Audit in practice Three psychiatric day centres in a London borough

Research on day care has tended to focus on the day hospitals rather than day centres. A substantial body of work has evaluated the success of the day hospital as an alternative to the acute admission ward (Herz et al, 1971;Creed et al, 1989). But many day hospitals appear to have taken on long-term supports, the role envisaged for the day centres, as their principal function, rather than short-term treatment (Pryce, 1982;McGrath & Tantam, 1987):for example, Pryce draws attention to the accumulation of long-stay psychiatric day patients in a day hospital in South Glamorgan, where 67% of patients have been attending for between two and 17years. The Camberwell High Contact Survey (Brewin et al, 1988) included a survey of the social and clinical characteristics of a group of day centre attenders and their levels of met and unmet need, examined using the MRC Needs for Care Assessment. The work of this group suggests that a higher level of unmet need is found among day centre attenders than among day hospital attenders, although for both groups, the majority of identified needs are met. Needs for behavioural programmes to address the problems of underactivity, socially embarrassing behaviour, poor personal hygiene and difficulty in using public amenities were particularly prominent among day centre attenders. Reassessment of the characteristics of the day centre population is particularly timely at present, as some day care has now been available for around 30 years, and the number of long-term day patients approaching old age is likely to be increasing. Before the advent of day care many chronic patients spent a large part of their lives in mental institutions and continued there until old age. Since this group may now have been attending day centres for ten or even 20 years it is likely that there has developed a core of elderly 'graduate' patients and this has important

Research on day care has tended to focus on the day hospitals rather than day centres.A substantial body of work has evaluated the success of the day hospital as an alternative to the acute admission ward (Herz et al, 1971;Creed et al, 1989).But many day hospitals appear to have taken on long-term supports, the role envisaged for the day centres, as their principal function, rather than short-term treatment (Pryce, 1982;McGrath & Tantam, 1987):for example, Pryce draws attention to the accumulation of long-stay psychiatric day patients in a day hospital in South Glamorgan, where 67% of patients have been attending for between two and 17 years.
The Camberwell High Contact Survey (Brewin et al, 1988) included a survey of the social and clinical characteristics of a group of day centre attenders and their levels of met and unmet need, examined using the MRC Needs for Care Assessment.The work of this group suggests that a higher level of unmet need is found among day centre attenders than among day hospital attenders, although for both groups, the majority of identified needs are met.Needs for behavioural programmes to address the problems of underactivity, socially embarrassing behaviour, poor personal hygiene and difficulty in using public amenities were particularly prominent among day centre attenders.
Reassessment of the characteristics of the day centre population is particularly timely at present, as some day care has now been available for around 30 years, and the number of long-term day patients approaching old age is likely to be increasing.Before the advent of day care many chronic patients spent a large part of their lives in mental institutions and continued there until old age.Since this group may now have been attending day centres for ten or even 20 years it is likely that there has developed a core of elderly 'graduate' patients and this has important implications for planning and resource allocation.
In the Southwark area, three main psychiatric day centres provide long-term care and support for the mentally ill.Wandle, Lea and Ravensbourne Day Centres were all established more than 15 years ago.Southwark's two catchment area hospitals are Guy's for the north part of the borough and the Maudsley for the south.The Maudsley includes the District Services Centre, which was set up in the early 1980s as a day unit and in-patient facility for rehabili tation of the long-term mentally ill.For residents of North Southwark, Chaucer Day Hospital is a further provider of day care.
The aim of the survey was to compare the client population of each of the three day centres and consider implications for service provision.

The study
Southwark's three psychiatric day centres were visited and the managers interviewed about each of the attenders.In addition, clients' notes were examined.For each attender, information was gath ered on age, sex, support, housing, and diagnosis, drug treatment, catchment area, original referral, duration and frequency of attendance, appropriate ness of placement, date of last review, and expected duration of attendance in future.

