final dissertation

The Becoming of the Psychiatric Bed Crisis:Using Ideas for Deleuze and Guattari

Steven Giles Boardman - 8986976

B.Sc. (Honours) Management (Marketing specialisation)

Dissertation Supervisor: Dr Christine Mclean

MAY, 2016The university of manchesterManchester Business School

Steven Boardman - 8985976

Declaration of Originality

This dissertation is my own original work and has not been submitted for any assessment or

award at the University of Manchester or any other university.

Acknowledgement

I would like to thank my dissertation supervisor Dr Christine McLean for supporting me

throughout my dissertation and introducing me to the thoroughly engaging ideas of Deleuze

and Guattari. I would also like to acknowledge the Institute of Brain, Behaviour and Mental

Health, along with the School of Midwifery, Nursing and Social Work, at the University of

Manchester and would like to say a special thankyou to their members who contributed to my

research.

I would also like to dedicate this dissertation to Hannah Day, who managed my mental

health, as I delved into the workings of Mental Health Care services.

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Abstract

Recently, in the media, the shortage of beds in psychiatric hospitals has been raised as a

matter of concern. It is said to have a damaging influence on the quality of care provided by

the NHS Mental Health services. In attempts to resolve this problem, within the 2016 Task

Report, published by the government, it was announced that large investments are going to

made into mental health care services. However, there is scepticism as to whether this

investment will help resolve the problem.

This dissertation explores the mental health bed crisis and the influence it has on the quality

of care provided, by implementing an ontological perspective. By removing structure and

agency, it can be seen that there are many components that contribute to the development of

the mental health crisis, not just the element of funding. This will be achieved by using

Deleuze and Gattari’s ontological philosophy. By using this ontological perspective, we will

be able to see how the bed crisis has an effect on the quality of care for Mental Health Care

Patients, whilst also exploring the becoming of the psychiatric bed crisis, with the hopes of

bringing overlooked components to the forefront of the issue.

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Table of Contents

1. Introduction……………………………………………………………………………...5 - 6

1.1. Code black ………………………………………………………………………5 – 6

2. Literature Review………………………………………………………………………7 - 23

2.1. Introduction to MHC Pathways…………………………………………………..7 - 8

2.2. The Issue of Community Care…………………………………………………..8 - 12

2.3. MHC Patients with Physical Comorbidities…………………………………...12 - 16

2.4. Further Ways MHC Patients Suffer Other than Physical Comorbidities……...16 - 17

2.5. Ideas from Deleuze and Guattari……………………………………………....17 - 22

2.6. The Usefulness of Deleuze’s Toolbox in Regards to the MHC Services……...22 - 23

3. Methodology………………………………………………………………………….24 - 29

3.1. The Reason for Using Qualitative In-depth interviews………………………..24 - 25

3.2. Participants…………………………………………………………………….25 - 26

3.3. Interview Ethics and the Reason for this……………………………….……...26 - 27

3.4. How Data was Analysed……………………………………………………....27 - 28

3.5. Secondary Data………………………………………………………………...28 -29

4.Results…………………………………………………………………………………30 - 43

4.1. Patient Placement and Categorisation…………………………………………30 – 33

4.2. Quality of Care…………………………...……………………………………33 – 34

4.3. Procedural Insurance………………………………………………....…….....35 – 36

4.4. Procedural Necessity……………………………………………………….....36 – 38

4.5. Resource and Staff Management……………………………...……………...38 – 41

4.6. Service Limitations………………………………………………...…………41 – 42

4.7. Evidence Based Treatment…………………………………………...………42 - 43

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Table of Contents

5. Discussion………………………………………..…………………………………..44 – 52

5.1. The Patient’s becoming and their Stratified Categorisations within MHC....44 – 47

5.2. The Virtual patient…………………………………………………………..47 – 50

5.3. The Derealisation of Time…………………………………………………..50 – 52

6. Conclusion……………………………………………………………………………53 – 55

6.1. Space………………………………………………………..………………53 – 54

6.2. Going Forward……………………………………………………..……….54 - 55

7. Bibliography…………………………………………………………………………56 - 61

8. Appendices…………………………………………………………………………..62 - 64

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1. Introduction

1.1. Code Black

The mental health bed crisis in the UK, is highlighted in the media as at a drastic point (BBC

panorama, 2016). With the crisis exists a number of concerns in terms of the quality of care

for not only psychiatric patients, but for many patients using any form of NHS mental health

care service (MHC), and are as follows: the reduction of beds in psychiatric wards across the

UK, which prevents patients from accessing the services necessary for their condition;

patients receiving inappropriate first line treatment as a replacement for the service they were

unable to access, which may prolong the duration of the illness; informal patients not having

the access they need to psychiatric wards, which results in them being detained under the

Mental Health Act (1983), causing discomfort due to the limitation of their liberty

(Buchanan, 2014); patients being located a substantial distance from their homes and

relatives, again causing discomfort (Meikle, 2016); and, the suboptimal treatment of physical

comorbidities, which in turn leads to shortened life expectancy (Lally et.al, 2015).

These factors are seen as impacting on the quality of care for patients and are viewed to stem

from the imperative of resource management in the MHC services. While there is a

government proposal, outlined in their 2016 task report, stating it will provide mental health

services with over £1 billion, in order to alleviate issues concerning access to mental health

(www.gov.uk, 2016) many question if this funding will serve its purpose. In fact, some

suggest that a more holistic analysis of the structure of the MHC may be required in order to

see how the mental health bed crisis exists in the MHC, as an ontology, and in turn the

damage of the quality of care for mental health patients (Loader, 2014).

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There are a number of questions that this dissertation will attempt to answer, from this

holistic approach, when exploring the micro-foundations contributing to the metal health bed

crisis and these are as follows: (1) Is the way in which mental health patients are categorised

beneficial when it relates to the service spaces available to them? (2) What components of the

patient can be considered that can contribute to the alleviation of the bed crisis, and the issues

that exist alongside it? (3) How does the perception of processes that take place within the

Mental Health Services have an impact on the bed crisis?

By answering these questions, the formation of the bed crisis can be explored, along with

how the bed crisis impacts on quality of care for patients.

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2. Literature Review

2.1. Introduction to MHC Pathways

There are two main mental health pathways to be taken in the network of mental health, at

current, in terms of locality, and these consist of community based care and in-hospital

services (www.nhs.uk, 2016) and “precisely how recent shifts in mental health spending in

England from hospital to community-based management have affected patient health and

wellbeing is not clear” (Green et.al, 2014, pp. 442). When originally introduced in the year

2000, Community Mental Health Teams (CMHTs) had the aim of treating “100, 000 patients

in the community per year by averting an inpatient admission or facilitating early discharge

from psychiatric hospital and, furthermore, reducing in-patient admission by 30%” (Loader,

2014, pp.151).

However, psychiatric hospitalisation is mandatory for patients who have been detained under

the Mental Health Act (1988) (Griffith et.al, 2014) and is used to ensure the safety of the

patient and others around them (Kahn et.al, 2012). This is the only initial pathway available

for patients detained under this act as they need to be nursed closely (Kahn et.al, 2012). This

kind of care will take place in a secure hospital ward, where patients are intensively

monitored. Nevertheless, there are also informal patients that exist within these wards. These

patients have the mental capacity to accept or refuse treatment (Owen et.al, 2008), therefore

these patients optionally reside within these hospital setting after they and a consultant have

agreed to it. It is within this pathway that the mental health bed crisis spurs.

Recently, alleviation of the NHS mental health bed crisis has come in the form of stage

specific treatment where there is a focus on early detection of serious mental illness (SMI)

and psychosis in particular (Marshall and Rathbone, 2011). This revolves around the idea that

outcomes for patients “might be improved if more therapeutic efforts were focused on the

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early stages of schizophrenia or on people with prodromal symptoms (Marshall and

Rathbone, 2011, pp.1111), thus minimising potential for relapse and maximise recovery in

the first two to five years (Iyer et.al, 2015) and in turn reducing the need for future admission

to psychiatric wards. This can be seen as long-term solution to the bed crisis, rather than an

immediate fix, such as placing patients elsewhere within the MHC services. It is therefore

imperative that the duration of untreated psychosis (DUP) (Birchwood et.al, 2013) is kept to

a minimal by having access to these services at the earliest stages of the illness as possible. In

order to achieve this there is a third pathway called Early Intervention Services (EIS)

(Birchwood et.al, 2013). These services consist of a team of medical professionals that have

connections with other mental health services (www.rdash.nhs.uk, 2016). The team works

around the individual and performs a number of tasks such as therapy for the patient and the

patient’s family, financial aid and help with medication (www.rdash.nhs.uk, 2016).

2.2. The Issue of Community Care

In January 2016 the UK government “announced almost a billion pounds of investment to

enhance mental health services across the country” (www.gov.uk, 2016). Of this, £250

million is to be invested in mental health services in emergency hospital departments and

£400 million to enable 24-hour access, seven days a week, to community based treatment

(www.gov.uk, 2016) which has been suggested to be a “safe and effective alternative to

hospital” (www.gov.uk, 2016). The question arises as to whether the investment money

coinciding with the current state of the MHC will be positively transformative in correlation

with the mental health bed crisis and the quality of care for mental health patients.

As highlighted in the media, the bed crisis in intensive care psychiatric wards, where the

number of available beds has been decreased by 3000 over the past 5 to 6 years, in

psychiatric hospital wards that are working at over 100% capacity and where, the institution

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regularly has to pay the private sector to take patients at over £1000 per person (BBC, 2016)

is at a pivotal point. The reduction of these beds is in conjunction with the introduction of

community based care. As Green states the “recent reductions in psychiatric beds have been

justified in England by increased spending on community psychiatry…” and “if mental

illness is treated in the community many people reason that hospital admission is not

required” (Green et.al, 2014, pp. 442). With the extra £400 million being invested into

community based treatment, the expectation for mental health patients to follow these routes

will increase, which could further justify the reduction of bed numbers in psychiatric hospital

wards.

The initial overall aim of the original implementation of the National Service Framework for

mental health (NSF) and the NHS plan in 1998, in relation to the introduction of community

based care was to “provide financial investment for a radical reform of the health service,

which should pivot around the patient” (Loader, 2014, pp.151). It is therefore clear that this

reform has existed alongside fundamental issues for the mental health service. These

problems include translating the resources available, in this case bed spaces, from one sector

of MHC (psychiatric hospitalisation) to another (community based care), when psychiatric

hospitalisation can’t afford to surrender any resources.

The recently proposed £400 million investment into community based mental health care,

holds the purpose of making the service more accessible for patients, 24 hours a day 7 days a

week, (www.gov.uk,2016) which could influence the pressure on the existing service further,

instead of providing the funding necessary for the service to function flexibly, within the time

constraints it already has, via the transformation of the overall assemblage.

The motivation of the implementation of community based treatment, based on the argument

that treating people in the community will provide patients with a more comfortable

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environment to be treated within (Loader, 2014), comes under scrutiny. This is because

community based Crisis Resolution Teams (CRTs) have been criticised as a tool for

efficiency, merely prolonging an inevitable admission because “20% of patients accepted to

the crisis team were later transferred to an inpatient unit” and “60% were admitted to an

inpatient unit following CRT intervention” (Loader, 2014, pp.154). Therefore, the majority of

people admitted to psychiatric hospitals had previously gone through Community Mental

Health Teams (CMHTs), and psychiatric hospitalisation serves a completely different

purpose to community care. For these patients, psychiatric hospitalisation as first line

treatment may have been beneficial. This infers that CRT’s may be in place to alleviate bed

spaces for inpatient admissions rather than being a means of treating psychiatric patients in

the best way possible, in terms of their quality of care. However, due to the shortage of beds

in psychiatric hospitals, admission as a first line treatment may not be possible, and further

funding to community based treatment, although temporarily alleviating bed spaces, in the

long term the crisis may continue, as it will be expected that patients take alternative routes to

psychiatric hospitalisation, with further transfer of beds from psychiatric hospital into spaces

in community based services.

