Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries

Objective To establish whether reinstitutionalisation is occurring in mental health care and, if so, with what variations between western European countries.Design Comparison of data on changes in service provision.Setting Six European countries with different traditions of mental health care that have all experienced deinstitutionalisation since the 1970s—England, Germany, Italy, the Netherlands, Spain, and Sweden.Outcome measures Changes in the number of forensic hospital beds, involuntary hospital admissions, places in supported housing, general psychiatric hospital beds, and general prison population between 1990-1 and 2002-3.Results Forensic beds and places in supported housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds has been reduced in five countries, but only in two countries does this reduction outweigh the number of additional places in forensic institutions and supported housing. The general prison population has substantially increased in all countries.Conclusions Reinstitutionalisation is taking place in European countries with different traditions of health care, although with significant variation between the six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to risk containment in a society, as indicated by the size of the prison population, may be more important than changing morbidity and new methods of mental healthcare delivery.     

No Apology for Geriatrics

A geriatric department is described where turnover has more than kept pace with demand over a period of 17 years. The department provides two basic services—a hospital service to the pensionable population in the community, and support to other hospital departments that care for the elderly.Community emphasis is on a high turnover of patients, enabling early contract and treatment. Over the years a fall in the proportion of “chronic” to “acute” beds has occurred and this has been achieved by having the majority of beds in the general hospital, where it is possible to provide a comprehensive medical service. The hospital role has been to prevent overloading acute resources with potential long-stay cases, and this has been possible without compromising our community obligations.     

Is London overbedded?

OBJECTIVE--To examine whether there are too many hospital beds in London. DESIGN--Analysis of data from the Hospital In-Patient Enquiry, Mental Health Enquiry, health service indicators, and Emergency Bed Service. SETTING--England, London, and inner London. RESULTS--Hospital admission rates for acute plus geriatric services for London residents were very similar to the national values in all age groups. In the special case considered in the Tomlinson report--acute services in inner London--the admission rate was 22% above the value for England. However, the admission rate of inner deprived Londoners was 9% below that of comparable areas outside London. For psychiatry, admission rates in London roughly equalled those in comparable areas. When special health authorities were excluded, in 1990-1 there were 4% more acute plus geriatric beds available per resident in London than in England. Bed provision has been reduced more rapidly in London than nationally. Extrapolating the trend of bed closures forward indicates that beds (all and acute) per resident in London are now at about the national average. Data from the Emergency Bed Service indicate that the pressure on available hospital beds in London has been increasing since 1985. CONCLUSIONS--Data regarding bed provision and utilisation for all specialties by London residents do not provide a case for reducing the total hospital bed stock in London at a rate faster than elsewhere. Bed closures should take account of London''s relatively poorer social and primary health care circumstances, longer hospital waiting lists, poorer provision of residential homes, and evidence from the Emergency Bed Service of increasing pressure on beds. Higher average costs in London, some unavoidable, are forcing hospital beds to be closed at a faster rate in London than nationally.     

海草床生态系统固氮微生物研究现状与展望

海草床生态系统是三大典型海洋生态系统之一,具有较高的生产力水平和十分重要的生态意义,其海草附着物中包括许多固氮微生物,通过生物固氮提供该生态系统"新"氮源,在一定程度上缓解了氮对初级生产力的限制.通过对近些年来固氮活性的测定方法、固氮群落组成以及影响因素等的研究进展进行了综合分析,较全面地分析了海草床生态系统的固氮微生物研究现状,并在次基础上对海草床固氮微生物的系统研究进行了展望.     

Voluntary medical male circumcision: matching demand and supply with quality and efficiency in a high-volume campaign in Iringa Region, Tanzania

The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency-including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing-the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.     

Community Demand for Doctors in the next 10 Years

The demand for doctors has increased despite improved community health, because the prevalence of chronic disease has increased, and because affluence, better education, and the growth of specialization have all stimulated demand.Most authorities have recommended an increase in the supply of doctors to meet the increasing demand. Nevertheless, a supply which preserves the present ratio of doctors to population might be adequate if medical productivity were raised. Moreover, an increase of the supply stimulates further demand; perhaps demand would fall if the supply were reduced, and community health might not deteriorate as a result of this.Other social institutions besides medicine have a claim on the available pool of talent from which doctors are recruited. It is possible that medicine already receives its fair share.     

