Inpatient Census 2019: parts one and two

2. Ward Type Breakdowns

• The majority of available beds in NHS Scotland were in acute wards (34%)
• Length of stay varied greatly between ward types, from an average 7 days in addiction wards to 1,451 days in forensic (LD) wards
• Bed occupancy varied by ward type from a low of 75% in dementia wards to a high of 102% in addiction wards

Pressures and demands vary across different ward types. Some such as continuing care/long stay wards may have more stable populations compared with acute wards. This section presents statistics broken down at ward level.

Overall, the occupancy rate for NHS Scotland was 84%, though this varied between ward types, with dementia wards having an occupancy of 75% and addiction wards over 100%. This can occur if a patient is "On Pass", temporarily freeing up a bed even though that patient is still counted as an inpatient. Wards also differ in the number of available beds. One in three beds in Scotland were in an acute ward, while one in five were in dementia wards.

Table 8: Available beds & occupancy rates by ward type, NHS Scotland, 2017 - 2019

	2017		2018		2019
Ward Type	No. Beds	Occupancy	No. Beds	Occupancy	No. Beds	Occupancy
Acute	1,525	88%	1,331	86%	1,352	88%
Intensive Psychiatric Care	139	76%	144	87%	133	78%
Rehabilitation (non-addict)	318	81%	311	85%	378	85%
Addiction Wards ¹	72	82%	40	83%	44	102%
Continuing care/long stay	500	74%	402	68%	239	86%
Perinatal	10	90%	12	100%	12	92%
Forensic (non-LD)	391	88%	410	90%	399	90%
Forensic (LD)	82	91%	79	85%	68	88%
Dementia Wards ²	795	86%	814	87%	858	75%
Young People/Children ³	54	70%	54	98%	54	87%
Learning Disability	179	90%	170	87%	190	77%
Eating Disorder	22	95%	22	55%	22	82%
Admission & Assessment	-	-	173	89%	161	91%
Other	118	83%	113	76%	12	92%
Scotland	4,205	85%	4,075	84%	3,922	84%

¹ Addiction wards are the combination of addiction rehabilitation and addiction detox wards
² Dementia wards are the combination of dementia assessment and dementia care & treatment wards
³ Young People/Children wards are the combination of Young people's units and children's units

Ward Security Levels

Wards have different levels of security which can vary the level of unrestricted communcation patients are allowed or restrict visitors and the movement of patients. The majority of patients, 2,334 (71%), in the 2019 Census were in a "General Psychiatric Ward". A futher 21% of patients (680) were in a ward with a security level of low, medium or high. Patients in these wards likely require extra levels of attention and therefore require a higher level of staff resources.There has been a small shift in the proportion of patients being treated within wards with extra security compared with those being treated in "General Psychiatric Wards".

For most ward types, "General Psychiatric" is the most common security level, and for three ward types; acute, admission & assessment and addiction wards, this security level makes up 100% of the ward's security level. However, other ward types have more varied security levels which likely reflects the complex nature of the cases these wards deal with.

Figure 2: Most wards have a security level of "General Psychiatric", however some wards have a range of security levels
Psychiatric, Addiction or Learning Disability Inpatient Beds, NHS Scotland, 2019 Census

* Excludes a number of cases where ward security returned was 'Not applicable' - 83 in total

Observation level

As well as wards varying by security levels, individual patients will also receive varying levels of observation depending on their individual needs. This can impact on staff resources within a ward. Based on current guidelines the level of observation of patients at the time of the Census was recorded. The observation levels are:

• "General Observation" – Staff should have a knowledge of the patients' general whereabouts.
• "Constant Observation" – Staff should be constantly aware of the precise whereabouts of the patient.
• "Special Observation" – Patient should be in sight and within arm's reach of a member of staff.
• "Enhanced care plan for therapeutic engagement" – Aims to improve observation practice through therapeutic engagement with suicidal, violent or vulnerable patients to prevent them from harming themselves or others at times of high risk during their recovery.

The majority of patients, 3,098 (94%), were under general observation during the 2019 Census. Some wards are more likely than others to have patients requiring more than general observation, for example, learning disability wards, both forensic and non-forensic and Intensive Psychiatric Care wards.

Figure 3: Most patients are under general observation, however some wards have a higher proportion of patients requiring higher levels of observation
Psychiatric, Addiction or Learning Disability Inpatient Beds, NHS Scotland, 2019 Census

Patients under Constant, Special or Enhanced Observation require a high level of staff resources. Of the 204 patients under one of these observation levels, 36 (18%) required at least two members of staff involved in their supervision. This varied greatly between different ward types. Patients under higher levels of observations in acute wards for example almost always only required supervision by one member of staff, in comparison to those in learning disability (both forensic & non-forensic) wards where 34% of patients under higher levels of observation required at least two members of staff.

The most common reason for a patient being on a Constant, Special or Enhanced Observation level was due to being a "risk of harm to others" (30%), followed by "risk of self-harm" (24%) and "risk of absconding" (13%). It should be noted that patients can be under observation for more than one reason, for example a patient may be under observation because they are a risk to themselves and others.

Status

Patients who have been detained under the provisions of the Mental Health (Care and Treatment) (Scotland) Act of 2003 are defined as having "Formal" status. "Informal" refers to voluntary Mental Health admissions.

