Access to medium secure psychiatric care in England and Wales. 2: A qualitative study of admission decision-making

Abstract

Decisions to admit to medium secure psychiatric care are complex, discretionary professional judgements. It is important to understand the assessor's ‘decision frame’, i.e. the values, assumptions and contextual pressures that shape the clinician's decision-making. The aims were to elucidate the values, beliefs and professional insights underpinning decisions to admit to medium security. The methods used were semi-structured interviews with a purposive sample of 55 lead clinicians from 36 medium secure units in England and Wales in 1999. Interviews were tape-recorded and a thematic content analysis of the verbatim transcripts was carried out. The results showed that a range of contextual pressures impinge on admission decisions, including the need to maintain a collaborative, shared vision amongst staff. Clinicians have a strong gate-keeping role in which collective views about appropriate patients, and the need to ensure turnover of places, are dominant considerations. The gate-keeping role involves managing expectations of referrers and managers, and the level of risk taken on by the medium secure service. There is fundamental adherence to seeking clinical benefit to patients, and therefore strong concerns about implementing proposed powers of preventive detention for dangerous individuals with personality disorder. It was concluded that admission decisions entail complex professional judgements about the ethos of the admitting unit and the wider context. Clinicians resist pressures they perceive to be in conflict with a primary therapeutic purpose for their services.

Keywords:

• secure units
• admission
• decision-making