The impact of demand factors, quality of care and access to facilities on contraceptive use in Tanzania

The low contraceptive prevalence rate and the existence of unmet demand for family planning services present a challenge for parties involved in family planning research in Tanzania. The observed situation has been explained by the demand-side variables such as socioeconomic characteristics and cultural values that maintain the demand for large families. A small, but growing body of research is examining the effect of supply-side factors such as quality of care of family planning services on the demand for contraceptives. This paper analyses the demand and supply factors determining contraceptive use in Tanzania using the Tanzania Service Availability Survey (1996) and the Tanzania Demographic and Health Survey (1996) data sets. The results show that access to family planning services and quality of care of services are important determinants of contraceptive use in Tanzania even after controlling for demand-side factors.     

Waiting list for nursing home admission gives limited insight of the problems. Study in handling of the waiting list and the consequences for the patients

The waiting list for nursing home admission is expected to remain unacceptably long. A study of the use and of possibly problematic consequences of the waiting list was described in a thesis. Despite long mean waiting periods and many problems (depressive symptoms, experiences of burden) already at the start of the waiting period, the majority of the informal caregivers were satisfied with the waiting times. This may be explained by a reticence to nursing home admission and by enlistment to the waiting list "out of precaution". Both a long and a short waiting period could be experienced as too long. Waiting list figures give insufficient insight in the "real" demand for nursing home care and in problematic waiting periods.     

Demand for patient care.

A study was performed to determine the extent to which patients of all types were receiving inappropriate levels of care. The needs of patients in acute and supporting hospitals, people in residential homes, and patients cared for at home were assessed. A sixth of the hospital inpatients did not need hospital care, while 5% of those in residential homes and 5% of those at home did need hospital services. These findings indicate that a realistic provision of hospital beds would be 4 per 1000 population for all specialties except regional specialties, psychiatry, mental subnormality, obstetrics, and paediatrics. About a third of these beds need to be acute, while the rest may be in supporting or community hospitals. Thus the current provision of acute beds (2-0 to 2-5 per 1000 population) exceeds actual need.     

Contribution of general practitioner hospitals in England and Wales.

A survey of a one-in-seven sample of general practitioner hospitals in England and Wales, performed to determine the contribution they make to overall hospital work load and the attitudes of the general practitioners working in them, showed that 3% of acute hospital beds in England and Wales were in general practitioner hospitals, which provided initial hospital care for up to 20% of the population. Altogether 16% of general practitioners and 22% of consultants were on the staffs, and they coped with more than 13% of all casualties, 6% of operations, and 4% of x-ray examinations. Nearly a million casualties were treated at no cost to the National Health Service. Twenty new district general hospitals would be needed to cope with the work load currently dealt with by general practitioner hospitals. The results of this survey indicate that these smaller hospitals deal efficiently and cheaply with their work load, and that morale is high. General practitioner hospitals could have an important part to play in providing certain types of care, but there are no financial incentives to enable general practitioners to realise this potential fully.     

How many beds? Helping consultants to estimate their requirements.

Two studies were carried out in different districts with clinicians who were concerned about the proposed numbers of beds to be provided based on regional targets and assessments. It was found that summary statistics can obscure wide variations over time in the demand for services. Providing beds according to average demand can therefore create a shortage of beds for a large part of the year. It is argued that the norms and targets set by regions should be seen as a starting point for negotiations rather than as the definitive answer for setting the levels of services provided. Because of their particular circumstances certain districts may need to provide more than the levels set by the region, and clinicians and community physicians can work together to provide evidence for this.     

Work of a day-bed unit 1972-8.

From 1972 to 1978 inclusive 32 311 patients were managed in a 24-bedded day-bed unit in a district general hospital. The principal specialties using this were urology, gastroenterology, general surgery, gynaecology, haematology, orthopaedics, and radiology. Patient selection, a high standard of secretarial work, and good liaison with general practitioners, the community nursing service, and the ambulance service are most important. Day care forms a large, important, and increasing part of the work of the hospital, and without it many of the specialties would be unable to cope with the demand, and their waiting lists would lengthen continuously.     

