An assessment of the feasibility of discharge of patients in hospitals for the subnormal.

IT is now widely accepted that subnormal patients who do not require hospital services should not be in hospital but should be in hostel-type accommodation under educational and welfare authorities if they cannot be cared for in their own homes. However, the application of this policy to patients already in hospital presents difficulties, both because there are differences of opinion about the proportion of patients who do not need hospital care and because even among patients whose discharge would be desirable it is not clear to what extent it is feasible, particularly in the case of those for whom hospital has been home, sometimes their only home, for many years. The purpose of the present investigation is to assess the proportion of Birmingham patients now in hospital who could in practice be discharged (not necessarily the same as the proportion who, on grounds of medical or other needs, do not need hospital care). A previous estimate (McKeown and Leck, 1967) had suggested that only about half of the Birmingham patients in hospitals for the subnormal needed the kind of care-essentially investigation, active treatment or the attention of trained nursing staff-which made it essential for them to be in hospital. This estimate was questioned by some consultants, working in the field of subnormality, on the grounds that it was based on an appraisal of medical, nursing, and other needs rather than a direct question to the consultant. In examining the feasibility of discharge we have therefore reassessed the proportion of patients needing to be in hospital, basing the estimate on the consultant's classification of his own patients. In the previous enquiry all (1,652) Birmingham patients in hospitals for the subnormal were included. For the present purpose it was considered sufficient to cover all (204) children under 16 and a random sample of 339 patients comprising one in four of those over this age. Consultants were asked to assign each of their 116 patients to one of six classes according to the type of care required-investigation or active hospital treatment; mental and basic nursing; mental nursing; basic nursing; checking and counselling; and sheltered environment. This is the classification used previously, with types of care arranged in order of decreasing complexity and each patient uniquely classified according to the most complex type of care required. Patients under the first four headings were considered to need hospital care and those under the last two were not. Since the earlier conclusions were questioned, we should clarify the changes in the present procedure. Previously, consultants and ward sisters were asked to see each of their patients together and to provide detailed information concerning their medical, nursing, and other needs, and these data were used to prepare the six-fold classification. In the present case consultants were invited to place patients directly into one of the six classes, and any differences between the results are due either to changes in the patients' needs since the previous survey or to the difference in procedure. Tables I and II show the classification of children and adults respectively according to the types of care required. (For a number of reasons, including particularly the greater scope for hospital investigation and active treatment, it was considered desirable to