NHS Inpatient Units (IPUs) are medically managed detox services that also deal with complex physical, mental health and behavioural issues and provide 24-hour nursing care to those with acute substance misuse issues. NHS inpatient units are unique and invaluable in that they are Consultant Psychiatrist-led and hospital-based, enabling them to manage and support the most complex patients that other services feel unable to support. They are fundamentally different to all other detox and rehabilitation services in England and provide an essential service to some of our most vulnerable members of society.
Due to funding cuts, their very existence is under threat and it is vitally important that they are protected and maintained. The survival of NHS IPUs is a matter of life or death for service users and their loved ones. With only 5 remaining units in England, 4 of which are members of NHS SMPA and NHS Inpatient Network (IPN), there is already a postcode lottery in terms of access for patients to these vital services.
What makes NHS IPUs unique?
NHS inpatient units are fundamentally different to all other detox and rehabilitation services in England. They are unique in seven key ways:
1. The level and extent with which NHS IPUs are able to assess complexity/acuity
Pre-admission referrals are managed by a team of highly skilled professionals such as Nursing Managers, Consultant Additions Psychiatrists and allied professionals. The enhanced skills amongst this professional team allows for a multidimensional care package for the patient, focusing on all their medical and psychiatric needs, not just their current addiction problem.
The extensive and ongoing assessment of complexity and acuity which takes place within NHS inpatient services ensures each patient receives the best quality care for all of their health needs.
2. The ability to effectively manage cognitive impairment
Up to 40% of patients with chronic alcohol dependence have some degree of cognitive impairment. NHS inpatient detox units see a high prevalence of patients presenting with cognitive impairment. This is predominantly due to other, non-NHS units feeling unable to accept these referrals because of the challenges in managing the risk factors associated with cognitive impairment while going through the detox process, such as a history of seizures or the severe level of alcohol dependence.
NHS IPUs use screening tools (such as ACE III or MOCAM) to detect particular problems associated with alcohol-related brain damage while also collating and reviewing information from multiple other sources to fully understand other potential causes. Once causes of the cognitive impairment have been ascertained, remedial action or treatment is undertaken, such as treating reversible causes, prescribing reviews/describing of drugs contributing to the impairment, treating or referring for treatment of psychiatric conditions. These actions are reviewed and the NHS IPU liaises with the referrer and other relevant agencies to ensure that appropriate management and interventions continue once the patient is discharged from the IPU.
3. The ability to manage complex mental and physical comorbidities
A recent acuity audit across the NHS inpatient services has highlighted the complexity and multi-morbidity of patients, both physically and psychologically. NHS inpatient detox services are able to respond to such complexity through structured, comprehensive and ongoing assessments of patients conducted using rating scales and special investigations. Once symptoms of withdrawal and comorbid health conditions have been assessed or diagnosed, an individualised, recovery-orientated care plan is developed.
4. The presence of a range of professionals including social workers, psychologists and pharmacists to enhance packages of care
NHS inpatient detox services have access to advice and support from both non-addictions psychiatric/psychological specialties and physical health professionals to manage the complex range and severity of conditions commonly presented. For example, specialists in eating disorders, perinatal psychiatry, forensic psychiatry, crisis teams and other approved mental health professional services as well as wound care specialists, dieticians, physiotherapists, pharmacists and other physical health specialists are available as needed.
This enhances the quality and suitability of the care package and also allows for treatment of comorbid physical and psychological/psychiatric conditions that will potentially impact on the long term success of rehabilitation and the patient’s quality of life.
5. NHS Hospital-based (NHS Mental health Trust)
The NHS Mental Health Trusts where NHS inpatient detox units are based are each linked to local NHS acute physical health hospitals through an on call system. This provides a link to specialist doctors and nurses and a level of response that stand-alone non-NHS units cannot replicate.
As experts in medicine management and developed specialisms for drugs & alcohol, all NHS inpatient units have access to an on site pharmacist with regular visits to support the clinical work of the ward. Furthermore, on site pharmacy services provide ease of access to medications and the hospital site enables medication availability out-of-hours.
6. Led by a Consultant Addictions Psychiatrist (CAP)
Unlike other rehabilitation and detox services, NHS inpatient detox units are led by a Consultant Addictions Psychiatrist (CAP). The CAP is an experienced doctor who has undergone approved training in addictions psychiatry as well as other psychiatric disciplines. Consultant Addictions Psychiatrists develop practice, lead the inpatient service and links with other services as well as the NHS Trust in which the service is located. The role of the Consultant Addiction Psychiatrist is uniquely commissioned in the NHS and is an indisputable asset when it comes to the successful and efficient running of addiction treatment services. Having those with the most experience at the front end of a treatment system journey means that people end up accessing the right sort of treatment earlier on, rather than the consultants being at the back end of the process. Due to their evidence based backgrounds, the CAP role also facilitates influence over how current systems might be modified in order to find new and increasingly effective treatments.