Multi-species spatially-explicit indicators reveal spatially structured trends in bird communities

Multi-species indicators are often used to assess biodiversity trends. By combining population trends across several species they summarise trends across a community. Composite indicators such as these are useful for examining general temporal patterns and may suggest important drivers of biodiversity change. However, they may also mask substantial spatial variation in population trends, particularly when they are calculated over large spatial regions. We produced spatially-explicit indicators for farmland and woodland bird communities in the UK and further separate these into trends for generalist and specialist species within each group. We found considerable spatial variation in the indicators, which is masked by indicators calculated at the national level. The farmland community indicator showed mostly positive trends in western areas and extensive declines in south-east England. The woodland community indicator showed a north–south divide, with increases in Scotland and northern England and stability in the southern regions. For both communities, indicator trends for specialist species were more negative than those for generalists. We found no significant difference in farmland community indicators between arable land and improved grassland. Woodland specialists had significantly more negative trends in broadleaf compared to coniferous woodlands, suggesting habitat-type is one of the drivers of changes in the woodland community. These spatial patterns in bird population trends may be used to highlight regional conservation priorities and identify where those may differ from the national scale. In combination with information about other environmental changes, they may also be used to develop hypotheses about potential drivers of change. We advocate that this approach is adopted for other taxa and geographical areas.     

Demographics and economic burden of un-owned cats and dogs in the UK: results of a 2010 census

ABSTRACT: BACKGROUND: The population of dogs and cats passing through rescue shelters may be subject to compromised welfare and increased susceptibility to disease. Little information exists to describe this population, its dynamics and associated management practices. The aim of this study was to carry out a census of un-owned cats and dogs in the UK in 2010, and to document the origins, destinations, husbandry and costs associated with the care of these animals. RESULTS: A sampling frame was constructed by searching the databases of publicly registered charities for England, Scotland and Wales, registers of breed rescues, and by internet searches of animal welfare websites. Overall, 2,352 contacts for 1,380 organisations were identified. All were sent a postal questionnaire asking for data on the number of dogs and cats housed, their origins and eventual outcomes, and details of husbandry between January 1st and December 31st 2010. For those which were registered charities (595), financial records were also obtained. A response rate of 38.8 % was obtained. Overall, in 2010, 89,571 dogs and 156,826 cats entered the care of the participating organisations. Approximately half of these animals were relinquished by their owners. Other origins included being found as strays or confiscated for welfare purposes. Seventy-five per cent of dogs and 77.1 % of cats were rehomed. The next most common outcome was euthanasia, accounting for 10.4 % of dogs and 13.2 % cats. For dogs and cats, 44.3 % and 62 % of participants respectively reported having a waiting list, which frequently exceeded the actual capacity of the facility. Over 19,000 people were involved in the care of these animals, on a paid or voluntary basis. Financial records were available for 519/595 (87.2 %) of the registered charities, and their total expenditure in 2010 was GBP340 million. CONCLUSIONS: This study showed that a large number of animals become un-owned each year, which could have considerable implications for their welfare. Despite the resources expended, demand still exceeds capacity for many organisations, and a substantial number of both cats and dogs are euthanased, suggesting that further understanding of how and why these animals become un-owned is essential in order to target interventions.     

Observations on Community School Facilities for the Mentally Retarded and Admissions to Institutions in Ontario, 1954-63

The relationship between community school facilities and first admissions of mentally retarded children to Ontario Institutions was investigated for the period 1954-1963. The number of educable (I.Q. 50-75) mentally retarded children aged 6-16 years in community schools rose consistently (92.1/100,000 population in 1954 to 190.1 in 1963), while first admissions of educable mentally retarded persons aged 5-19 years to Ontario Hospital Schools showed no consistent trend (2.0/100,000 in 1954 and 2.0 in 1963). The number of trainable (I.Q. 20-50) mentally retarded children aged 5-18 years in community retarded children''s schools rose steadily (10.9/100,000 population in 1954 to 42.8 in 1963), while first admissions in this category aged 5-19 years demonstrated no consistent trend (2.6/100,000 in 1954 and 2.2 in 1963).No indication was found that the age distribution of these first admissions had changed from 1954 to 1963. Any effect that increased school facilities might have had in reducing first admissions may have been nullified by the very large demand for a limited number of beds.     