Furthermore, the impact EIS is having on DUP seems to be failing, yet this is not in line with

the ineffectiveness of the service, rather it is the influence of barriers in accessing EIS

(Birchwood et.al, 2013). One such barrier to entry includes patients being referred to CMHTs

before later being referred to EIS (Birchwood et.al, 2013), when the patient has progressed

further into DUP. This problem involves a substantial number of patients that access EIS in

UK, as 48% of these previously accessed CMHT and 6% accessed Child and Adolescent

Mental Health Services (CAMHS) (Birchwood et.al, 2013). Again this shows how standard

community based treatment as a focal point of the mental health service will also cause long

term issues in terms of bed availability, as it contributes to the likelihood of patient relapse

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into psychosis because DUP is prolonged whilst patients are being treated by generic mental

health teams.

There are a number of reasons why these generic mental health services, such as CMHTs and

CAMHS are not suitable for patients suffering with psychotic illnesses, or patients that

display prodromal psychotic symptoms. Firstly, “community mental health teams are

pressured services and have to deal with a wide range of mental health problems”

(Birchwood et.al, 2013, pp.62) and are not the specialist service required to treat mental

illness of such severity, not containing the skills required to treat and diagnose said patients.

This creates even further barriers to the access of EIS as there is under-recognition of the

symptoms of such illnesses (Birchwood et.al, 2013), thus diverting the therapeutic efforts

aimed at the early stages of psychotic illnesses (Marshall and Rathbone, 2011). Again, DUP

is prolonged in such ways and there is an increased likelihood of re-admission to psychiatric

wards in the future. With this it is probable that psychiatric wards will be working at over

100% capacity in the long-term.

Secondly, Birchwood suggests that “young people with psychosis do not engage well with

out-patient services such as CMHTs and are often discharged as a result” (Birchwood et.al,

2013, pp.62). Meaning, the cognitive impairment that corresponds with their mental illness,

means they may not engage with community services effectively and ultimately the pathways

to EIS may be hindered simultaneously, or even treatment at all. Without treatment at all the

average DUP for patients with psychotic illnesses lasts from 1 to 2 years (Birchwood et.al,

2013) and with such prolonged exposure to the illness, not only does it increase the likelihood

of relapse but it poses extra risk of self-harm and increases the risk to other people. It is

therefore evident that community mental health services are not fully equipped to deal with

psychotic illnesses, yet they are still the focal point of the NHS mental services, with the

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proposition of further funding and the expectation of more mental health patients to use the

services, regardless of their need for more specialist care.

2.3. MHC Patients with Physical Comorbidities

The psychiatric bed shortage controversy has also been connected to developments in an

efficiency based model when it comes to resources provided to the different bodies within

mental health. In terms of budgeting as a resource, finances are perceived from the

perspective of money allocated per bed and with psychiatric hospitalisation being “the most

expensive component of mental health care, any additional general hospital costs incurred

during the course of a psychiatric admission stretch the budget further…” therefore “…

simultaneous registration in both psychiatric and general hospital is an inefficient use of

resources” (Lally et.al, 2015, pp.579). “In the UK, Naylor et al. reported that the total

healthcare costs are raised by at least 45% by people with long-term health conditions and co-

morbid mental health problems” (Behan et.al, 2014, pp.108) and in conjecture with this,

psychiatric patients receive suboptimal treatment for physical morbidities when admitted to

general hospital, in turn drastically lowering life expectancy (See figure 1) (Lally et.al, 2015).

Diagnosed Mental Illness: Life Expectancy Shortened By (Years):

Psychosis 15 – 20

Substance Abuse 14 – 15

Personality Disorder 18 – 19

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Figure 1: Lally et.al (2010 – 2011) study of shortened life expectancy in relation to diagnosed mental illness, in long-stay psychiatric in-patients.

Resource: Lally, J., Wong, Y., Shetty, H., Patel, A., Srivastava, V., Broadbent, M. and Gaughran, F. (2015). Acute hospital service utilization by inpatients in psychiatric hospitals. General Hospital Psychiatry, 37(6), pp.577-580.


What’s more is in the study conducted by Lally et.al (2015), only 25% of psychiatric patient

admissions to general hospital were due to self-injury or self-poisoning and therefore the

other 75% were due to physical morbidities. This shows that the majority of shortened life

expectancy is not attributable of the mental illness, rather it could be the influence of

receiving suboptimal treatment in general hospital.

In spite of this, the study does not take into account suicides that were fully completed before

arrival at the hospital. Meaning that a large quantity of this shortened life expectancy could

be attributed to suicide caused by the mental illness. On the other hand, Behan states that

“people with psychosis have a higher prevalence for all risk factors for a first cardiac event

and young people with psychosis are 2-3 times more likely to develop cardiovascular disease

than their peers, making this more common than suicide as a cause for premature death”

(Behan et.al, 2013, pp.108). Meaning that this shortened life expectancy is most likely

attributable to physical comorbidities rather than suicides and it is vital that patient with

serious mental illness (SMI) have access to general hospital for physical morbidities.

For Vasudev, there is also “a need for improved access to physical health-care in long-stay

psychiatric settings” (Vasudev et.al, 2012, pp.363) as people with SMI have higher chances

of developing certain physical morbidities for a number of reasons. This includes “unhealthy

lifestyles, polypharmacy and inadequate healthcare” (Vasudev et.al, 2012, pp.364).

Inadequate healthcare worsens the consequences of the unhealthy lifestyle and the

polypharmacy, but the three together have been shown to “contribute to the high natural

mortality rate” (Vasudev et.al, 2012, pp.364) of long-stay psychiatric patients.

With anti-psychotics being first-line treatment for people with SMI (Vasudev et.al, 2012) it is

essential that access to physical treatment is improved for psychiatric patients, because anti-

psychotic medication is associated with metabolic side-effects, which include; diabetes

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mellitus, weight-gain, and dyslipidaemia, all of which increase the risk of cardiovascular

disease (Vasudev et.al, 2012). This coincides with the data found by Lally et.al (2015), where

the life expectancy of patients that suffer with psychosis is shortened by 15 to 20 years,

suggesting that this may indeed be the result of anti-psychotic medication. However, this

excessive mortality rate may be improved if psychiatric patients didn’t receive suboptimal

care for physical morbidities and had greater access to treatment for physical comorbidities.

Although treatment for physical comorbidities in mental health patients may be perceived as

suboptimal, there is recognition of the danger of the medication that people with SMIs are

prescribed, as NICE guidelines state that the physical health of patients with SMI should be

monitored by primary and secondary health care (Behan et.al, 2013). Therefore, “it is

imperative that physical health is checked regularly in these patients” (Vasudev et.al, 2012,

pp.364) and is done so via the monitoring of physical health parameters including; weight,

blood pressure, blood sugar level, liquids and ECG (Vasudev et.al, 2012).

However, this metabolic monitoring of patients with SMI still proves to be problematic in the

MHC as it “is carried out by psychiatrists who often feel ill equipped to treat medical

problems such as abnormal cholesterol or disturbances of glucose metabolism” (Behan et.al,

2014, pp.108). This infers that the monitoring of the physical health of mental health patients

should take place in general hospitals or general practice, where physical illness can be

clearly treated. The issue is therefore deciding on which environment to treat the patient in,

whether this be in mental health care or physical health care. This issue therefore corresponds

with the idea of suboptimal treatment, as although the patients are being monitored in a

psychiatric setting, they are not being treated and are only able to access the treatment they

need in general hospital because psychiatrists do not have the training necessary to do so.

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This matter creates further problems when it comes to quality of care for psychiatric patients

as the lack of clarity about who should be detecting and treating physical symptoms creates

service related barriers (Behan et.al, 2014). This problem is further intensified due to the

increased time and cost it takes to treat the patient as coordination between MHC and general

hospital is not clear cut. With a strict focus on resource management in this overstretched

body of the NHS, they cannot afford to increase time spent on patients, neither can they

afford to increase the money spent on patients. These barriers can lead to further suboptimal

treatment, as resources will already have been stretched allocating the patient to the correct

body.

In addition to this, the current form of MHC, that is, community based treatment and

psychiatric hospitalisation, may further jeopardise the screenings used to monitor the physical

health of patients with SMI. This is because, “blood tests and physical health screenings in

patients on antipsychotic medication are less robust in the community as compared to in-

patient units” (Vasudev et.al, 2012, pp.364) and this issue may be highlighted by the amount

of years that life expectancy is shortened by in patients with who suffer with psychotic

symptoms. As stated within the NICE guidelines, these screenings should be carried out

regularly and in equal measures whether the patient is being treated in the community or in an

in-patient facility (Behan et.al, 2014). This suggests that treatment within the community

increases the “barriers to the recognition and management of physical illnesses” (Behan et.al,

2014, pp.108) and these barriers include patient related factors such as; social isolation,

cognitive impairment and negative symptoms (Behan et.al, 2014), all of which are ably

managed within inpatient facilities. Thus, community based service is deemed to be an unsafe

alternative to psychiatric hospitalisation for certain individuals and one cannot replace the

other in terms of service provided. This again highlights the flaws of the initial aims of

reducing inpatient admission by 30% via community based treatment (Loader, 2014) and

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reinforces the notion that the current plan to fund community based treatment by a further

£400 million (www.gov.uk, 2016) may have an adverse effect on patient care, as this funding

has the imperative averting patients into community based treatment, where recognition of

physical health conditions may not be recognised and issues with this include insufficient

management of the patient, ultimately leading to a lower life expectancy.

2.4. Further ways MHC patients suffer other than physical morbidities

From this, it is evident that the main patients that suffer from the psychiatric bed shortage are

informal patients, who have the mental capacity to accept or refuse treatment and for their

decision to be accepted (Owen et.al, 2008) and have agreed to treatment within a psychiatric

hospital. This is because, these patients will benefit from treatment in psychiatric hospitals as

the option is put forward by a healthcare professional and may also feel the most comfortable

in this environment, as they have agreed to the treatment. However, the mental health bed

crisis prevents these patients from attaining a bed as patients who have been detained under

the Mental Health Act require a bed immediately for the protection of themselves and others

and are kept as an inpatient for a minimum of 72 hours (Gangaram and Kumar, 2008), thus

will be prioritised a bed. With the service running at over 100% capacity (BBC, 2016), it is

unlikely that the voluntary patient will get a bed.

This has resulted in doctors giving patients inappropriate treatment in accordance their mental

health condition. After questioning 576 trainees working in psychiatry across the UK, the

Royal College of Psychiatrists established that, “18% said their decision to detain a patient

under the Mental Health act (section someone) had been influenced by the fact that doing so

might make provision of a bed more likely” (Buchanan, 2014, pp.3). Compulsory detention

in this way may not be the best option for patients because the inability to choose the

environment in which they are treated, for patients with efficient mental capacity to make

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their own choices (Griffiths, 2014), it may prove more destressing (Buchanan, 2014). In

addition to this, trying to efficiently manage via calculability goes against standard five of the

NSF, which is concerned with “effective services for people with severe mental illness”

(Chady, 2001, pp. 985) and states that all patients that should require a bed are entitled to one

(Wrycraft, 2009) whether this is optional admission or compulsory detention.