Findings
Duration of attendance.At Lea and Wandle, many of the clients were very long-term attenders with 35 (26%) having attended for more than ten years and another 27 (20%) for more than six years.However, Ravensbourne had a significantly lower proportion of long attenders x2= 40.7 P< 0.0001) and 66% of its clients had been attending for less than a year.Future attendance.In total, 114(83%) were expected by managers to continue at their respective day centres indefinitely.Of the remaining group, Lea had a clearer idea about how long their clients were likely to stay whereas for Ravensbourne the future attendance of this group was usually rated as 'uncertain'.
Age.Only 7% (10) of the people were under 30 and Wandle had only one attender under 40.At Wandle in particular, a striking proportion of attenders were becoming elderly, with 55% of clients aged over 60 years.There was a highly significant relationship between increased age and a longer duration of attendance (T= 0.352, P< 0.0001).
Table II shows the diagnostic breakdown of clients attending.Ravensbourne had a much lower pro portion of people suffering from schizophrenia than the other two and the new client group (attendance less than one year) comprised predominantly (66%) diagnoses other than schizophrenia.For the pur poses of the analysis, clients with unspecified or unclear or no diagnosis were excluded, and for comparison the remaining group was divided into schizophrenia and other diagnoses.There was a significant association between long attendance and schizophrenia %2=\2A, /><0.005).In all, 51% of Wandle clients and 43% of all Lea but only 6% of all Ravensbourne clients had attended for more than six years and had a diagnosis of schizophrenia.
Medication.Of the clients, 110 (80%) were on psychotropic drugs, 22 (16%) were not and for the other 5 (4%) the information was not available.At Lea a qualified RMN was available to give depot injections to certain clients.82) lived in council flats, while only 36% (50) lived in some form of supported accommodation such as a hostel or group home.Thirty-nine per cent (53) of people lived alone and a further 26% (35) lived with relatives.

Comment
A high proportion of clients were not only expected to attend indefinitely but had also already attended for many years.This suggests a population with a high level of chronic disability and long-term needs.Predictably, the majority of attenders suffered from schizophrenia, the mental illness most commonly causing severe disability in adulthood, suggesting that resources were appropriately used supporting many such patients in the community.Ravensbourne had a lower proportion of clients with schizophrenia than the other two centres and its recent influx of new attenders may reflect an empha sis on providing a mental health facility for a less chronically disabled population.While many day hospitals seem to serve the psychiatric chronically disabled population for whom day centres were planned, Ravensbourne in some respects seems to be catering for those with short-term needs or having difficulty retaining some of those with long-term needs.
The lack of psychiatric or other support for some people, and, the fact that many lived alone in un supported accommodation further emphasises the crucial role of the day centres in long-term care and support for this vulnerable group.However, it also casts some doubt on the existence of effective collaboration between psychiatric and social services staff in the management of this group.
A striking finding is the very large population of elderly clients and of clients in their 50s due to become elderly in the next 15years.It is vital for local services to make long-term plans to provide for this.While Southwark has a model day centre for the elderly demented, there is no specific day centre provision for elderly people with functional mental illnesses.It is important that staffing levels and facilities at day centres are regularly reviewed to con sider this, particularly in the light of the additional physical impairments the elderly often suffer from: for example, the two flights of stairs at one of the centres were obviously inappropriate for an ageing population.It may be preferable to provide different, age-appropriate, rather than work-related activities for the elderly.Thirty years ago this group of people would probably have died in mental institutions but now they will need continued support in the community.Further research is needed in order to plan effectively for this elderly isolated and vulnerable group.

A cknowledgemen ts
Thanks to Jim Birley for suggesting this survey and his comments on an earlier draft.Thanks to Pat Stafford of Southwark Social Services for her sup port and encouragement in carrying out this study and to the staff of the three day centres for their cooperation.Thanks also to the management com mittee of Lea day centre which is run as a charity.

TABLE I
Comparisons between the three day centres