Worryingly, along with the decline in NHS IPU’s we are also seeing a rapid decline in the prevalence of the Consultant Addiction Psychiatrist; funding cuts are having a detrimental effect on the quality and provision of treatment services as well as their innovation. The noted impact is a reduction of capacity for clinical leadership, complex case-management and ability to contribute specialist expertise to training, research and policy development.
7. Provision of training and guidance
Each NHS IPU has a wide range of professionals at different stages of training attached to it including students in medicine, nursing, pharmacy, social work and other disciplines. Junior doctors at all levels and types of training will rotate through an IPU. Students cannot get this medical training in alcohol and substance use detox and rehabilitation anywhere else, meaning that IPUs are the only places in England to be training staff to enter this area of the medical field.
What does the provision of NHS IPUs look like across the UK?
The four NHS SMPA members providing NHS inpatient alcohol and substance misuse units currently operating in England are:
ACER - Blackberry Hill Hospital, Bristol
Edward Myers - Harplands Hospital, Stoke-On-Trent
Chapman Barker - Prestwich Hospital, Manchester
Bridge House - Maidstone
It is notable that the units are located few and far between, already making it difficult for some service users to access the essential care that they need. The units are also seeing higher levels of complexity and acuity in the patients that are being referred. Patients are requiring increasing levels of testing, engagement with in-house and allied health professionals, treatment and observation to support their detox and co-morbid physical or psychiatric health conditions.
Despite the many challenges being faced by the IPUs, they continue to be outstanding in their treatment and rehabilitation of patients. The four NHS SMPA units treated a total of 1742 patients in 2017/18, with an average successful completion rate of 81.49%.
“The current NHS inpatient detox provision in England is at breaking point and there is a real risk that patients living with the most life threatening addictions will not be able to access essential treatment in the very near future.”
The current NHS inpatient detox provision in England is at breaking point and there is a real risk that patients living with the most life threatening addictions will not be able to access essential treatment in the very near future.
Without secured funding for NHS IPUs to manage and treat the most complex and acute patients which other NHS and 3rd sector services are unable to manage, there will be an increase in the number of substance use and alcohol related deaths and morbidity (such as liver disease).
The impact would also be felt by acute trusts, mental health trusts primary care and other agencies who would experience a high increase in admission rates, unplanned admissions and re-admissions as well as increased periods of stay. Nationally, there are more than 20,000 admissions to acute hospitals each year due to alcohol-related liver disease. The impact would also be felt across adult social care with a higher rate of acute admissions which such services would not be able to support. Similar impact would also be felt across the criminal justice system impacting crime levels. Without secure funding there is not only a significant risk to patients, but also the likelihood of a huge burden being placed upon the wider healthcare system, other drug and alcohol services and society as a whole.
The NHS SMPA and NHS Inpatient Network have launched a national campaign in order to secure the future funding of these essential services. The NHS SMPA and NHS IPN believe that due to the acute nature of the clinical services, commissioning arrangements for NHS Inpatient Detox units should be changed to allow NHS England to directly commission/fund all existing NHS Inpatient Detox Units under a single specification in line with similar Tier 4 specialist services such as Specialist Inpatient CAMHS and Perinatal Mental Health units. This will safeguard the existence of these acute services in the short term and allow a stable foundation from which to ensure that there is sufficient access to this provision across England for the patients.
The SMPA and Inpatient Network believe there would be substantial improvements to patient care planning and interventions if NHS IPUs were directly commissioned/funded in this way. They have launched a Tier 4 funding business case and will submit an application for specialist commissioning via NHSE.
Download the business case:
In addition, NHS APA and the Inpatient Network are also campaigning for NHS England, in partnership with Public Health England, to undertake further reviews of the demand for this provision as well as scoping what a sufficient national model of NHS Inpatient Detox provision could look like. This will inform future investment and future commissioning decisions.
“NHS APA and the NHS IPN believe that due to the acute nature of the clinical services, commissioning arrangements for NHS Inpatient Detox units should be changed to allow NHS England to directly commission/fund all existing NHS Inpatient Detox Units under a single specification in line with similar Tier 4 specialist services such as Specialist Inpatient CAMHS and Perinatal Mental Health units”.
How Can You Support the Campaign
We appreciate NHS APA and NHS IPN supporters taking the time to support our #KeepTheFewNHSIPUs campaign.
We will soon be launching a IPU survey in which you can pledge and offer support to the campaign in the coming weeks. In the meantime please visit our NHS IPN campaign page here