As well as effecting the correct decision when it comes to detaining a patient under the

Mental Health Act (1983), the psychiatric bed shortage also influences the location of the

ward in which the patient is to be admitted. This is because local bed shortages have resulted

in patients having to travel hundreds of miles, away from their families and homes (Meikle,

2016). An independent commission, supported by the Royal College of Psychiatrists found

that approximately 500 patients a month travel further than 31 miles for acute care in

psychiatric wards (Meikle, 2016) and from this it was deduced that this time spent travelling

is dangerous to the patient. Not only does it remove the patient from the security of family

members and familiar surroundings when it comes to the locality of the psychiatric ward, but

the time spent travelling when a patient is feeling suicidal and are at their lowest is seen as

even more damaging to the patient’s mental health (Meikle, 2016).

2.5. Ideas from Deleuze and Guattari

By incorporating ideas from Gilles Deleuze and Felix Guattari, the ever-changing state of the

service space within the MHC can be explored. This approach turns “thought (and ethics)

away from internal meanings, causes and essences, and toward surface effects, intensities and

flows” (Malins, 2004, pp.85). It elaborates on a heterogeneous reality where there are no

signifiers to determine a stratas definition (Deleuze and Guattari, 1988), whether they are

tangible or intangible. This reality, where there is no internal meaning of an assemblage’s

becomings are defined from an ontological perspective (Rae, 2014) and an assemblage is

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always in a state of becoming. Thus, there is no constant state of any assemblage, rather it is

formed via the connection of chains (Deleuze and Guattari, 1988). Therefore, assemblages

cannot exist without the connection of heterogeneous components (Mark Bonta and John

Pretevi, 2004).

Deleuze and Guatarri’s ontology can be perceived as componentry, in particular the ontology

as a whole can be broken down into realms, the virtual (the plane of consistency) (Deleuze

and Guattari, 1988) and the actual (Mark Bonta and John Pretevi, 2004). As explained by

Bonta and Pretevi (2004) the virtual is the space in which systems exist in a far from

equilibrium state. Thus, multiplicities in the virtual cannot be viewed, instead they have

potential to become complex systems (Mark Bonta and John Pretevi, 2004). On the other

hand, when these multiplicities are locked into a steady state, to form an assemblage at near

equilibrium, they can be stratified (Mark Bonta and John Pretevi, 2004). Thus, the actual is

populated by actualised systems that can be recognised (Mark Bonta and John Pretevi, 2004).

By implementing this train of thought, the problem can be reconceptualised and explored

from an alternative perspective. Whereas before the mental health bed crisis has sought to be

resolved via the funding of an external force with greater agency, this is not possible when

we consider the reality of strata as a series of connected assemblages. Instead, the becoming

of an assemblage should be explored via its internal complexity, with a focus on systematic

behaviour and without having to rely on an external organising agent and removing the

structure agency/debate which is problematic in social sciences (Mark Bonta and John

Pretevi, 2004).

Such functionalist approaches that consider structure and agency, argues that “’agency’

represents… ….the best hope for radical transformative social action” (Connor, 2011, pp.98).

This proves problematic for a number of reasons; firstly, it considers individualism without

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exploring what constructs this individualism and in turn agency. Also, as a result of this,

these single actors are the immediate cause of events (Connor, 2011), which takes away the

influence of multiplicities within an assemblage. Therefore, a dichotomy that only considers

structure and agency does not take into account change via the relationship between the

connection of heterogeneous components. Therefore, the focus on structure, whether this be

organic, inorganic or social structures, is placed upon “emerging functional structure from a

multiplicity of lower level components” (Mark Bonta and John Pretevi, 2004, pp.5).

Just like a “’plateau’ is the self-ordering set of productive connections between forces

without reference to an external governing force” (Mark Bonta and John Pretevi, 2004, pp.9),

assemblages are formed, actualised and stratified in such a way. Thus, change happens

naturalistically without the influence of structure and agency, as “rhizomes creep

horizontally, shooting off in unexpected, non-linear directions which are not dependent on or

generated by a fixed, unifying centre or inner essence” (Rae, 2014, pp.89). Therefore, when

change is considered rhizomatically it can be described as nomadic, where there is no

necessary organic arrangement (Hodgson and Standish, 2006) the network will grow outward

in an unorganised fashion, in every direction. In this way, components that are part of an

assemblage deterritorialise and then reterritorialise, becoming part of other assemblages and

following a new lines of flight.

These assemblages reach stability through processes that take place along these lines of flight

and these processes travel at different intensities until an equilibrium point is found (Mark

Bonta and John Pretevi, 2004). At this point, assemblages are stratified but it is essential not

to acclaim the stability of the strata (Mark Bonta and John Pretevi, 2004), as it too, like

everything, will always be in a state of becoming and components can change lines of flight

and reterritorialise or deterritorialise with the assemblage.

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These components can also be viewed in the terms of space. Striated space is “a regulated

space, space that is coded, defined, bounded and limited” (Gunson et.al, 2014, pp.22) and is

defined through the measurement of strata, however these strata are not homeostatic as

networks would be described in structuralist theories (Mark Bonta and John Pretevi, 2004),

instead they are formed by the bodies following lines of flight as they reterritorialise with

assemblages (Deleuze and Guattari, 1988). While striated space may rely on linear models to

measure stratified systems with a focus on strata that have been actualised as homogenised

components near equilibrium (Mark Bonta and John Pretevi, 2004), in smooth space

components are more “deterritorialised and capable of resistance and transgression” (Gunson

et.al, 2014, pp.22). Thus, in this space, connections (desiring machines [Deleuze and

Guattari, 1988]) have not been actualised and stratified, instead there is the potential for the

connection of components to influence the becoming of an assemblage. Therefore, strata in

this space are not measured in a linear fashion, they are flexible and inconstant.

From considering the ontological space in this way, it is evident that we are not taking a

positivist and in turn a reductionist approach to the to the becoming’s of singularities,

multiplicities and assemblages (Mark Bonta and John Pretevi, 2004) as we are not simply

perceiving and denoting from our perception of the experience, we are understanding the

creation of this metamorphosing experience. This is because if one simply rationalises a

perceived object it comes from an individualistic approach and problems arise with such

approaches. With such social sciences being coined by Deleuze and Guattari (1988)

“problematics”, the issues of such science can be highlighted with the example of Rational

Choice Theory, where social phenomena are the outcome of rational action that has been

taken (Boudon, 2003). As already established, this cannot be the case as assemblages exist as

a meeting point of different multiplicities, thus an assemblage as a social phenomenon should

not be explained as a causal factor of anything, albeit a rational action. This notion merely

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simplifies the multiple natures of assemblages to a point where it can be understood via the

rational senses and does not think to question it further (Boudon, 2003).

When positive models are used in such a way, they also ignore certain dimensions that are

vital to the understanding of rhizomatic change, along with the understanding of becoming.

One such example is the insignificance of time in the reversibility of time arrows thesis in

physics (Mark Bonta and John Pretevi, 2004). This contradicts the recognition of strata and

the time involved in the process of becoming, because with Complex Theory (Deleuze and

Guattari, 1988) time exists within two realms; the actual and the virtual (Mark Bonta and

John Pretevi, 2004). Time in the actual is paired with striated space, as it is a measurement of

movement and change, whereas in the virtual time is paired with becoming, as it is the time

of an actual event (Mark Bonta and John Pretevi, 2004). Such events allow becomings, with

change occurring on the way, with different components of an assemblage travelling at

different intensities. This is essential to the process of rhizomatic change, as although this

change is chaotic and moving in every which way, virtual time (Aion) (Mark Bonta and John

Pretevi, 2004) must be acknowledged as necessary for the process of new becomings to

occur.

With rhizomatic change and the movement of such time, no two events can be the same and

rhizomatic change cannot stop as everything is in a constant state of becoming due to

deterritorialisation and reterritorialisation of singularities. However, there can be the tendency

for habit because “complex systems, when studied in equilibrium, steady state, or stable

conditions, are so locked into basins of attraction governing habitual behaviour that the

influence of other attractors is silenced” (Mark Bonta and John Pretevi, 2004, pp.22).

Therefore, at a stratified level these events and assemblages are seen to be similar, with

similar issues and multiplicities. Such consistencies can be seen across a range of

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assemblages, including movements and social institutions (Mark Bonta and John Pretevi,

2004).

2.6. The Usefulness of Deleuze’s Toolbox in Regards to the MHC Services

As Deleuze “offers his philosophy as a toolbox of concepts to be used for practical ends”

(Tynan, 2008, pp.329), it can serve a number of purposes when applied to the MHC services.

Ultimately, it lets us understand the assemblages becoming and how the multiplicit issues that

are concerned with the quality of care of mental health patients have come about. In addition

to this, we can see how multiplicities have been actualised in the MHC services and what

influence this stratification has on other multiplicities in terms of attractants. An example of

this is the patients themselves. These patients may be stratified based on the homogeneity of

components that have territorialised in order for the patients becoming and thus, from this the

patient can be actualised (Mark Bonta and John Pretevi, 2004). In turn, this actualisation can

lead to habitual tendencies (Deleuze and Guattari, 1988), as other multiplicities such as

treatments may be homogeneous in accordance to this stratification.

In this way, using Deleuze’s toolbox will allow for the exploration of the intensities within

multiplicities and how balanced these intensities are. Such multiplicities to be explored in this

way are: the patient, the different bodies of the MHC services, the service spaces within these

bodies, treatments available for the patients and staff within the different bodies. By

exploring these components at lower levels, we can see how overall quality of care is

influenced by problems that arise due overpowering intensities that lead to habitual behaviour

(Mark Bonta and John Pretevi, 2004). Such problems include the psychiatric bed crisis.

Furthermore, the solution to the psychiatric bed crisis is often perceived from functionalist

and in turn, a reductionist approach. In previous literature great agency has been placed on

the role of the government and them simply underfunding the MHC services. Although this is

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a component of the mental health bed crisis, it is a multiplicity with a number of singularities

contributing to its becoming. Therefore, by implementing Deleuze’s toolbox in this way, the

idea of an external governing force is removed (Mark Bonta and John Pretevi, 2004) and all

dimensions of the bed crisis can be explored.

Finally, the stratification of assemblages and the application of measurements in the MHC

services can be assessed. Thus, we can see how striated and smooth spaces influence the bed

crisis and patient quality of care. From this we can denote where there is habitual striation

which has a negative impact on quality of care and vice versa.

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3. Methodology

3.1. The Reason for Using Qualitative In-depth Interviews

As a qualitative approach is useful for attaining perceptions and ideologies about a topic, for

this study such an approach was employed. The plight of the mental health bed crisis and

how it has come into being is intricate, taking place within different bodies of the NHS. It is

therefore important to establish several different viewpoints from participants who have

existed within these bodies, or have an extensive understanding about how processes and

people within these bodies interact with one another. Thus, a qualitative method was used

because it has “greater value in the identification of underlying causes, as well as the

understanding of processes” (Granot et.al, 2012, pp.547). Therefore, it is a useful way of

conducting a Deleuzean perspective, as this theoretical approach calls for the understanding

of processes and allows for a more phenomenological approach to be taken (Groenewald,

2004) when assessing the development of the service space and the mental health bed crisis.

To find such qualitative data, individual semi-structured in-depth interviews were conducted,

with the intent of allowing the participant to elaborate on points, with the bulk of the verbal

transaction flowing one way, from interviewee to interviewer. In doing so, the interviews

should “present comparative quality information” (Sofaer, 2002, pp.332), so that the answers

given by respondents can be compared and contrasted. This allowed for the expression of the

individual’s subject experience in the topic, which cannot be “viewed separately from the

multiple influences that have an attempt to unfold the meaning of people’s experiences and

increase understanding of the world from their perspective” (Lowes and Gill, 2006, pp.588).