Differences in durations of stay for surgery in the NHS and private sector in England and Wales.

Median durations of stay in England and Wales for eight "marker" operations were consistently shorter for patients in pay beds in the National Health Service than for patients in independent acute hospitals or public sector beds. This pattern was seen for both preoperative and postoperative stay and among specific age groups. Differential use of other hospitals for part of the period of care was not a factor, except for patients having hip replacement operations treated in NHS pay beds, one in seven of whom appeared to transfer to public sector care postoperatively. These findings suggest that there is scope for a possible further reduction in durations of stay in public sector beds and, within the private sector, for an assessment of whether spells in independent hospitals need be longer than in NHS pay beds.     

Waiting times for nursing-home placement: the impact of patients' choices.

OBJECTIVE: To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home. DESIGN: Cohort study. PARTICIPANTS: All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990. MAIN OUTCOME MEASURE: Length of time waiting for nursing-home placement and relative rates of placement. RESULTS: The variable found to shorten the waiting time the most was the patient''s choice of a for-profit or nonprofit secular facility; other significant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait. CONCLUSION: The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.     

景感生态学视角下的健康社区构建

景感生态学是基于中国传统人居环境营造理论与实践结合现代生态学基本原理形成的新兴学科,注重探讨生态系统服务与可持续发展的关系。可持续发展目标中健康与福祉是其重要内容,因此健康人居环境的营造也是景感生态学的重要应用领域之一。在健康人居环境的营造过程中,健康社区构建具有作为"细胞工程"的基础性作用。因此,从景感生态学的视角探讨健康社区的构建,有助于景感生态学进一步应用于可持续发展与人居环境营造的实践,为健康与福祉的顺利实现提供支撑。从健康社区的定义和主要理念出发,基于健康社区构建的需求本体和供给客体及其相互作用关系,结合生态环境科学的"时-空-量-序"的视角,探讨了生态环境研究应用于健康社区构建的作用及面临的系统性不足、人文性不足和耦合性不足等挑战;进而以景感生态学作为连接生态环境学科与建筑规划学科的纽带,探讨了景感生态学在应对上述挑战中的作用。从景感生态学视角来看,健康社区构建就是将人类健康这一愿景融入到社区健康需求本体与健康供给客体及其相互关系的调控与营造,从而实现社区及人群的健康和可持续发展。健康社区的构建强调社区人群主观健康需求与客观健康供给之间的互动与耦合,与景感生态学强调"景"与...     

Access to adult liver transplantation in Canada: a survey and ethical analysis.

OBJECTIVES: To describe the substantive and procedural criteria used for placing patients on the waiting list for liver transplantation and for allocating available livers to patients on the waiting list; to identify principal decision-makers and the main factors limiting liver transplantation in Canada; and to examine how closely cadaveric liver allocation resembles theoretic models of source allocation. DESIGN: Mailed survey. PARTICIPANTS: Medical directors of all seven Canadian adult liver transplantation centres, or their designates. Six of the questionnaires were completed. OUTCOME MEASURES: Relative importance of substantive and procedural criteria used to place patients in the waiting list for liver transplantation and to allocate available livers. Identification of principal decision-makers and main limiting factors to adult liver transplantation. RESULTS: Alcoholism, drug addiction, HIV positivity, primary liver cancer, noncompliance and hepatitis B were the most important criteria that had a negative influence on decisions to place patients on the waiting list for liver transplantation. Severity of disease and urgency were the most important criteria used for selecting patients on the waiting list for transplantation. Criteria that were inconsistent across the centres included social support (for deciding who is placed on the waiting list) and length of time on the waiting list (for deciding who is selected from the list). Although a variety of people were reported as being involved in these decisions, virtually all were reported to be health to be health care professionals. Thirty-seven patients died while waiting for liver transplantation in 1991; the scarcity of cadaveric livers was the main limiting factor. CONCLUSIONS: Criteria for resource allocation decisions regarding liver transplantation are generally consistent among the centres across Canada, although some important inconsistencies remain. Because patients die while on the waiting list and because the primary limiting factor is organ supply, increased organ acquisition efforts are needed.