Just over half of patients (51%) in the 2019 Census were admitted with a formal status. This has been increasing annually since the 2016 Census (44%) and is now 7 percentage points higher. The status of a patient can change during their stay, for example, on the day of the 2019 Census 53% of patients had a formal status, a 2 percentage point increase.

There are significant differences in the lengths of stay for people detained under formal status compared with those with informal status. At 2019 Census the average (median) length of stay for a patient currently held under a formal status was 9 months (275 days) compared to just over 2 months (69 days) for patients with an informal status.

The proportion of patients being held formally varies between ward types as shown in Table 9. Forensic Wards are almost exclusively formal patients, while intensive psychiatric care wards also tend to have a high proportion. In contrast, most patients in acute, addiction and dementia wards tend to be voluntary admissions. However, the proportion of patients being held formally is generally increasing across most ward types.

Table 9: Patients held formally at time of Census by ward type, NHS Scotland, 2016 - 2019

Ward Type	2016	2017	2018	2019
Acute	37%	40%	41%	44%
Intensive Psychiatric Care	88%	94%	92%	99%
Rehabilitation (non-addict)	65%	69%	71%	73%
Addiction Wards ¹	2%	17%	3%	0%
Continuing care/long stay	22%	28%	37%	48%
Forensic (non-LD)	98%	99%	100%	100%
Forensic (LD)	96%	96%	99%	97%
Dementia Wards ²	21%	22%	20%	20%
Learning Disability	66%	75%	80%	85%
Eating Disorder	44%	43%	50%	61%
All	44%	47%	49%	53%

¹ Addiction wards are the combination of addiction rehabilitation and addiction detox wards
² Dementia wards are the combination of dementia assessment and dementia care & treatment wards

Hospital Based Complex Clinical Care

A patient is defined as receiving HBCCC if they have care needs that cannot be met in any setting other than hospital and require long-term complex clinical care. Under the definition of HBCCC, a patient cannot be a delayed discharge. As expected, patients with HBCCC have significantly longer lengths of stay. At the 2019 Census, HBCCC patients had an average (median) length of stay of 1 year and 10 months (672 days) compared to just under 3 months (83 days) for patients without HBCCC.

There were 742 (22%) patients receiving HBCCC occupying a mental health or learning disability inpatient bed at the 2019 Census. Most of these patients (44%) are being treated in dementia wards. Table 10 shows that while most HBCCC patients are being treated in wards with longer lengths of stay, a small proportion are being treated in acute wards.

Table 10: Number of HBCCC patients by ward type, NHS Scotland, 2017 - 2019

Ward Type	2017		2018		2019
	HBCCC patients	% of ward	HBCCC patients	% of ward	HBCCC patients	% of ward
Acute	86	6%	37	3%	65	5%
Rehabilitation (non-addict)	98	38%	65	25%	57	18%
Continuing care/long stay	286	77%	171	62%	140	68%
Forensic (non-LD)	131	38%	64	17%	101	28%
Dementia Wards ¹	218	32%	321	45%	328	51%
NHS Scotland	924	26%	731	21%	742	22%

¹ Dementia wards are the combination of dementia assessment and dementia care & treatment wards

Delayed Discharge

Timely discharge from hospital is an important indicator of quality and is a marker for person-centred, effective and integrated care. A delayed discharge occurs when a hospital patient who is clinically ready for discharge from inpatient hospital care continues to occupy a hospital bed beyond the date they are ready for discharge.

At the 2019 Census,262 patients were a delayed discharge. Most of these delayed discharge patients were either in dementia wards, 72 (27%), acute wards, 69 (26%) or learning disability units (non-forensic), 54 (21%).

The length of delay varies greatly between different ward types. Patients in acute wards tend to have shorter delays, an average (median) of 41 days at the 2019 Census, the same as 2018. Patients in forensic units tend to have longer delays, with those in forensic units (excluding learning disability) delayed for an average (median) of 390 days at the 2019 Census. However, the longest delays to discharge are observed for patients in learning disability units, both non-forensic (760 days) and forensic (786 days).

Length of Stay

The average (median) national length of stay is 142 days. However this varies significantly between ward types. The longest average (median) length of stay was just under 4 years (1,451 days) for patients in forensic learning disability units. Patients in continuing care/long stay wards also had significantly longer lengths of stay, 3 years and 7 months (1,318 days), as would be expected. In contrast, patients in addiction wards had an average (median) length of stay of one week (7 days).

Table 11: Average (median) length of stay by ward type, NHS Scotland, 2016 – 2019

Ward Type	2016	2017	2018	2019
Acute	41	41	36	40
Intensive Psychiatric Care	65	57	54	57
Rehabilitation (non-addict)	770	840	537	582
Addiction Wards ¹	13	7	7	7
Continuing care/long stay	1,462	1,255	1,170	1,318
Forensic (non-LD)	861	832	779	922
Forensic (LD)	1,709	1,371	1,398	1,451
Dementia Wards ²	205	206	204	269
Learning Disability	840	1,401	447	799
Eating Disorder	90	85	88	100

¹ Addiction wards are the combination of addiction rehabilitation and addiction detox wards
² Dementia wards are the combination of dementia assessment and dementia care & treatment wards