcomingsof the legalconceptof ‘¿psychopathy', but is still one of the best models of medical audit on the careof detainedpatients currently available. The authors discoveredthat many psychoticpatients were unhappy about their medication and observed medication to have limited efficacy, as over half were

still considered deluded by their consultants. Less than half of the patients who had received electro convulsive therapy felt helped by the procedure and their case notes did not reveal to the researchers whether they had actually been helped or not. Less than a third had ever experienced psychotherapy or social-skills training. Only 54% felt satisfied with their care, and the most frequent cause of dis satisfaction was that patients felt overlooked and that

their case was not receiving sufficient attention. A number appeared to have been “¿lost in the woodwork―.Doctors felt that they knew their patients well in a total of 73% of cases;but it was not until a doctor ‘¿knew his patient well' that hewas everlikely to recommendrelease.Only 24% werenot consideredready for dischargeby their consultants. Having nowhere elso to go appeared to be the most common reason for patients not leaving the hospital. Dell & Robertson (1988)were also highly critical of the admission circumstances of psychopaths. They observedthat the majority were detained for treatment without any indication about why they werethought to requiretreatment,what the treatment should be, and in what way it would affect their part of undergraduate and postgraduate medical propensity to reoffend. The authors also criticised education.The Committeedid not anticipatedramatic the consultants' approach to the diagnosisof these improvement in the quality of medical care in the patients.A smallproportion had receivedmedication short term, but anticipated an improvement by at somestage,and 43% had at somepoint received individual psychotherapy. However, 71% had at thosewhosepractice would be considered‘¿less than satisfactory', with encouragementto those doctors some time taken part in group psychotherapy, but who arecurrently regardedas‘¿good' or ‘¿acceptable'.a worrying 49% reported it as not of much use to Audit inevitably extendsto the care of detained them. The opinion of those receiving social-skills patients, where accuracy in diagnosis, appropriate training was generally favourable and a larger treatment and management,assessmentof adverse proportion of psychopaths (75%) felt helped by side-effectsof medications,and adequateexplanation Broadmoor than the psychotic men. Thirty-seven of procedures,legalrights, and clinical management per cent were thought ready for discharge, but a to patients and relatives are all essentialto those third of the remainder (21%) were thought to no whose civil rights have been altered in the course longer require maximum security. It wasconcluded of compulsory treatment. Treasaden(1985)showed that discharge decisions related to the gravity of that treatment in a regional secure unit can effect the original index offence and not to the response a sustained improvement in measuresof patient to treatment, thus militating against the principle behaviour, including personal violence, treatment of detaining such patients for treatment in the refusal, self-harm, and arson, thus indicating first place. The researchersdid not employadequatemeasures outcome as one measureof quality of care. A survey of mentally ill and psychopathic men of clinical improvement or responseto psychiatric detainedin Broadmoor Hospital (Dell & Robertson, treatment. However, their observations inevitably 1988) comes closer to the expectations of the give causefor concern and have highlighted many Standing Medical Advisory Committee. The study areas for more objective assessment. These include

618

COLD

accuracyof diagnosis, timeavailable forpatient managementthrough the model of medical audit. care,consumersatisfaction,true needfor the highest But from the patient's point of view it appearsthat level ofsecurity, shortage ofalternative resources,quality of life relatesmost strongly to the quality of etc., all factors within the expectations of the the patient/carer relationship, usually perceived as Standing Committee and directly relating to quality more important than the hospital conditions in which assurance and thepatients' hierarchy of needs,as they are detained. Issues of security can adversely described above. affect this relationship and require special attention from all clinical teams to achieve an appropriate com promise. Research has shown that detained patients Conclusions require special attention to their needs for purposeful Despiteincreasing pressure on healthcarepro activities and diversions while in security. These fessionals toprovide thehighest standards ofquality should bear a relationship to and, where possible, careto their patients,this paperhasidentified several prepare patients for a future in the community. major problems in ensuring quality of life for Health care professionals are now becoming detainedpatients. In the UK, the legalprinciplesthat aware of increasing economic pressuresto ration withinthehealthservice, butmanagers would clarify their rights haveneverbeenformalised. resources Similarly, the basicstandardswhich patients havea are dependent on those who deliver services for right to expect have not been tested in court. This accurate information on which to base their decision is in stark contrast to growing pressureson staff to making. It is therefore essentialfirstly to establish ensurequality. But this can also result in a demand the standards of the quality of life that detained from both patients and staff for more resourcesto patients are entitled to expect, and secondly to facilitate the process.This may in turn be strongly develop objective measures to show whether a quality resistedby managerswho mustcontain costs,thereby service is being delivered. So far, the development risking polarisation betweenhealthcareprofessionals of appropriate indicators by clinical staff in and management,especiallyif ‘¿quality assurance'is conjunction with economists and managers has not perceived by staff as merely a means to increase been entirely successful. output without incurring additional costs.Fewwould The quality-adjusted life year (QALY) approach argue that improvement in quality of care and is an early prototype of resource allocation which maintenance of the highest clinical standards are is based on economic measures as well as quality essential.However, inequitable resourceallocation of life and life expectancy (Office of Technology and failure to developserviceshaveledto considerable Assessment, 1979; Williams, 1985, 1987; Gudex deficits in the quality of life of somepatients. Such 1986).If the moral dilemmas of such an approach failures could be addressed without additional are ignored, this procedure still poses problems for evaluating which treatment programmes should be resourcesbut require better management. Setting some agreed levels of quality of life for financially supported within psychiatry (Wilkinson detained patients is perhaps the first step towards et a!, 1990). both adequate provision and uniform models of Carr-Hill & Morris (1991) have warned that good practice, but developing suitable research seriousand far-reaching consequencescould result instruments to measure quality of life still poses from the use of unvalidated instruments to collect problems. In the early stages, quality could be health-related data, on which QALY are ultimately recorded in a dimensional manner using simple calculated. Lifeexpectancy, a cornerstone of this models such as the ‘¿hierarchy of needs'. More approach,bearslessrelationship to thecurrent sophisticated instruments could later be developed philosophy ofmentalhealth caredelivery, thanto requiring medicaland surgical inter as shown by Fitzpatrick (199la,b), but objective conditions measurementsmust ultimately be carried out in a vention. Concern has also been expressed that standardisedway. Simply asking detained patients those whose lives have a lower quality than others how they perceive their health and quality of life is according to these measures (for example, the not good enough. mentally handicapped) will be provided with pro The quality assurancemodel has beenpromoted portionally fewer resources(Crisp, 1991).If health as one important meansof ensuring quality of life. care managersseriously intended to use QALY or This is already an important part of nurse training similar approaches on which to base resource and practice(Pearson, 1987),and could be extended allocation in the future, then more appropriate to other disciplines. The Department of Health now measuresmust be developed. places special requirements on medical staff to ensure Development of better measuresin cooperation quality of clinical care, treatment, and patient with economists and managers poses a major

619

QUALITY OF LIFE IN HOSPITAL

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