Thus, we can unfold the multiple meanings of the MHC by interviewing a number of

participants in this way.

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However, there were key points that needed to be met in order to explore some of the issues

that arose in previous literature, therefore the interviews were kept semi-structured and the

same series of seven open questions were asked to each of the participants. Participants could

then give their perception on the previously discovered issues and elaborate further,

expanding on these issues and revealing their “subjective understanding” (Granot et.al, 2012,

pp.549). This is a vital part of understanding how these participants interacted with others and

processes, in the part of the MHC they existed or exist within, as their points of view

ultimately help determine what it is that creates the mental health service space.

This type of interview is also essential to the study as it is partially politically charged and

concerns the wellbeing of others, therefore rapport needs to be built between interviewee and

interviewer, which allows for openness and in turn a shared understanding of the answers

given (Rossetto, 2014, pp.483). A face-to-face interview allows for this rapport building as

the interview will be more personal, and such openness will result in a better understanding

of the participant’s meanings, emotions, experiences and relationships (Rossetto, 2014). Such

meanings and relationships will yet again elaborate on the processes within the MHC, and the

anecdotal retelling of experiences within these networks will reveal issues and emotions will

convey whether there are any issues in particular that these participants felt strongly about.

3.2. Participants

Overall, there were 8 respondents, who took part in the individual in-depth interviews. All

interviewees within the study were members of the Institute of Brain, Behaviour and Mental

Health or the School of Midwifery, Nursing and Social Work, at the University of

Manchester. Many of the participants in the sample are either currently working in the MHC

or have previously worked there, with roles ranging from senior members of the trust and

down the hierarchical structure. These roles include; clinical mental health nurse, non-

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executive director of the care quality commission, leader of the National Suicide Prevention

Strategy, honorary consultant psychiatrist and more. Thus, based on the expertise and

knowledge of these individuals, due to the combination of their research in association with

the University of Manchester and their experience with the employment in the MHC, the

sample chosen to take part in the in-depth interviews was purposive (Wilson, 2014) with the

intention of retrieving as much information possible about different areas of the MHC and to

attain an overall understanding of the processes that take place in the MHC.

3.3. Interview Ethics and the Reason for This

In addition, ethics had to apply to these interviews. When, conducting qualitative research

that concerns health and social sciences, researchers must “generate knowledge through

rigorous research and to uphold ethical standards and research” (Damianakis and Woodford,

2012, pp.708) In order to ensure the epistemological approach to be authentic and allow for

the information collected from the participants to be accurate (Damianakis and Woodford,

2012) the names of the participants are kept anonymous. In this way, the interviewees will be

willing to give answers without the others knowing the source of these answers. This allows

the participant to express what they believe to be true about the MHC and therefore these

alternative and accurate point of views will help direct the studies agenda from an ontological

point of view (Damianakis and Woodford, 2012)

What’s more, the anonymity of these participants is essential to their professional lives, as the

interviews were conducted within the same community. Therefore, the different participants

within the organisations are likely to know each other, and in fact, access to new participants

was acquired via recommendations of other participants. Due to the fact that the qualitative

answers given were anecdotal and of individual opinions, they are likely going to conflict

with one another in cases based on the viewpoint of the participant. In such small connected

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professional networks, there is a higher risk of confidentiality to be breached (Damianakis

and Woodford, 2012) therefore keeping anonymity based on not naming the participant in the

transcript and ensuring the participant are aware of this, is essential to protect the professional

reputation of these individuals and reassure them that their reputation will not be tarnished.

The in-depth interviews were all consented to by participants and they were allowed to

withdraw from the interview at any point, or refuse to answer questions. Again, this was to

ensure that the respondent felt confident in the interview and willing to answer the questions

within their comfort zone.

3.4. How Data was Analysed

In order to analyse the data retrieved from the interviews, coding was used to establish

themes that allowed for the comparison of the participants answers (Gibbs, 2007). To

establish these codes, all written recordings of the interview were taken, and transcribed into

one document where intensive reading (Gibbs, 2007) was applied to individual answers. This

was achieved by segregating relevant parts of answers and creating codes for these pieces of

information, whether they be individual words, sentences or sections of an answer. The code

applied to these pieces of information were initially descriptive about processes and reasons

in relation to the questions, and were also deciphered on the basis on what is deemed

important to discovering the sources of the mental health bed crisis, the interaction of

components in the MHC, the quality of care mental health patients received and issues that

are applicable to the conceptual side of the study. All of these issues were taken from

previously read literature and were applied to the interviews in order to extract a subjective

understanding of these issues.

These codes were then compiled into a list, and from this, recurrent ideas, throughout all

interviews, could be identified within the collated codes, forming analytical categorisations

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(Perrin, 2001) and allowing for the identification of themes and ideas that recurred in the

transcript (Perrin, 2001). These categories were conceived by looking at codes that could be

related topically and had an influence upon one another. Once the heterogeneous themes of

these relatable codes were discovered, the transcript was reread and what participants had to

say about these themes was found. These topical answers were found via observing the codes

they had previously been assigned, and thus could be related to the new categorisations

formed from these codes.

In all, seven categories were deducted from the transcript and these consisted of: Patient

Placement and Categorisation; Quality of Care; Procedural Insurance; Procedural Necessities;

Service limitations; Resource and Staff Management; and Evidence Based Treatment. All of

these aspects, as highlighted within the interviews, influenced the patient’s service space, as

well as the bed crisis and the anecdotal qualitative answers given by participants highlighted

how these themes contribute to this formation, from a phenomenological perspective.

3.5. Secondary Data

Secondary data was also used when conducting the study and this took the form of publically

published audits that had been conducted by organisations external of the NHS and focused

on the NHS in several regions across the UK. Such institutions are as follows; the

Information Service Division Scotland, Unify2 data collection, the Health and Social Care

Information Centre, and the Care Quality Commission.

Data from these sources made national trends in MHC accessible and comparable with the

qualitative data collected from the in-depth interviews. Thus, these pieces of information

were also assessed using the categories deducted from the interviews and the coding used in

the assessment of the transcript. In this way, quantitative data could be used to support the

viewpoints of the respondents to the study, or on the other hand comparisons can be drawn

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between the numerical data and the qualitative answers, which in turn increases the validity

of the data collected.

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4. Results

4.1. Patient Placement and Categorisation

All respondents suggested that patient categorisation and patient placement was a very fluid

process. Firstly, patients can be placed within two routes of care and these are primary and

secondary care. Primary care consists of first-line treatments that can be carried out by the

patient in the community and of their own accord, without any referral needed. Typically,

these include; visiting the GP, using medication, and visiting counselling and readily

available psychotherapies such as cognitive behavioural therapy (CBT). Patients who would

be placed in primary care are often categorised as having mild to moderate mental illness

such as depression, anxiety and OCD. In spite of this, a number of respondents expressed

their concern about categorising patients this way suggesting “mild to moderate mental

illnesses are inappropriately named, as they too can be deadly just as SMI is” (Interviewee 7).

Secondary mental health care exists generally for patients who are considered to have more

serious mental health problems such as bipolar disorder, schizophrenia and psychotic

illnesses and within secondary care patients can be further categorised and placed

accordingly. These categorisations include standard risk and enhanced risk and access to

routes vary with these categorise. Routes within secondary care consist of CMHTs, CRHTs,

EIS, and hospital admission and generally, people who are categorised as at enhanced risk are

hospitalised, whereas patients of standard risk are expected to follow the other community

based routes.

Although all of this suggests that patients are categorised and placed diagnostically, all

participants suggested that patients are indeed categorised and placed based on the severity of

whatever illness they have, thus displaying the fluidity of patient placement and

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categorisation. Therefore, categorisation in relation to diagnosis is habitual as certain

illnesses are perceived as of greater risk than others and these illnesses tend to be psychotic

illnesses.

As it is risk that is associated with the placement of patients within the MHC and not the

diagnosis of the patient, there are two pieces of legislation in place that assess the risk factors

of the patients and these include the Mental Health Act (2007) and the Mental Capacity act

(2007). Assessment in accordance with these acts can categorise the patient as either of

standard or enhanced risk and when a patient is categorised as enhanced, either section 135 or

section 136 will be used to detain the patient, where they will be admitted to a psychiatric

hospital.

There is however the notion of doctors trying to achieve a “level of genuine consent”

(Interviewee 3) with a patient who they believe should be hospitalised, yet they do not need

detaining under the Mental Health Act. These patients are known as informal patients and are

able to leave the mental hospital when they want. There is an issue with these patients being

allocated a bed however as patients who have been detained under the Mental Health Act

(2007) are prioritised beds and informal patients may struggle to be placed in a hospital bed.

To counter this though, respondents expressed that the majority of patients that are admitted

to psychiatric hospitals are formal patients and it was “rare for patients to be in a psychiatric

hospital if they had not been detained” (Interviewee 2). It was expressed that to even be

hospitalised the Mental Health Act (2007) or the Mental Capacity Act (2007) had to be used.

What’s more, formal patients tended to have quicker access to service routes and this is

generally perceived as a positive thing, as certain treatments for SMIs are dangerous, such as

the antipsychotic medications clozapine and olanzapine, thus these patients need to be

monitored closely.

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In spite of this, after assessing an audit released by the Information Service Division

Scotland, it was determined that from 2008 through to 2012, 84.6% of patients in psychiatric

hospitals in Scotland were informal. Therefore, the problem of finding a bed space for

informal patients may be a larger issue than anticipated by the interviewees.

2008 2009 2010 2011 2012

Male 83% 83.5% 83.7% 82% 81.8%

Female 86.5% 88.1% 87.2% 85.2% 86.2%

A further type of patient categorisation outside of all of these is circumstantial patients and

these patients are not likely to be placed anywhere within the MHC. These patients tend to be

“experiencing relationship issues that affect them emotionally, or they are intoxicated”

(Interviewee 7). These patients tend to experience a minimum liaison in which whatever

route to access they have gone to see, be this A&E or the GP, they will be assessed and if in

A&E may have an informal chat with a psychiatric nurse. In addition to this, there are often

documents handed to the patients known as HELP documents, which highlight psychotherapy

services available for them to access without the referral from A&E or the GP.

Interview participants did express concern with the disbarment of patients from these service

who first present when intoxicated. Often these patients are expected to have drink and drug

issues resolved before they are treated for any form of mental illness. This is problematic

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Figure 2: Percentage of adult patients within psychiatric hospitals in Scotland that were informal from 2008 – 2012

Source: Information Service Division Scotland (2012)


because “roughly 50% of people with mental illness will have a drink or drug dependency

and therefore services may be losing up to 50% of their clientele” (Interviewee 7).

What was unanimously agreed upon by all interviewees was despite patient categorisation

and placement, all patients do receive a thorough assessment based on risk factors and correct

decisions are made by doctors about the decision of where to place the patient. Yet, in spite

of this, there it was expressed that governmentality is an issue within the MHC, as

categorising patients and placing them has been seen as a source of funding in the past. The

example given of this was the previously used two tier care programme approach, where

patients received a standard and enhanced status. From this, patients were often moulded in a

way in which they were suitable for institutions such as CMHTs and with these organisations

receiving larger numbers of patients they would receive larger funds. Yet, after this was

recognised as an issue, the two tiered CPA was abolished and long term CPA is only

applicable to enhanced patients that are in secondary care.

4.2. Quality of Care

From the interviews it was established that there are four main factors that contributed to

quality of care for a MHC patient and these are patient comfort, correct patient placement,

correct staff allocation and treating the patient as a whole.

Firstly, patient comfort is essential to quality of care because it is important for the recovery

of the patient. If the patient is distressed during treatment, the recovery process is likely to be

slower, also the outlook of the treatment will likely be hindered. The comfort of the patient is

therefore achieved by the patient receiving the “least restrictive treatment” (Interviewee 3),

whilst at the same time having the lowest risk to themselves and others as possible. All

interview participants placed importance on the point that compulsory detention is a last

resort when it comes to treatment routes. Least restrictive care is taken into consideration

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from initial access to the MHC, at assessment when they first reach access points such as

A&E or GPs and the decision of patient placement will in turn feed into their comfort.

What’s more, least restrictive treatment allows for the patient to maintain an overall

satisfying lifestyle, which is again important for the patient’s recovery. Often patients express

that they prefer community based care, and doctors and psychiatrists acknowledge that family

and friend intervention is an essential part of the recovery process.

The notion of least restrictive treatment therefore feeds into the idea of treating the patient as

a whole rather than just treating the patient for the mental illness symptoms. Participants

expressed there are different aspects of the patient’s life that should be addressed to ensure

high quality care and collectively these are; physical health, mental health, social life,

finances and lifestyle. As most patients are socially resilient, it should be possible to address

these parts of their life by using community based treatment. However, it was the physical

health of the patients that was addressed mostly in the interviews when it came to quality of

care and the most pressing issue within this was the antipsychotic medication MHC patients

with SMI are on. Problems with such medication include: the alteration of metabolism and

brain chemistry; shutting down the part of the brain that registers that the stomach is full;

stimulating appetite; and sedative effects, which leads to patients not being able to exercise.

With these side effects comes metabolic diseases such as heart disease and diabetes. One

interviewee explained that as a result of this the “patients can put on up to five stone within

the first year of treatment on antipsychotics” (Interviewee 7). What’s more, the lifestyle of

these patients often contributes to poor physical health. For example, “70% of patients on

psychiatric wards smoke, and a large number of patients with mental health problems use

drugs or drink” (Interviewee 7).

Thus, to ensure quality care for the whole person, staff allocation is a large contributing

factor, as different staff should be present to address the different aspects of the patient’s life. 34 |

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4.3. Procedural Insurance

Procedural insurance within the MHC consists of the procedures that are in place to handle

uncertainty and reduce risk to the patient, or people around the patient. They help reinforce

decisions made by doctors and psychiatrists, by placing insurance upon these decisions. Two

forms of procedural insurance were made clear by the interviewees and these were; pre-

emptive procedural insurance and follow-up procedural insurance.

Pre-emptive procedural insurance takes place at the assessment of the patient and is

concerned with the placement of patients. For example, this assessment may be the triage

process when the patient first presents at A&E and is assessed by front-line teams such as a

mental liaison team. Procedural insurance that can be used by staff at this level mainly

consists of patient categorisation in association with risk, that is standard or enhanced

patients, and from this, placement ensures risk is reduced. In addition, as all patients go

through this thorough assessment process before categorisation, it is also ensured that no

patient is missed out when they require treatment within the MHC, or that people receive

treatment unnecessarily. There is also legislation in place during the assessment process that

forms an outline for these decisions to be made. In terms of legal categorisation of a patient,

there is the Mental Health Act and the Mental Capacity Act (2007), which reduce the

uncertainty of the decisions made by staff. This is because within these pieces of legislation

there are criteria that measure the patient’s categorisation.

Follow-up procedural insurance is in place to insure the pre-emptive procedural insurance

and is concerned with the possibility of the wrong decision being made at assessment and

increasing the likeliness of risk to the patient or others. Occasionally, “if patients are not

referred to part of the MHC, they may be asked to meet with primary health care services if

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their condition does not improve” (Interviewee 3), thus allowing for further assessment,

primary health care treatment, such as medication, and the correct alternative placement if

need be. In this way, procedural insurance is also partially the responsibility of the patient, as

resilient patients and patients of mental capacity are deemed as able to assess their situation

and retrieve treatment when necessary.

Procedural insurance may also fall upon the responsibility of other “people who are in close

contact with the patient, such as family members” (Interviewee 8). Often, the decision to

detain someone under the Mental Health Act (2007) will take into consideration if there are

family members at home to care for the patient, as these people will be of greater resilience to

assess the person’s condition. If they therefore deem further assessment is necessary, “the

patient can be brought back to hospital” (Interviewee 5).

In addition to pre-emptive and follow-up procedural insurance, there is also procedural

insurance surrounding the physical health of mental health patients. Again this takes the form

of assessment and monitoring. Physical health concerned with medication, this being the

main issue of physical health, is procedurally insured with pre-emptive blood glucose and

blood pressure tests. From this staff can decide whether to place a patient on anti-psychotics,

or whether they are at too greater risk. The MHC therefore uses procedural insurance in

attempts to prevent further physical comorbidities.

4.4. Procedural Necessity

Procedural necessity considers tasks that must be carried out, yet have some element of risk

to them. The necessity of these procedures therefore looks at the opportunity cost of carrying

them out and making the correct decision, based on the lesser risk or the greater quality of

care for the patient.

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Firstly, there are occasions when the notion of least restrictive treatment must be abandoned,

as more restrictive treatments may be a necessity for patients who lack the motivation to get

better, or are too cognitively impaired to recover on their own. The most restrictive form of

access to the MHC, as expressed by interview participants, is police use of the Mental Health

Act and Mental Capacity Act (2007) where the “patient would be directly transported to a

mental health ward” (Interviewee 7). Otherwise, compulsory detainment on its own was

perceived by interviewees, as restrictive. The cost of this, as previously mentioned, is patient

distress, prolonged illness and in turn, reduced quality of care. However, the risk of not

carrying out restrictive procedures in these cases, is deemed to be greater than the risk of

employing them, as in not doing so increases the likelihood of harm to oneself or others in the

community. As a precursor of this, all interviewees expressed that there will always be a need

for mental health wards and community mental health services cannot replace these services.

In contrast with this, participants also expressed the necessity of sending people home who

do not need to be detained under the mental health act. It was explained that detaining

patients unnecessarily would worsen the mental health bed crisis and take spaces from

patients for which hospitalisation was necessary. It’s highlighted that the follow-up

procedural insurance will alleviate the risk of this anyway and makes it possible to carry out

this procedural necessity.

With the consideration of restrictive treatments and the necessity of sending people home, a

further necessity is highlighted and that is the prioritisation of hospital beds in psychiatric

wards. Patient categorisation feeds into this prioritisation, as “patients that are at enhanced

risk will be prioritised a bed over patients that are of standard risk” (Interviewees 1&7). This

contributes to issues for patients that are informally admitted as they could be “sent home for

a period of up to 48 hours” (Interviewee 1), in which time risk may be perceived as high and

procedural insurance needs to be implemented in order to reduce the risk. However, with this 37 |

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the opportunity cost is measured on the basis of these categorisations and to physicians and

psychiatrists, enhanced patients that have been detained need immediate access to beds and in

turn faster access to routes. This is because they will have an increased amount of cognitive

impairment and are unlikely to make rational choices.

Although the process of prioritisation seems a rigid process based on patient categorisation,

psychiatric evaluation allows for the process to become more fluid. This evaluation allows for

patient history to be taken and from this it can be determined whether relapse is inevitable or

preventable. Thus, patients that are of high mental capacity at that moment, but are inevitably

going to fall into relapse, will be prioritised a bed also. Therefore, bed prioritisation is fluid as

it can be patient variable.

Bed prioritisation also is associated with medication, as rigorous and regular testing may need

to take place and a hospital environment. In addition to this, the prescribing of these

medications are seen as a procedural necessity in themselves, as they pose high risk to

patients. Despite these risks, the mental illness symptoms are seen to cause more threat to life

than the physical implications of the medication and all interviewees agreed that it is essential

for patients with psychotic symptoms to be on this medication.

Overall, procedural necessities are in place to reduce risk to the patient and are implemented

via patient evaluation, highlighting the opportunity cost for the patient in situations where

these necessities need to be applied. Therefore, procedural necessities contribute to the

quality of care for patients, although they may initially be seen to influence this quality of

care negatively, especially from the patient’s point of view.

4.5. Resource and Staff Management

Resource and staff management takes place throughout the MHC and different stages of the

patient’s treatment. Gatekeeping services in the MHC play a large part in resource 38 |

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management and often focus on patient placement in accordance with providing the correct

patient with the correct resources and staff. When it is deemed necessary for a patient to have

a bed in a psychiatric ward, the responsibility of correctly placing the patients falls into the

hands of the bed management system, where it is determined if and where these patients can

be placed in a psychiatric ward. With this “regional factors and busy periods contribute to the

placement of the patient” (Interviewee 6), as different areas in the country will have different

levels of demand at one time. This being a basis of patient placement, lies in conflict with

other contributing factors such as ensuring the least risk possible to the patient, along with

patient comfort and thus, patient quality of care. This is because if psychiatric wards are too

busy to hold the new patient, the length of time between assessment and admission to a

hospital is prolonged, giving a larger window of opportunity for the patient to be at risk. In

addition to this, if the patient has to be moved to another region based on bed availability,

patient comfort is jeopardised as long journeys at a time when the patient is most vulnerable

and in crisis can be further damaging to the patient’s mental health. What’s more is when

patients are placed far away from family and friends, this causes further discomfort.

Gatekeeping to psychiatric wards may also take place in other parts of the MHC. Taken from

audit data published by Unify2 Data collection (2016), an average of 97.8% of patients

admitted to psychiatric wards, from years 2010 through to 2016, were gate kept by CRHTs.

As explored in previous literature, this too can be perceived as damaging to the patient’s

quality of care, because it prolongs the time when the patient is placed incorrectly and

receiving the wrong treatment.

In addition, interviewees highlighted that resource and staff management plays an important

role in the physical health of mental health patients. Participants elaborated that it was not

resources that were problematic when treating psychiatric in-patients with physical

comorbidities, rather it was issues to do with staffing. As, “psychiatrists are only variably 39 |

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trained in physical health conditions” (Interviewee 4) and only have the resources available to

detect physical health conditions as opposed to treating them, often patients will have to be

admitted to general hospital. This is worsened by the physical health conditions related to

antipsychotic medication a large amount of patients with SMIs are on. This has implications

for staff and the staffing available on psychiatric wards, as often when a patient is admitted to

a physical health ward it is a legal requirement that a mental health nurse or member of staff

joins the patient, which is attributable to staff shortages on psychiatric wards. Alternatively,

physicians can visit psychiatric wards to tend to the patient, yet this is an inefficient way of

caring for the patient as it takes up a large amount of the doctor’s time and the resources may

not necessarily be available on the ward for the correct treatment to be carried out.

Ultimately, this leads to conflict between doctors and psychiatrists about who should be

monitoring physical health conditions in the first place.

In spite of staff management as being seen as the main issue when treating psychiatric

patients for physical morbidities, resource management proves problematic when readmitting

a patient to psychiatric ward after they have been on a general hospital ward for a period of

time. With psychiatric beds being scarce, they will “often be filled very quickly when a

patient is transferred to a general ward” (Interviewee 3), highlighting that the psychiatric

wards are working at 100% capacity. This creates barriers to re-entry to the psychiatric ward,

which again is problematic for the patient’s mental health and will cause patient discomfort

for a prolonged period of time.

Interviewees also highlighted similar staffing issues that occur in the community setting.

These issues contribute to how overstretched CMHTs are, which influences the quality of

care staff are able to give within a this setting. “With individual community staff members

having to care for a large number of patient, it is difficult for them to provide the holistic care

that is readily available in hospital settings or the previously used asylum based care” 40 |

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(Interviewee 1). In such places, a similar number of staff are able to watch over numerous

patients simultaneously, whereas in a community setting, “on average, one member of staff

will be expected to look after up to 45 patients” (Interviewee 1), making the upkeep of

quality care difficult.

Participants also explained that the expectation of staff to care for a number of patients in this

way has contributed to the bed crisis in an accumulative fashion. This is because when

originally introduced, CMHTs had the staff available to care for the quantity of patients,

which would alleviate psychiatric bed spaces to a certain extent. However, over time, cost

cutting was taken too far in regards to community mental health, as it was deemed a viable

way to continue cutting beds and thus, an unsustainable amount of patients with illnesses

unsuitable for community care, were diverted down these pathways. In addition to this, the

highly skilled psychiatrists that were originally placed in community care were moved to

other parts of MHC and the staff that replaced them were deemed as being of lesser skill to

certain interviewees. Thus, the service went from being seen as a highly specialised service,

able to cope with patients with SMI, to a generic service, dealing with a wider range of less

severe mental illness.

Overall, all participants said, cost cutting, resource management and staff management were

highly important to the service. This is because there needs to be an amount of economic

sustainability in order for the MHC to continue functioning, however it needs to be balanced

with producing the best outcome in terms of quality of care.

4.6. Service Limitations

There are numerous service limitations when MHC is assessed at its micro-foundations,

however, interviewees were able to elaborate on the holistic contributing factors to all of the

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limitations within different bodies. These overall limitations are: the lack of flexibility in the

entire MHC services, and services that don’t mesh well.

Flexibility was referred to by participants in terms of the ability to alter the capacity of the

service spaces in order to meet demand, as well as being able to the same with the staff

available. This was an underlying theme in both community care and in psychiatric hospitals.

The ability to alter these aspects were important due to periodic increases in demand for

service spaces and this change often took place in accordance with annual seasons.

Interviewees expressed that the service will go through busy periods and these periods took

place around festive seasons and the winter months. At this time, it is difficult to meet

procedural necessities, as there is not enough capacity to allow for the fluid carrying out of

tasks that cannot be overlooked, such as admitting a patient to a psychiatric ward in a given

period of time. In addition, the duration of a patient’s crisis is variable in relation with that

particular patient and thus it is “impossible to predict the amount of time a patient will spend

using the service” (Interviewee 3). Therefore, forecasting cannot be carried out to assess

when service spaces will open up to new patients.

With this comes the idea of services not meshing well and the main services said not to mesh

well were community based services and psychiatric hospitalisation. This is because, in

relation to capacity, there is the expectation of community based treatment, to increase this in

psychiatric hospitals, by decreasing demand for their use. In spite of this, community based

treatments are, themselves, over-stretched in terms of capacity, as staff cannot cater for the

large quantity of patients they are expected to. Thus, community based treatment cannot

serve its purpose of increasing capacity in psychiatric hospitals and the services don’t fit with

one another.

4.7. Evidence Based Treatment

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A number of interviewees explained that these limitations coincide with the funding of

services and service outcomes that are not based on evidence. For example, the

implementation of CMHTs was said to have a flawed imperative from the start, as “it was

underfunded and under researched” (Interviewee 4) and therefore it was not known whether

this service was able to alleviate bed spaces in psychiatric wards when it was introduced. This

lack of research also means that professionals don’t know how effective the treatment from

CMHTs is, or whether it bodes well for the patient’s outlook. This outlook seems to be

negative considering that 97.8% of patients in psychiatric hospitals are referred straight from

community services, thus these services cannot meet their needs and are not effective. In

addition to this, of recent times there is a lot funding going into these services without the

research, which could contribute to the problem worsening.

Instead, it’s expressed that services and treatments should be evidence delivered and cost

analysed, considering their long-term implications. One such example of services is EIS,

which has researched a number of aspects of the patient’s life which contribute to faster

recovery, such as, social interaction, employment and therapy. Therefore, there is evidence

that supports that EIS are beneficial for patients.

Furthermore, these services are cost analysed and focus on long term savings, via the

reduction of demand for psychiatric beds. It has been made evident that by focusing on stage

specific elements of the illness and catching it early, relapse is preventable. Therefore, “the

implementation of these evidence based services may cost in the short term, yet they propose

long-term savings” (Interviewee 7).

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5. Discussion

5.1. The Patient’s becoming and their Stratified Categorisations within MHC

The patients becoming can be seen in striated space as it is actualised, stratified and measured

(Mark Bonta and John Pretevi, 2004) in terms of risk. Patient stratification and the

measurement of risk is a component that forms patient placement and with differing

measurements in striated space, the patients becoming will deterritorialise, following a new

line of flight and reterritorialise with different multiplicities (Deleuze and Guattari, 1988)

within patient placement. For example, when risk is measured as high, the patient will

reterritorialise in a new assemblage such as a psychiatric hospital, where the patients

becoming can then be stratified as that of a psychiatric patient.

Issues arise when this process becomes overly striated (Malins, 2004) and the measurement

of risk exists within an assemblage where patient diagnoses has a greater intensity. With this

patient placement goes through rhizomatic change and becomes habitual in relation to

diagnostic components. Thus, the component of risk becomes overpowered by the intensity

of diagnostic, proving problematic for a number of reasons. Firstly, in such an assemblage,

diagnoses are stratified and measured, for example, there is the notion of mild to moderate

illnesses such as, OCD, depression and anxiety (interviewee 7). However, the severity of

these illnesses could be perceived as of just as greater risk than illnesses that are measured as

severe, such as psychotic illnesses, as they too can pose just as much risk to a patient’s life.

Therefore, when patient diagnoses are perceived in smooth space, it highlights the potential

for all stratified illnesses to become of higher risk, which allows for the formation of an

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assemblage where risk prevention is of a greater intensity and procedural necessities can be

employed.

In addition, when patient placement reterritorialises with an assemblage where diagnostics

are of a higher intensity than risk the patient may be misplaced within the MHC services.

This is because with the diagnosis being the most intensified component of patient placement,

all multiplicities within that assemblage will be less homogenous. With other components

within the assemblage of patient placement, such as procedural necessities, and resource and

staff management being more homogenous with risk’s line of flight, the use of these

components within the assemblage may be hindered or incorrectly used. For example, the

notion of least restrictive treatment (Interviewee 3) may be overpowered, as it worked

alongside the idea of people who are at less risk having the ability to be placed within least

restrictive treatments. Thus, when diagnostics are the stratified measurement that overpowers

the measurement of risk, people who do not need to be placed in restrictive settings in terms

of risk, may be placed there, taking up valuable resources. Such a restrictive setting is a

psychiatric ward and the resources used include bed spaces. Therefore, the overly striated

perception of patient categorisation and placement may contribute to the psychiatric bed

crisis.

Patient placement in association with diagnostics, contributing to an assemblage that can be

stratified as problematic in accordance with patient risk, is supported by the Royal College of

Psychiatrists study which states that doctors have had to use the Mental Health Act (2007)

inappropriately, to secure a bed for patients in psychiatric wards (Buchanan, 2014). Thus,

with the over-striation of patient categorisation, procedural necessities also follow a new line

of flight and become homogenous with other multiplicities within patient placement that can

be stratified as problematic. When looking at this problem in the realm of the actual, it is

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suggested that using the Mental Health Act in such ways has a negative influence on patient

outlook and recovery, due to their discomfort (Buchanan, 2014).

On the other hand, procedural necessities being used in such a way show their multiplicit

nature and their ability to be applied smoothly. The issue is that the overly striated perception

of patient categorisation in accordance to diagnoses is attracted to the multiplicity that is the

bed shortage and this may have a stronger intensity than the reterritorialised procedural

necessities and although these necessities are applied smoothly, there is the lack of resources

in the assemblage of psychiatric bed hospitalisation, with all of these components

contributing to its becoming.

Furthermore, the fluidity of patient placement, when the intensity of risk is greater than the

intensity of diagnosis, is also evident when patients are stratified as formal or informal

patients. It makes clear smooth access to psychiatric hospitalisation and as a desiring machine

(Deleuze and Guattari, 1988) informal admission is attracted to fast recovery, which in turn,

exists in a multiplicity where there is more bed space capacity in psychiatric hospitals.

However, again the notion diagnosis related categorisation may have a stronger intensity

within the multiplicity and occurs alongside bed shortages. Thus, it may be difficult to

allocate informal patients a bed and with the majority of in-patients being informal in certain

regions of the UK (Information Service Division Scotland, 2012) the intensity of the bed

crisis increases.

To make matters worse, striated categorisation is perceived by some as a way to alleviate the

bed crisis. Stratified as governmentality (interviewee 7), measurements are applied to the

number of patients that exist within different bodies of the MHC services and associated with

increased funding and resources. Although these components may be heterogeneous with one

another, they should be not considered from a minimalist notion where there is cause and

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effect. However, regardless of risk, patients have been directed to different areas of the MHC

services in association with a diagnosis, in the hopes that more resources and funding will be

received in accordance with the higher number of patients. Not only is the intensity of striated

categorisation increasing in this way, but the minimalist notions ignore the other components

in the MHC services that contribute to the shortage of resources.

5.2. The Virtual patient

With the understanding that there are stratified issues when it comes to the physical health of

mental health patients and the treatment for physical comorbidities (Lally et.al, 2015),

Deleuzean philosophy can be used to explore the patient at their micro-foundations in order

to assess what multiplicities territorialise to form their becoming. From this, it can also be

seen that the deterritorialisation and reterritorialisation of these multiplicities contribute to

stronger intensities of their lines of flight. With the imbalance of these intensities comes the

issues that have been actualised. Thus, to see the becoming of these stratified issues, we must

take the patient out of the actual and perceive them in the virtual, where singularities and

contributing factors can be seen (Mark Bonta and John Pretevi, 2004).

It is clear from the interviews that there is a strong need to treat the patient as a whole

(interviewee 2) which can be a contributing component to lessened intensity of suboptimal

treatment for physical comorbidities, when its line of flight is more intense. At the same time,

it is also a multiplicity territorialised with the potential for fast recovery, in terms of their

mental health. In this perception of the patient in smooth space, it is clear what components

currently contribute to the mental health patient’s becoming and the multiplicities that have

the strongest intensities within this becoming are; physical health, mental health, social life,

finances and lifestyle. It is also clear that these multiplicities are heterogeneous, existing as

attractants in near equilibrium (Mark Bonta and John Pretevi, 2004). However, it is also clear

47 | P a g e


that these components may territorialise together to form these issues in the NHS. For

instance, there is the notion of drinking, drug abuse and smoking, which contribute to the

multiplicity of lifestyle and are considered to be also habitually territorialised with mental

health. Mental health is a multiplicity that can also exist within the assemblage that is treating

mental illness, however, also within this assemblage there may be the component of

antipsychotic medication, which is strongly attracted to physical health and the multiplicities

that contribute to its becoming.

There are two of these components that have a tendency for stronger intensities than the

others, when as a multiplicity, they reteritorrialise with assemblages that can be stratified as

medical and these are ‘mental health’ and ‘physical health’. Both together are multiplicities

within the NHS, however these multiplicities aren’t as heterogeneous as one would expect.

This is because, whilst at the same time as being a multiplicity of the patients becoming, they

can also be a multiplicity of the treatment the patient receives and when in the MHC services,

the intensity of mental health may have the tendency to increase and overpowers physical

health, whereas in general health services the opposite tendency may occur.

In this way, it is clear that the treatments within the MHC services and general hospital can

be homogenous, with the near equilibrium state being stratified as problematic. One example

of this is this use of antipsychotic medication as a treatment in the MHC services, which can

be seen to have a stronger intensity than the physical health of patients, where SMI with

psychotic symptoms is a contributing factor. However, this treatment may be actualised as a

procedural necessity, which in itself, exposes a heterogeneous stratification within MHC

services and general hospital, and that is risk reduction. In striated space, risk reduction is

actualised and measurable (Mark Bonta and John Pretevi, 2004), where the highest measure

is seen as preferable. But, in virtual space, risk reduction is a multiplicity which can be

territorialised with both the assemblages; MHC services and general hospital. With the 48 |

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tendency for highly intense risk reduction in both services, there it may outweigh other

multiplicities that exist within the assemblages and this may not only be treatments that are

offered, but also patient risk, which is a multiplicity that can be territorialised with both

assemblages and the virtual patient. Yet again, patient risk can also be stratified and measured

in striated space, where the lowest measure possible is preferable and with the striated space

being viewed in this way, along with the reterritorialisation of procedural necessities, risk

reduction can have a higher intensity in the virtual.

What can be taken from all of this is that the NHS services can be overly striated when it

comes to treating the patient as a whole, however it can also be overly smooth. When the

services are too striated, there is potential for the bodies of the NHS to be too focused on

patient components, as singularities in each multiplicity becoming attracted and forming a

becoming that can be stratified as problematic. Yet if perceived too smoothly, where patient

components are not understood in a stratified way, they may not reterritorialise with any part

of the NHS services, and the virtual patient will be too chaotic (Deleuze and Gattari, 1988).

As stratified by the interviewees, the different components of the patients that can be

considered so that the quality of care is at near equilibrium, and where in striated space it is

measured as preferable, are the five patient components that are previously mentioned;

physical health, mental health, social life, finances and lifestyle.

At this level of striation when the patient is stratified in space, there may also be potential for

staff in the MHC services and general hospital to be viewed in similar space. As interviewees

expressed, the main problem when treating patients for physical comorbidities is staff and

resource management. Conflict between staff arises alongside confusion as to who should be

carrying out certain treatments, for example, the physical monitoring of mental health

patients (Behan, 2014). When multiplicities that contribute to the becoming of staff are

viewed in the same striated and smooth space as the patient, where staff can be viewed as 49 |

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multiplicities, they may have a desiring machine (Deleuze and gattari, 1988) that has habitual

occurrences similar to the multiplicities that make up the patient. Thus, there is potential for

other attractors to be silenced (Mark Bonta and John Pretevi, 2004), such as the confusion as

to who should be carrying out the procedures. Therefore, with the multiplicities that

contribute to the patients becoming having the potential to be heterogeneous with the

treatment they receive, and staff being a multiplicity within the assemblage of treatment

received, when the intensity of the five stratified patient components increases, it may silence

other actors in all multiplicities.

Furthermore, this notion is applicable to resources and staff quantity. With interviewees

expressing that the services aren’t flexible enough to meet patient needs, it is clear that they

are looking at the issue from a minimalist point of view, as staff quantity and resources such

as funding, are, like everything, multiplicit in nature and can be looked at in the virtual, along

with the virtual patient. From this, we know there is potential for the components of the

patient to reterritorialise with staff quantity and resources, and there is also potential for these

components to have a higher intensity than other multiplicities within these assemblages.

5.3. The Derealisation of Time

Stratified in the actual as a symptom of anxiety disorder, derealisation is defined as subjective

experiences of unreality of the outside world (Hoyer et.al, 2013). Deleuzean philosophy may

suggest, that rather, the person is not looking at the world in terms of familiar stratification.

Similarly, this can be applied to time by considering it outside of the actual, where it is not

measurable; instead, time is considered in the virtual via the becoming of an event (Mark

Bonta and John Pretevi, 2004).

The perception of time is beginning to become more smooth in the MHC when treatment is

stratified in accordance with virtual time. In this case, time is being perceived in terms of the

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becoming of the patient, and the becoming of their illness. With this, treatment in relation to

the patients becoming is understood better. Attracted to this are the multiplicities that are

faster recovery, better patient outlook and capacity in psychiatric wards. The evidence for this

occurring is the use of stage related treatments such as the use of EIS. What these services do

in terms of time is they consider what stage the illness is at, thus they are assessing its

becoming in relation to the event that is occurring and in turn it is actualised and stratified.

By stratifying the event rather than time, EIS are able to focus on the event and are

themselves a multiplicity that reterritorialises within the becoming, with the hopes of having

a stronger intensity than other multiplicities within that event which contribute to the

becoming of the illness.

When interviewees referred to EIS being an evidence based treatment, it is clear that they

were stratifying the habitual tendencies of these services when they are connected to the

becoming of the illness. This stratification elaborated that there is a tendency for EIS to have

a stronger intensity than other multiplicities within the illness and this intensity increases

when it is also connected with other components, such as research. Thus, although it is

recognised that no two events are the same, and the implementation of EIS is not full proof,

their line of flight when research is connected is more intense.

What’s more, the stratification of these tendencies and the recognition of intensities has

helped the reterritorialisation of time, within the MHC, where it’s becoming is not measured

in the short term, but rather as long term versus short term. In this way it is possible for

measured time as a component to be attracted to EIS services as an assemblage, and it

reterritorialises and is also an attractant of positive patient outlook, which in turn can be

connected to bed capacity in psychiatric ward. This is because long term positive patient

outlook has a tendency to have a strong intensity when connected to EIS, which can silence

the multiplicity of demand for psychiatric beds in that assemblage. 51 |

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In addition, when interviewees looked at the short comings of community based care

suggesting it was an idea that was taken too far, it is clear that when EIS isn’t a multiplicity

connected to the MHC, there is an overly striated focus on stratified short-term time in

relation to events. This is because, in terms of actual time there are no considerations for the

measurable future when looking at psychiatric bed reduction in relation to community based

treatments. What’s more is a very minimalist approach was taken with the introduction of

community mental health services, looking at it with the notion of cause and effect; this being

that the introduction of CMHTs would reduce the demand for beds. Instead, a preferable way

of approaching it is considering the intensity of the line of flight of community based

treatment and understanding that this can change and components of it can deterritorialise

and reterritorialise (Deleuze and Guattari, 1988), just as it can in EIS. However, this would be

a smoother perception of time that can be stratified to consider long-term events.

When time is stratified in this way, components in service limitations can be silenced, such as

services not meshing well. These may not have meshed well due to minimalistic expectations

of cause an effect, where other components in the multiplicities have not been considered.

Thus there, is the need for all services to be viewed more smoothly.

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6. Conclusion

6.1. Space

The fundamental answer to the research questions posed in the introduction of this

dissertation seems to lie with the multiplicities becoming in different space, along with

tendencies within the MHC services and the entire NHS, which mean these multiplicities are

habitually perceived in striated and smooth space. In this way, the components becomings

take place in different space, and multiplicities selected for this study are habitual attractors

to the psychiatric bed crisis and are often reterritorialising with it as a multiplicity. It is clear

that within this multiplicity, poor quality care can have a strong intensity, which silences

other multiplicities such as good patient outlooks. Such multiplicities that have

reterritorialised with poor quality care and have made it stratifiable at a near equilibrium

point are: poor quality physical care and poor patient placement, and what multiplicities that

contribute to these have been explored too.

The way in which patients are categorised can be beneficial when it relates to the service

spaces available to them. However, these categorisations have a tendency to be overly

striated, and based upon diagnostics. When the patients becoming takes place in smoother

space and is restratified to a componentry level and the services available within MHC are

attracted to this, beneficial patient placement can reach a near equilibrium point and the

patient can be treated holistically. With this it is possible for the line of flights of fast

recovery can be more intense and silence other components that contribute to the patient’s

illness. In turn, when connected to the psychiatric bed crisis, this component exists alongside

increased bed capacity, and this may intensify.

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Although when the patient’s becoming is explored via the multiplicities that are connected

within it, striation is important in this way. Without striation where the components of the

mental health patients can be actualised, these components cannot not be recognised. As

elaborated on by interviewees, the components that are being explored to allow for a more

holistic view of the patient and in turn allow for holistic care to be perceived are: physical

health, mental health, social life, finances and lifestyle. On top of this, risk can be measured

in striated space, yet is less striated than measuring the patient diagnostically and within this

stratified multiplicity lies patient placement. When stratified in this way, patient placement

can be perceived in the actual as beneficial and a contributing factor to high quality care.

Also, in this case, the perception of processes has been explored in connection to time and

this times becoming in different spaces. When time exists in smoother space, where it can be

measured against processes and events rather than being a measure itself, other multiplicities

can be seen in this case and their becomings can be explored. One example offered up is the

becoming of the patient’s illness and in this way, the illness can be treated in association with

the multiplicities that contribute to it. This has a tendency to be connected to improved

patient outlook and in turn, psychiatric bed capacity, as time is restratified as long-term

versus short-term.

6.2. Going Forward

To improve research in this area, there are a number of alternative ways to carry out data

collection. Due to time constraints with this study, the size of the sample for the in-depth

interviews could have been larger and in future studies this should be considered. With this, a

larger range of anecdotal qualitative data can be collected, thus allowing for a greater range

of perceptions when it comes to the issues at hand. In turn, this could allow for a more in

depth analysis from an ontological perspective.

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Furthermore, a larger timeframe may allow for qualitative data to be collected from front-line

staff who currently work in the MHC full time. This is because time restraints prevented the

corrected documentation from being submitted, which allowed access to these front-line staff.

These staff may have had alternative opinions to offer that would be considered in further

research.

In addition to the qualitative data, some of the quantitative data may have been too regional

specific and in turn, not representative of the entire population of the UK. This may have

rendered the data less valid to the study and in future the research could either focus on the

issues based on region or further national data could be retrieved.

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7. Bibliography

1. BBC, (2016). Britain's Mental Health Crisis. [video] Available at:

http://www.bbc.co.uk/iplayer/episodes/b006t14n?page=2 [Accessed 28 Oct. 2015].

2. Behan, C., Doyle, R., Masterson, S., Shiers, D. and Clarke, M. (2014). A double-

edged sword: review of the interplay between physical health and mental health. Irish

Journal of Medical Science (1971 -), 184(1), pp.107-112.

3. Birchwood, M., Connor, C., Lester, H., Patterson, P., Freemantle, N., Marshall, M.,

Fowler, D., Lewis, S., Jones, P., Amos, T., Everard, L. and Singh, S. (2013).

Reducing duration of untreated psychosis: care pathways to early intervention in

psychosis services. The British Journal of Psychiatry, 203(1), pp.58-64.

4. Bonta, M. and Protevi, J. (2004). Deleuze and geophilosophy. Edinburgh: Edinburgh

University Press.

5. Boudon, R. (2003). Beyond Rational Choice Theory. Annu. Rev. Sociol., 29(1), pp.1-

21.

6. Buchanan, I. (2000). Deleuzism. Durham, NC: Duke University Press.

7. Buchanan, I. (2016). Patients sectioned 'because of pressure on beds' - BBC News.

[online] BBC News. Available at: http://www.bbc.co.uk/news/uk-27656241

[Accessed 25 Nov. 2015].

8. Chady, S. (2001). The NSF for mental health from a transcultural perspective. British

Journal of Nursing, 10(15), pp.984-990.

9. Connor, S. (2011). Structure and agency: a debate for community

development?.Community Development Journal, 46(Supplement 2), pp.ii97-ii110.

56 | P a g e


10. Damianakis, T. and Woodford, M. (2012). Qualitative Research With Small

Connected Communities: Generating New Knowledge While Upholding Research

Ethics. Qualitative Health Research, 22(5), pp.708-718.

11. Data.gov.uk. (2016). Datasets. [online] Available at: https://data.gov.uk/data/search?

tags=mental-health [Accessed 29 Apr. 2016].

12. Deleuze, G. and Guattari, F. (1988). A thousand plateaus. Minneapolis: University of

Minnesota Press.

13. England.nhs.uk. (2016). Statistics » Mental Health Community Teams Activity.

[online] Available at:

https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-

community-teams-activity/ [Accessed 28 Apr. 2016].

14. Gangaram, P. and Kumar, P. (2008). The use of section 5(2) of the Mental Health Act

1983: an audit. Medicine, Science and the Law, 48(2), pp.151-154.

15. Gibbs, G. (2007). Analyzing Qualitative Data. London: Sage Publications Ltd, pp.38 -

56.

16. Gov.uk. (2014). Mental Health Taskforce announced - News stories - GOV.UK.

[online] Available at: https://www.gov.uk/government/news/mental-health-taskforce-

announced [Accessed 2 Apr. 2016].

17. Gov.uk. (2016). New investment in mental health services - News stories - GOV.UK.

[online] Available at: https://www.gov.uk/government/news/new-investment-in-

mental-health-services [Accessed 16 Feb. 2016].

18. Gov.uk. (2016). Prime Minister pledges a revolution in mental health treatment -

Press releases - GOV.UK. [online] Available at:

https://www.gov.uk/government/news/prime-minister-pledges-a-revolution-in-

mental-health-treatment [Accessed 26 Apr. 2016].

57 | P a g e


19. Granot, E., Brashear, T. and Cesar Motta, P. (2012). A structural guide to in‐depth

interviewing in business and industrial marketing research. Jnl of Bus & Indus

Marketing, 27(7), pp.547-553.

20. Green, B. and Griffiths, E. (2014). Hospital admission and community treatment of

mental disorders in England from 1998 to 2012. General Hospital Psychiatry, 36(4),

pp.442-448.

21. Griffith, R. (2014). Mental capacity and mental health Acts part 1: advance

decisions.British Journal of Nursing, 23(14), pp.812-813.

22. Griffith, R. and Tengnah, C. (2012). Deprivation of liberty: the Mental Health Act or

the Mental Capacity Act?. Br J Community Nursing, 17(12), pp.640-643.

23. Groenewald, T. (2004). A Phenomenological Research Design Illustrated. The

International Journal of Qualitative Methods, 3(1), pp.42 - 55.

24. Gunson, J., Warin, M., Zivkovic, T. and Moore, V. (2014). Participant observation in

obesity research with children: striated and smooth spaces. Children's Geographies,

14(1), pp.20-34.

25. Hodgson, N. and Standish, P. (2006). Induction into Educational Research Networks:

The Striated and the Smooth. Journal of Philosophy of Education, 40(4), pp.563-574.

26. Hoyer, J., Braeuer, D., Crawcour, S., Klumbies, E. and Kirschbaum, C. (2013).

Depersonalization/derealization during acute social stress in social phobia. Journal of

Anxiety Disorders, 27(2), pp.178-187.

27. Hpft.nhs.uk, (2015). Acute Services. [online] Available at:

http://www.hpft.nhs.uk/our-services/acute-services/ [Accessed 3 Dec. 2015]

28. Hscic.gov.uk. (2016). Find data - Health & Social Care Information Centre. [online]

Available at: http://www.hscic.gov.uk/searchcatalogue?

58 | P a g e

http://www.hpft.nhs.uk/our-services/acute-services/


productid=20074&topics=0%2fMental+health&sort=Relevance&size=10&page=1#to

p [Accessed 29 Apr. 2016].


Available at: http://www.hscic.gov.uk/searchcatalogue?

productid=19118&topics=2%2fMental+health%2fHuman+rights

%2fMental+Health+Act+1983&sort=Most+recent&size=10&page=1#top [Accessed

29 Apr. 2016].


Available at: http://www.hscic.gov.uk/catalogue/PUB19098 [Accessed 29 Apr. 2016].

31. Hscic.gov.uk. (2016). Mental health - Health & Social Care Information Centre.

[online] Available at: http://www.hscic.gov.uk/mentalhealth [Accessed 29 Apr. 2016].

32. Isdscotland.org. (2016). Mental Health | Publications | Data Tables | Health Topics |

ISD Scotland. [online] Available at:

http://www.isdscotland.org/Health-Topics/Mental-Health/Publications/data-

tables.asp?id=1390#1390 [Accessed 29 Apr. 2016].

33. Iyer, S., Jordan, G., MacDonald, K., Joober, R. and Malla, A. (2015). Early

Intervention for Psychosis. The Journal of Nervous and Mental Disease, 203(5),

pp.356-364.

34. KHAN, F., RICE, D. and TADROS, G. (2012). The use of supportive observations

within an inpatient mental health unit for older people and dilemma of using the

Mental Health Act (2007) or the Mental Capacity Act (2005) in England and

Wales. Journal of Psychiatric and Mental Health Nursing, 20(1), pp.91-96.

35. Lally, J., Wong, Y., Shetty, H., Patel, A., Srivastava, V., Broadbent, M. and

Gaughran, F. (2015). Acute hospital service utilization by inpatients in psychiatric

hospitals. General Hospital Psychiatry, 37(6), pp.577-580.

59 | P a g e


36. Loader, K. (2014). Resolving the psychiatric bed crisis: a critical analysis of

policy. British Journal of Nursing, 23(3), pp.150-155.

37. Lowes, L. and Gill, P. (2006). Participants' experiences of being interviewed about an

emotive topic. J Adv Nurs, 55(5), pp.587-595.

38. Malins, P. Head, J. (2004). Machinic assemblages: Deleuze, Guattari and an ethico-

aesthetics of drug use, 7(1), pp.84 – 104

39. Marshall, M. and Rathbone, J. (2011). Early Intervention for

Psychosis. Schizophrenia Bulletin, 37(6), pp.1111-1114.

40. Massumi, B. (1987). The Simulacrum According to Deleuze and Guattari. Realer

than Real, 1(1), pp. 90 – 97

41. Meikle, J. (2016). Mental health patients 'should not have to travel across England

for beds'. [online] the Guardian. Available at:

http://www.theguardian.com/society/2016/feb/09/mental-health-patients-travel-

across-uk-for-beds [Accessed 22 Mar. 2016].

42. Mhsc.nhs.uk. (2016). Manchester Mental Health and Social Care Trust - Services -

Community services. [online] Available at:

http://www.mhsc.nhs.uk/services/community-services.aspx [Accessed 18 Mar. 2016].

43. NHS England (2016). NHS England » 7. Reducing mortality for people with serious

mental illness (SMI). [online] England.nhs.uk. Available at:

https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/sop/red-prem-

mort/smi/#seven-two [Accessed 13 Apr. 2016].

44. Nhs.uk. (2016). Glossary of mental health services - NHS services - NHS Choices.

[online] Available at: http://www.nhs.uk/NHSEngland/AboutNHSservices/mental-

health-services-explained/Pages/services-explained.aspx [Accessed 29 Apr. 2016].

60 | P a g e

http://philpapers.org/go.pl?id=MALMAD-4&proxyId=&u=http%3A%2F%2Fwww.janushead.org%2F7-1%2FMalins.pdf

http://philpapers.org/go.pl?id=MALMAD-4&proxyId=&u=http%3A%2F%2Fwww.janushead.org%2F7-1%2FMalins.pdf


45. Owen, G., Richardson, G., David, A., Szmukler, G., Hayward, P. and Hotopf, M.

(2008). Mental capacity to make decisions on treatment in people admitted to

psychiatric hospitals: cross sectional study. BMJ, 337(jun30 1), pp.a448-a448.

46. Perrin, A. (2001). The CodeRead System: Using Natural Language Processing to

Automate Coding of Qualitative Data. Social Science Computer Review, 19(2),

pp.213-220.

47. Rae, G. (2014). Traces of Identity In Deleuze’s Differential Ontology. International

Journal of Philosophical Studies, 22(1), pp.86-105.

48. Rossetto, K. (2014). Qualitative research interviews: Assessing the therapeutic value

and challenges. Journal of Social and Personal Relationships, 31(4), pp.482-489.

49. SOFAER, S. (2002). Qualitative research methods. International Journal for Quality

in Health Care, 14(4), pp.329-336.

50. Tynan, A. (2009). Who’s Afraid of Deleuze and Guattari? (review). symploke, 16(1-

2), pp.329-331.

51. Vasudev, K., Thakkar, P. and Mitcheson, N. (2012). Physical health of patients with

severe mental illness. International Journal of Health Care Quality Assurance, 25(4),

pp.363-370.

52. Wilson, V. (2014). Research Methods: Sampling. Evidence Based Library and

Information Practice, 9(2), p.45.

53. Wrycraft, N. (2009). Introduction to Mental Health Nursing. Maidenhead: McGraw-

Hill International (UK) Ltd.

54. www.rdash.nhs.uk. (2016). What is Early intervention. [online] Available at:

https://www.rdash.nhs.uk/services/our-services/adult-mental-health-services/early-

intervention-in-psychosis-services/what-is-early-intervention/ [Accessed 13 Apr.

2016].

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8. Appendices

1. Ethics form for participants

University of Manchester

Faculty of Humanities

Manchester Business School

CONSENT FORM

[To be completed by each participant]

If you are happy to participate in this study, please complete and sign the consent form below.

Please Tick Box

I confirm that I have read the attached information sheet on the above project and have had the opportunity to consider the information and ask questions and had these answered satisfactorily.

I understand that my participation in the study is voluntary and that I am free to withdraw at any time without giving a reason and without detriment to any treatment/service.

I agree to take part in the above research project.

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Name of participant Signature Date

Name of person taking consent

Signature Date

2. Email sent to participants

Dear…….

I am currently conducting a research project examining the impact of austerity cuts on the NHS with a specific focus on mental health care. This includes the growing pressures to provide a more cost efficient service while still maintaining a high level of treatment and patient care. In particular, the research seeks to examine the issues around the shortage of beds within the NHS and more specifically the provision of acute mental health beds. This includes the debates over the treatment of general medical issues alongside psychiatric conditions in relation to the allocation of beds, in addition to the different pressures underlying the process of managing a psychiatric service that has many different demands, such as the unpredictable movement of patients and different timings of care.

Given you knowledge and experience in this area, it would be wonderful if I could come along to meet with you and discuss these issues further.

Yours sincerely,

Steven Boardman

3. Interview questions

When a patient is admitted, what options do they have in terms of services and care?

With two types of care programme approach, (Standard and enhanced) how do their options differ when it comes to the admittal process?

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Would one be prioritised a bed over the other as a necessity if there was a shortage of beds and do you think this would clash with standard 5 of the NSF?

With psychiatric hospitalisation being the most expensive component of mental health care, could it be problematic admitting patients to general hospital for physical morbidities in terms of funding and bed allocation?

There’s the idea that psychiatry should be redefined as treating for the whole person rather than just mental health. Is this a productive way of managing psychiatric patients?

Could alternative to admission, such as CRT contribute to the shortage of beds due to expectations to follow other routes? (Decrease the amount of beds)

Some people are critical about the NSF saying it is an incentive to reduce costs, what do you think?

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final dissertation

Documents

Transcript of final dissertation