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 1, 2016
THE UNIVERSITY OF MANCHESTER
Manchester Business School

Steven Boardman - 8985976
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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 ofContents
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 ofContents
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
Figure 1:Lallyet.al (2010 – 2011) studyof shortenedlife expectancyin relationto diagnosedmentalillness, inlong-
staypsychiatric in-patients.
Resource: Lally, J., Wong, Y., Shetty, H., Patel, A., Srivastava, V., Broadbent, M. andGaughran, F. (2015). Acute hospital
service utilizationbyinpatients inpsychiatric hospitals. General Hospital Psychiatry, 37(6), pp.577-580.

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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
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).
Figure 2: Percentage of adultpatientswithinpsychiatrichospitalsin Scotlandthatwere informal
from2008 – 2012
Source:Information Service Division Scotland (2012)

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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
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.

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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.

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

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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.
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

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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
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

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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
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

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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
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

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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”
(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

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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
limitations within different bodies. These overall limitations are: the lack of flexibility in the
entire MHC services, and services that don’t mesh well.

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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
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

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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
assemblage where risk prevention is of a greater intensity and procedural necessities can be
employed.

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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
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).

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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
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

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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
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

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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
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

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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
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

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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
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

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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.
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

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