Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0124The Development of Day Hospitals and Day CareRosie Jenkins and D. J. JolleyPenn Hospital, Wolverhampton, UKORIGINSDay hospitals are said to be among the few notable creations thatpsychiatry has given to medicine 1 . The concept that older peoplecould be given treatment, rehabilitation and care withoutresorting to ‘‘inpatient’’ status within hospitals or related‘‘institutions’’ was accepted enthusiastically in the UK from thelate 1960s. ‘‘Partial hospitalization’’ (usually day hospital care,but sometimes night care, relief admission programmes, rotatingcare or shared bed schemes), linked to active community services,has been a feature of the services provided for the elderly, not onlyby psychiatrists but also geriatric physicians. Non-medicalagencies, such as social services departments and voluntarybodies, have also participated. Interestingly, and perhaps significantly,the private sector has been much less enthusiastic forpartial hospitalization schemes. This appears to be true for othercountries.inappropriate locations, frequently operating with waiting lists,that saw patients dying before admission 4 .A review of provision based on the 1971 census was to establishthe baseline for inpatient services 5 and health authorities wereencouraged to create day hospital places in equal numbers, oftenstarting from zero 6 . As little guidance was given in respect of thedevelopment of these day hospitals, a wide variety of interpretationsarose from practitioners and planners trying to produce thebest possible facilities. Between 1976–1986 the total number ofday hospital places for the mentally ill increased by 50%.Provision for the elderly ranged from 129 places/10 000 in EastAnglia to 693/10 000 in the North West 7 . Wide variations persistbetween areas in respect of day hospital places available to theelderly populations served, and the Royal College of Psychiatry’srecommendations of one place for every 500 (or fewer) of theelderly population 8 is not yet seen everywhere, for a variety offinancial and other reasons.ATTRACTIONSThe attractions of day care are most obvious for the patient, whois enabled to maintain his/her home routines and contact with his/her supports, whilst taking advantage of professional expertise intreatment during certain parts of the day. Family members orcarers may have mixed perceptions: their burden of anxiety andresponsibility for the ill or disabled patient is relieved onlyepisodically and only in part; yet many are pleased with thisopportunity to continue to contribute to care and for therapy withthe guidance of professionals. The resources of the day hospitaladd to the resources of family life 2 . For the health care agency (theNational Health Service), day hospital development has beenattractive for its flexibility and apparent cheapness. It may not,however, represent a cheap option. Its importance to health caresystems lies in its influence on the effectiveness and smoothrunning of inpatient and other domiciliary or extramural andpartial hospitalization projects. These are increasingly likely to becooperative ventures with other care-providing agencies, such associal services 3 .SPREAD WITHIN THE UKAt the end of the 1960s, the Department of Health was promptedby a pressing need to review the services it was providing to theincreasing numbers of older people suffering from dementia andother major psychiatric disorders. This revealed a woefulsituation, with relatively few beds, badly supported and inSTRUCTURESThe cheapest option for developing day hospital provision was toplace the facility in a disused part of a mental hospital, and riskthe deficiencies of the parent hospital transferring to the new unit.Interestingly, the effect tended to be positive, for both the newventure and the existing facilities for this patient group, andillustrates a potential of such care—the link with inpatient servicesbenefits the day care unit, its attenders and their carers, andencourages wards to provide care more relevant to populationneeds. Alternatively, developments took advantage of existingpremises, designed for other purposes but away from the mentalhospital and often in the area to be served 9 . ‘‘Travelling’’ dayhospitals used a network of such premises, staff moving betweenthe locations to provide care on different days 10 , a useful systemfor rural communities.The ideal would be purpose-built units, probably on healthauthority land and sited conveniently in the catchment area. Nobed provision is required and staff are not employed when theunit is closed. These developments can also create a positiveimage for a vital, if unfashionable, service by raising itscommunity profile.Such ‘‘stand-alone’’ day hospitals run the risk of being seen asdistant from the inpatient services, and may detract from thereputation of the latter, especially as they are often seen as morethrusting and challenging. This can hinder cooperative efforts,such as when a patient requires a period of short-term, rotating orprolonged inpatient care 11 . Probably the best model places dayhospital and inpatient facilities within the same unit, with severalPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd