Socio-economic deprivation and admission rates to secure forensic psychiatry services

Annual admission rates from the North-East Thames Region to maximum- and medium-secure forensic psychiatry services demonstrated a highly significant correlation with social deprivation measured at district health authority level using the Jarman UPA 8. There were specific associations with the number of unemployed persons, overcrowded households, and persons from ethnic minorities in the districts studied. There was a 10-fold difference in treated prevalence rates across the region, indicating that certain purchasing authorities may be seriously underfunded to meet the needs of their catchment area populations for secure forensic psychiatry services. Further research is required into the nature of the association between admissions to these services and social deprivation. It is readily apparent that a new formula is required for the allocation of resources in the face of such wide disparities in demand from different geographical locations.

It is increasingly apparent that there are widely differing admission rates to psychiatric facilities in different geographical locations and that these correlate with measures of social deprivation (Hirsch, 1988;Thornicroft. 1991;Jarman et al, 1992: Thornicroft et al, 1992. There are large discrepancies between the true health care needs of different populations, and demand is con siderably increased in socially deprived loca tions. A literature review by Thornicroft (1991) demonstrated strong associations between trea ted prevalence rates of mental disorder and social class, gender, marital status, ethnic group, and living alone; and moderate associ ations with living in inner-city areas and a high degree of social mobility. Jarman et al (1992) developed two statistical models which could be used to predict district psychiatric admissions as an aid to resource allocation, based on national data from the 1981 population census for England and Wales. By combining census data with data from the 1986 Mental Health Inquiry for psychiatric admissions according to district health authority (DHA), it was observed that the actual number of admissions varied from 79% above to 54% below that expected. This has major implications for the funding of services. It is possible that the financial allocation to some health authorities for mental health could be in excess of their requirements. This would give considerable scope for the shifting of funds from psychiatry Into other services. In contrast, under-provision could result in the removal of resources from other services in an attempt to provide the basic minimum standards for the mentally ill. If this was confirmed, it would provide a prima/acte case that a new formula is specifically required for the allocation of funds for mental health services.
Questions have been raised over whether a combination of inequity in resource allocation to health authorities, inadequate provision of med ium secure forensic services, and high-level demand have led to overspending and subse quent financial crisis for certain inner-city purchasers (Murphy et al 1997). A comparison of forensic admissions from two Thames regions compared to five non-Thames regions over a seven-year period revealed that Thames patients were more likely to be suffering from schizophre nia, committed more serious offences, placed higher levels of demand on security, and required more costly and longer admissions. Despite the level of demand on these services, a substantial proportion of admissions from the Thames regions over the past decade have been to private hospitals owing to the failure of the Thames regional health authorities to develop adequate provision of medium secure beds for inner London. This represents a major disinvestment from forensic services in London and results in the placement of patients a considerable distance from their homes and families in other parts of England and Wales.
There have been no previous published studies which have examined the treated prevalence rates of mentally abnormal offenders admitted to secure facilities from a defined geographical area over a prolonged period. Prior to this study, it had been observed by clinicians in the North-East Thames Region that there appeared to be a disproportionate number of admissions to med ium security from a relatively small number of DHA catchment areas located in the inner-city areas of North and East London. But it remained unclear whether these findings applied equally across the region and whether admissions to maximum security were similarly affected.

The study
A pilot study was carried out on all admissions to secure psychiatric beds in both maximum (special hospital) and medium security from the 15 district health authorities of the North-East Thames region. The intention of the pilot was to examine the feasibility of a larger, national study which will report in the future. The aim was to obtain the annual rate of admissions per 100 000 population from each district to both levels of security. From the rates obtained, it was intended to measure differences in usage of inpatient forensic psychiatry services by different districts; compare treated prevalence rates in maximum and medium security; and identify what specific factors of social deprivation demon strated statistical associations with service use.
At the time of the study, the regional forensic service was divided into three components based in interim units, which were located in Friern, Hackney, and Runwell hospitals.
Owing to insufficient regional beds, additional places would be found by clinicians on an extracontractual referral basis, usually within the private sector, and paid for by the regional health authority. Financial responsibility for such pa tients was subsequently devolved to the pur chasing authorities. Data for medium security therefore included all admissions to the three interim secure units, to private beds, and to other National Health Service medium-secure units outwith the region during the study period.
Complete data for medium-secure admissions were available from the catchment area DHA's covered by the Friern-based service for 1986-1992, the Hackney service 1988-1991, and the Runwell-based service 1989-1991. Annual ad mission rates from each district were therefore calculated over a similar time period from the data available for -1992for Friern, 1988-1992for Hackney, and 1989-1992 for Runwell. In addition, annual admission rates for each DHA were calculated on the basis of all admissions from the North-East Thames Region to the three special hospitals for the six-year period, 1987-1992. The address of each patient at the time of the index offence was determined from the case notes. If a patient was of no fixed abode then the catchment area was determined by the location of the index offence. Spearman's rank correlation coefficients were carried out between rates of admission to maximum and medium secure beds; rates of admission to maximum-and mediumsecure beds (combined) and Jarman UPA 8 deprivation scores for each DHA. Data on the DHA populations and the Jarman indices of social deprivation for each DHA were derived from the 1981 national census.

Findings
There was a 10-fold difference across the region in the annual rate of admission to secure beds in both maximum and medium security (Table 1). This varied from the highest rates for both 1. Spearman's rank correlation coefficient for rates of maximum compared to minimum security, R=0.72,P=O.OQ2 Socio-economic deprivation and admission rates maximum and medium security from the City and Hackney district per 100 000 population com pared to Waltham Forest which had the lowest. The table also demonstrates the rates of admis sions ranked according to district. There was a highly significant correlation between the rates of admission to maximum-and medium-secure services. Table 2 demonstrates the correlation between the annual rate of admission to maximum and medium-secure beds combined for each DMA with their Jarman 8 deprivation scores. Signifi cant correlations were found between the rate of admissions and persons unemployed: over crowded households; persons from ethnic min orities: and the overall scores (UPA 8) for deprivation for each district concerned.

Comment
The study demonstrates a highly significant statistical association between social deprivation at DHA level in North-East Thames Region and the annual rates of admission to secure forensic psychiatry services of residents from these areas. However, the nature of this statistical relation ship appears to be complex and not all indicators derived from the census variables which consti tute the Jarman UPA 8 score are relevant to secure bed usage. It is also important to bear in mind that deprivation indices are only proxy indicators of need. Factors such as the level of unemployment and overcrowding in a DHA catchment area are unlikely in themselves to have directly influenced the number of individ uals admitted to secure facilities. They reflect other features of London's inner-city areas which have a demonstrated higher prevalence of per sons with severe mental disorder (Johnson & Lelliott, 1997) and where additional social factors may operate and lead to higher rates of criminal behaviour by mentally disordered persons. The findings correspond to those of previous re- searchers who have examined admission rates to ordinary psychiatric facilities and have two major implications for future health service research in forensic psychiatry. First, the ob served differences in treated prevalence rates between DHA's indicate that there are substan tial differences in the level of demand for expenditure on secure hospital placements born by different health authorities and that a new formula is required for more equitable resource allocation; second, the siting of in-patient ser vices and their interface with community-based services to facilitate the treatment and rehabili tation of the maximum number of patients who are most in need is in need of review. Forensic psychiatry services represent lowvolume/high-cost care for purchasing authori ties. Patients remain for prolonged periods in these facilities and staffing levels are high. The average price of a bed in medium security is currently Â£95000 per annum. Beds in special hospitals continue to be funded centrally, but there are proposals that local health authorities should take over the funding of patients in maximum security in the future. This study had demonstrated a correlation between admis sions to maximum and medium security. Unless this finding is taken into account, purchasers of secure care for inner-city populations will be further disadvantaged in the future. The 10-fold difference in the rate of admissions across the Region also highlights the paradox that inner London purchasing authorities have experienced a reduction in their funding in recent years, with a redistribution to the outer London authorities and the Shires. For forensic psychiatry, this has placed both financial and managerial strain upon an already unstable and underdeveloped system.
The specific factors which account for these wide discrepancies in demand for secure beds require further study. It remains unclear whether the findings revealed in North-East Thames extend to other regions. It is also unclear whether they largely reflect the epidemiology of different DHA catchment area populations, or whether the level of provision of additional resources, such as the overall number of psychiatric admission beds in a DHA and locked wards, are the more important factors. Unpub lished data on crimes known to the police in the London boroughs indicate that all categories demonstrate higher levels in the inner London ring of the most socially deprived boroughs, in contrast to outer London. It is probable that the same social factors which lead to high overall levels of crime in these areas have had some influence on the criminal behaviour of the mentally disordered in these areas. Nevertheless, it is important to bear in mind that the majority of admissions to secure forensic psychiatry facilities follow the most serious crimes of violence, sexual offences, and arson, together with a smaller proportion of patients who are transferred to these facilities when they cannot be contained in a conventional psychiatric hospital setting. The relationship between these specific behaviours and crime rates, which are primarily constituted by acquisitive offending, may or may not be a direct one. One additional factor requiring further study is the contribution of Afro-Caribbean patients to raised treated prevalence rates from the inner-city DHA's. Murray (1996) demonstrated that Afro-Carib bean patients constituted 40% of the overall population in a national point prevalence survey of all patients in medium-secure facilities in 1991. There is growing evidence that the demand for psychiatric service provision may be espec ially high in areas characterised by higher proportions of African-Caribbeans (Ineichan et al, 1984;McGovern & Cope, 1987;Harrison et al, 1988;Owens et al 1991;Davies, 1996: McCreadie et al 1997. Independent of their diagnosis. Black African-Caribbean patients are more likely to have contact with the police and forensic services (McGovern & Cope, 1987), to be treated in intensive care facilities if detained under the Mental Health Act 1983 (Moodley & Thornicroft, 1988), and to have criminal convic tions if they are young and male (Wessely et al 1994). Although admission rates in this study correlated with ethnicity at a relatively low level of significance, this finding may have been more robust if data from the 1991 national census had been included. This subdivided ethnicity into several categories in contrast to the 1981 census data which was incorporated into the Jarman UPA 8 score used in this study and which combined all ethnic minorities into one category.
Future study will require a considerably larger sample and should cover a larger geographical area than a single region before a new formula can be proposed for the reallocation of funding. It will also need to take into account the level of provision of other psychiatric facilities locally to avoid penalising areas that have developed a wider range of services, such as locked wards, and have reduced inappropriate demand on a higher level of security. For example. Table 1 indicates that two districts deviated considerably from the general trend. Haringey was higher in the table than might have been expected from its Jarman ranking and Waltham Forest was con siderably lower. This posed the important ques tion of whether poor quality local provision for mentally abnormal offenders in the Haringey district and contrasting good provision within Waltham Forest could have influenced treated prevalence rates in the forensic psychiatry services. This highlights the complexity of the interaction between the epidemiology of a catch ment area population, which may determine its true level of need, and additional psychiatric service provision, a combination of which may ultimately determine the level of demand on secure forensic psychiatry services.
to predict psychiatric service utilisation.