In-patient services have always accounted for the bulk of expenditure on mental healthcare. Although they deal with small numbers of people, they are required to provide for all of a patient's daily needs: safety, food, accommodation, daytime activities and treatment of their mental disorders, and often wider social needs. This requires expensive buildings, 24-hour staffing and a multidisciplinary team of trained professionals. In the UK, a mental health in-patient service is defined as a unit with ‘hospital beds’ that provides 24-hour nursing care (NHS Confederation, 2012). It is able to care for patients detained under the Mental Health Act, with a consultant psychiatrist or other professional acting as ‘responsible clinician’. This does not mean that all or even a majority of patients will be detained.
Even after decades of investment in community services, in-patient services in the UK, from acute admission wards to high-security hospitals, account for around 40% of mental health services spending by the National Health Service (NHS), with health and social care provided in other settings (including nursing and residential care homes and places funded through continuing care) accounting for a further 20%, pharmacy costs 9% and management costs 4% (Department of Health Commissioning Development, 2011). Most of this can be broadly described as being spent on rehabilitation services, that is, longer-term services aiming to improve the quality of life, independence and functional abilities of people suffering with complex mental health problems.
A comprehensive definition of UK rehabilitation is clearly relevant to many in-patient services but by virtue of their philosophy and approach rather than, necessarily, the badge on the door:
A whole system approach to recovery from mental ill health which maximizes an individual's quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and which leads to successful community living through appropriate support. (Killaspy et al, 2005: p. 163)
It is also vital to remember that in-patient services can be the opposite of rehabilitative, providing poor care, disempowering people and damaging their health (Davies, 2004), as illustrated yet again in the recent Francis report on the scandalously inadequate care provided in one physical healthcare setting in the UK (Francis, 2013).